Making misleading health claims online just got a little more problematic

I’ve developed several Google custom searches to make it easier to pick though the data and identify practitioners making misleading and potentially dangerous claims. These custom searches are like having a version of Google that limits itself to the websites of specific groups of alternative practitioners. They're not perfect - you'll get false positives as well as false negatives. But they do work very well.

Here are Google search engines limited only to websites belonging to members of:

• British Chiropractic Association
• Scottish Chiropractic Association
• McTimoney Chiropractic Association
• General Osteopathic Council
• Complementary and Natural Health Council
• Alliance of Registered Homeopaths
• Kinesiology Federation

You might find, for instance, that there are still some British Chiropractic Association members claiming to treat colic. Or you might find that some CNHC members are claiming they can treat ear infections by sticking a candle in your ear. Or maybe you’ll find a homeopath that is telling people that magic sugar pills can help with eczema.

Google's custom search system is far from perfect. It randomly seems to drop results, then pops them back in again. Text that is clearly found on many sites can't be found. But I expect this to improve over time as the indexing improves.

Despite these problems, if you're making misleading claims it’s now far more probable that you'll get caught. Fingers crossed that whoever finds them hasn't got FishBarrel installed.

FishBarrel: Keep what you highlight short & to the point

I’ve been looking through some of the complaints that have gone in via FishBarrel. While I can’t see the background information that people have entered, I can see what was highlighted.

A few of the complaints seem to include really large chunks of highlighted text, which is going to reduce the effectiveness of the complaint and may even mean it gets initially rejected.

Here is an example of some text that was highlighted recently:

Aromatherapy combines massage with the use of therapeutic essential oils which are found naturally in plants. Tricia Swensson The essential oils are applied to the skin and are absorbed into the blood stream which can have a therapeutic effect on the body systems. Aromatherapy massage can help to reduce stress and tension, relieve muscular pain, improve circulation and encourage the removal of toxins from the body. Aromatherapy may help with a wide range of treatments such as: Insomnia Menstruation problems Respiratory conditions Digestive disorders The use of plant extracts for health have been documented for thousands of years, the ancient Egyptians used essential oils for health and beauty and also during embalming. Aromatherapy as we know it was revived when a French chemist Rene-Maurice Gattefosse burnt his hand during an accident; he placed his hand in a bowl which he believed contained water but in fact contained lavender oil he was amazed at how quickly the wound healed leaving no scarring. It is Gattefosse who first coined the phrase `aromatherapie’.

Much of this information is true. The complaint would be far stronger if the specific misleading claims were highlighted individually. Even if there are two sentences with misleading claims next to each other, it’s worth separating them out by highlighting them individually. Here’s how I’d deal with the above text:

#1 Aromatherapy massage can help to reduce stress and tension, relieve muscular pain, improve circulation and encourage the removal of toxins from the body.

#2 Aromatherapy may help with a wide range of treatments such as: Insomnia Menstruation problems Respiratory conditions Digestive disorders

(Note: If the header of your complaint states you’re listing misleading claims, you probably wouldn’t need to enter any background info about the above.)

#3 French chemist Rene-Maurice Gattefosse burnt his hand during an accident; he placed his hand in a bowl which he believed contained water but in fact contained lavender oil he was amazed at how quickly the wound healed leaving no scarring.

For #3's background info, I’d add: “The above text misleadingly implies that aromatherapy is an effective treatment for burns.”

This way it’s clear what you’re complaining about and you’re not asking the ASA to do all of the work for you.

There is one exception I can think of where you might highlight a lot of text and that where the practitioner just lists a large number of diseases that their therapy treats. In this case, highlight the full list.

It's a real shame nobody will help stop Boots making false claims

Sadly, the 240 ASA complaints about quack medicine products being sold at Boots got nowhere. Boots took the rather cowardly decision of withdrawing the 3 for the price of 2 offer to take their products outside of the ASA's remit, rather than defend the claims they make about their products.

I didn't think they'd be able to get away with this, though I'm continuing to learn about how the ASA operates. When I complained about the GCC's patient information leaflet last year, the GCC agreed to remove the claims, but initially continued making the claims on a PDF on their website. When I queried the ASA about this, they asked them to remove it even though being online, the PDF was presumably outside their remit.

When I asked about this apparent double standard, the ASA replied as below (I'd skip reading it, it's quite dull):

Dear Simon,

Thank you for your e-mail, I’m sorry for the delay responding to you. As I explained, our remit does not cover material on advertisers own websites where it does not refer to a sales promotion. While I appreciate your concern about these claims and the manner in which Boots have brought their promotion into line with the CAP Code, the ASA (at this time) is not entitled to comment on claims on companies’ own websites (outside of promotions), such as the Ladycare menopause relief magnet you mention.

Leaflets available to download on advertisers websites, when they are also distributed to the public as hard-copy (the contents of which therefore fall within the ASA’s remit) are generally also subject to any ASA Council adjudication on the hard-copy. However, this only applies where the leaflet itself is available to download in identical form to that which is distributed as hard-copy material.

Our main aim in cases such as the original investigation into the objections you raised about numerous claims on Boots’ websites is to ensure claims which fall within our remit are amended or removed. In this instance, Boots agreed to ensure that any claims subject to the CAP Code would in future conform, without a formal adjudication from the ASA Council being necessary and there do not appear to be grounds to challenge this decision, nor material within space governed by our remit which appear to give us grounds to investigate further.

However, claims made on companies own websites is sometimes subject to specific legislation which Consumer Direct (0845 4040506) or the MHRA (020 7084 2000, www.mhra.org.uk) might be able to advise further.

Again, I realise this will disappoint, but thank you for taking the time and trouble to contact us with your concerns.

Kind regards

Sam

So I think I've hit a dead end with the ASA. Next stop Trading Standards. The thing is, Trading Standards doesn't really do anything unless a lot of people complain.

And I can't imagine there will be many people who will have come back inspired by the excellent TAM London speakers, ready and willing to do the following:

• Choose one product to complain about. You might like to complain about the Fanny Magnet that apparently "helps to reduce or completely eliminate the symptoms of menopause". Or maybe about the BioFirm Danish Detox Plan, which they claim "naturally supports the body’s own internal processes of elimination and detoxification." Or maybe you're really angry that they sell "Boots Teething Pain Relief" which claims, in the title, that it is for teething pain relief yet can't possibly work as it's homeopathic.
• Go the Consumer Direct Complaints Form.
• Fill it out. I've helped with that below by making it easy to copy & paste some basic info that will be relevant to all complaints.
• Submit the form.
• Put a comment below so I can see who did what.

Sadly, I doubt anyone will do this. What a shame.

Helpful advice and information to copy & paste:

Section 1:

Clearly quote any text you believe to be unsupported by robust evidence. Point out that Consumer Protection Regulations 2008 require the company to be able to back up any claims with evidence.

Section 2:

Name of Trader: Boots UK Limited

Address: 1 Thane Road West

Town or City: Nottingham

County: Nottinghamshire

Postcode: NG2 3AA

Telephone Number: 0115 918 2000

Trader's website address: http://www.boots-uk.com

Trader's email address: [Leave blank]

Section 3:

Have you paid for goods or services from this trader?: NO

Leave rest of Section 3 blank.

Section 4:

Please let us know how you heard of Consumer Direct: Website/Internet search.

But as I said, I can't imagine anyone will actually do this and comment to let me know they have done so. Real shame.

Off skiing in Tignes.

A Step-by-Step ASA complaint

Recently I’ve had lots of requests for advice on the best way to complain to the Advertising Standards Authority about various devices falsely claiming health benefits. The good news is that it’s easy. But of course, if you hadn’t done it before you wouldn’t know that.

I’m going to walk you through the process with a quick example, an advertisement for a Reflexology Circulation Enhancer in July 25th’s Sunday Telegraph.

The first step is to look through the ad, sentence by sentence, to see if you can find any specific misleading claims. You’re not just looking for outright lies, but also what Harry Frankfurt defines as bullshit. Claims that have been made up without concern for whether they’re true or not.

Sometimes the advertiser won’t make their claims clearly, they will imply them. The ASA can still adjudicate against misleading implications.

You can click the picture to the right to see a clearer view of the ad. If I work through from the top, we find something pretty quick.

1. The title “circulation enhancer” clearly implies that this product is able to increase circulation. I do not believe that the manufacturer JML have any evidence to substantiate this claim.

Easy.

The subtitle is the next obvious bit. “The ingenious electronic device uses ancient Chinese reflexology techniques to relieve the stresses and strains of the day and boost your energy levels through the power of your feet!”. So I’d simply quote this, then question it:

2. The advertisement claims “The ingenious electronic device uses ancient Chinese reflexology techniques to relieve the stresses and strains of the day and boost your energy levels through the power of your feet!”.

I doubt that JBL have any evidence to back up their claims that:
a. This system is capable of relieving stresses and strains.
b. This system is capable of “boosting energy levels”.
c. It is in any way possible to “boost your energy levels through the power of your feet!”.

Again; easy. The ad continues:

“For centuries, the Chinese have believed that every part, gland and organ of the body is connected to specific areas of your feet which when manipulated using fingertips help soothe and re-energise, restoring a natural feeling of well being again.”

“Bringing that philosophy into the 21st century, the JML Circulation Enhancer uses proven T.E.N.S technology to create the same effect – but this time at the touch of a button and in the comfort of your home.”

I’ll quote this text to the ASA, and then make the following observations:

3. While it may be true that some people believe that manipulating parts of the feet can “soothe and re-energise, restoring a natural feeling of well being again”, that advert is implying that these beliefs are true. I do not believe that the advertiser possesses evidence to back these claims up.

4. When JML state “proven T.E.N.S technology” they are implying that T.E.N.S has been proved to be effective for the specific claims they make, for example to “re-energise”.

5. When JML state that their technology creates “the same effect” as reflexology, I do not doubt them, as reflexology is unlikely to have any effect. However, the implication is clearly that both their product and reflexology have a beneficial effect on health.

6. JML state “Chinese have believed…”. While there may be Chinese people who do believe this, I have found no evidence to suggest that it is believed by a significant portion of the Chinese population. I find this statement offensive because it implies that the Chinese are a particularly gullible race.

I should clarify that I don’t think JML are a racist organisation, I don’t think they’ve thought through the implications of what they are saying. That last point was for my own personal amusement.

There is also a testimonial:

“The effect is amazing. I could feel it working from the moment I switched it on!”

7. Statements made in testimonials need to also be backed by evidence. This clearly implies that the device is efficacious for the health benefits outlined at the top of the advert.

Under benefits, they state “Low frequency micro-currents safely stimulate the reflex points in your feet”.

8. I do not believe that there is any evidence to suggest that “reflex points” actually exist, let alone that they are capable of being “stimulated” by this device.

And “Reinvigorates tired parts of the body”.

9. I do not believe JWL have evidence to show that this device is capable of doing this.

There is also the picture with the magic blue bullshit field around the legs of the lady on the chair.

10. The picture showing the rings around the lady’s feet are clearly designed to imply that there is some sort of magic field emanating from the device. I doubt that JWL have any evidence to show that this field exists.

Once you’ve made the points, simply wrap it up in an email. I generally prefer to email the ASA rather than use their online form because of attachment size limits on their form, but either way is fine if it works.

Here’s the final product.

To: new.complaint@asa.org.uk
Subject: Complaint about Circulation Enhancer advert in The Sunday Telegraph.

To whom it may concern:

I am writing to complain about an advertisement I found on page 20 of the Lifestyle section of the Sunday Telegraph on the 25th July. The advert makes a number of what I believe to be unsubstantiated health claims.

I have attached a copy of the advert.

1. The title “circulation enhancer” clearly implies that this product is able to increase circulation. I do not believe that the manufacturer JML have any evidence to substantiate this claim.

2. The advertisement claims “The ingenious electronic device uses ancient Chinese reflexology techniques to relieve the stresses and strains of the day and boost your energy levels through the power of your feet!”

I doubt that JBL have any evidence to back up their claims that:
a. This system is capable of relieving stresses and strains.
b. This system is capable of “boosting energy levels”.
c. It is in any way possible to “boost your energy levels through the power of your feet!”.

The advert also states:
“For centuries, the Chinese have believed that every part, gland and organ of the body is connected to specific areas of your feet which when manipulated using fingertips help soothe and re-energise, restoring a natural feeling of well being again.”

“Bringing that philosophy into the 21st century, the JML Circulation Enhancer uses proven T.E.N.S technology to create the same effect – but this time at the touch of a button and in the comfort of your home.”

3. While it may be true that some people believe that manipulating parts of the feet can “soothe and re-energise, restoring a natural feeling of well being again”, that advert is implying that these beliefs are true. I do not believe that the advertiser possesses evidence to back these claims up.

4. When JML state “proven T.E.N.S technology” they are implying that T.E.N.S has been proved to be effective for the specific claims they make, for example to “re-energise”.

5. When JML state that their technology creates “the same effect” as reflexology, I do not doubt them, as reflexology is unlikely to have any effect. However, the implication is clearly that both their product and reflexology have a beneficial effect on health.

6. JML state “Chinese have believed…”. While there may be Chinese people who do believe this, I have found no evidence to suggest that it is believed by a significant portion of the Chinese population. I find this statement offensive because it implies that the Chinese are a particularly gullible race.

There is also a testimonial:

“The effect is amazing. I could feel it working from the moment I switched it on!”
7. Statements made in testimonials need to also be backed by evidence. This clearly implies that the device is efficacious for the health benefits outlined at the top of the advert.

Under benefits, they state “Low frequency micro-currents safely stimulate the reflex points in your feet”.

8. I do not believe that there is any evidence to suggest that “reflex points” actually exist, let alone that they are capable of being “stimulated” by this device.

And “Reinvigorates tired parts of the body”.

9. I do not believe JWL have evidence to show that this device is capable of doing this.

10. The picture showing the rings around the lady’s feet are clearly designed to imply that there is some sort of magic field emanating from the device. I doubt that JWL have any evidence to show that this field exists.

I am complaining as a concerned member of the public and wish to confirm I have no commercial interest.

[full name, address and phone number]

Many thanks,

Simon Perry

At Boots, it's 3 for the price of 2 on quackery

At 2pm on the 14th July, Skeptic Kash Farooq alerted me via Twitter to a quack medicine product on the Boots web site that he was going to make an Advertising Standards Authority complaint about.

The only problem was that the ASA does not regulate web site content. And this has been a problem stopping us from tackling Boots for some time. If Boots has false or unjustifiable claims to make about a product, they only seem to make them in areas where the ASA can’t touch them. They use packaging, point of sale materials and their web site to make their claims – all outside of the ASA’s remit. I’ve personally never seen widespread false claims made by Boots on posters, leaflets or in the press where the ASA can start issuing adjudications against them.

Whether this is a deliberate strategy by Boots, or just through chance alone I cannot be sure. But yesterday, they slipped up.

Kash had noticed that Boots had a 3 for the price of 2 offer “across all vitamins, complementary medicines and herbal products”. There are a couple of exceptions where the ASA will regulate claims made on the web. One is:

“We regulate sales promotions, such as special offers, prize draws and competitions wherever they appear.”

Boots appeared to have put their entire range of alternative health products – the products for which they regularly make unjustified claims of health benefits – fully within the remit of the Advertising Standards Authority.

I had no idea of how long this promotion would last, and with the ASA sometimes taking over a week to look at a case, I did not want the claims to fall out of remit before my complaint went in. Boots may have seen the tweets about them and realised they needed to withdraw the promotion. For the best chance of success, the complaint had to go in by the start of business the next morning.

I started going through the claims and realised that there was no possible way I could get through them by myself. Boots had 679 products in the range, many of which were making clearly unjustifiable claims. And in comes the power of Twitter. With a couple of Tweets, I suddenly had a small army of helpers.

I created a shared Google Spreadsheet in which a team of 9 or 10 people started adding URLs from the Boots web site and copying and pasting next to them the unjustifiable claims made about the product. With a little help from technical wizard @tommorris answering my call for help, I found a program that would automatically download the large number of web pages and print them to a local PDF to hold as evidence.

Watching what was happening on the Google Spreadsheet was awe-inspiring. When I started letting people into the document, there were 80 URLs copied and pasted into the list. By the time I got 15 more URLs into it, @the_beacon, @richardtomsett, @HelenaThomas, @dellybean, @kashfarooq, @nwoolhouseuk, @cherryblack, @RoisinThomas and @kingmuskar had pretty much copied and pasted all of the claims and were now waiting on me.

By the end of the evening, we’d sent off complaints to the Advertising Standards Authority about 107 Boots products.

The claims they were making varied from shocking – claiming that a homeopathic remedy is “to relieve the pain of teething.” To the bizarre – a magnet which you put in your knickers which they claimed “helps to reduce or completely eliminate the symptoms of menopause” – something one of my helpers described as a “Fanny Magnet”. There were some less serious claims such as listing “30c Aconitum napellus” as an active ingredient on a product when I can say with 99.999999999999999999999999999999999994% certainty that if manufactured carefully contains no Aconitum napellus (and I worked that number out, it’s not just a guess).

But my helpers continued after I finished. @nwoolhouseuk, @ScepticLetters,
@GDLockUK, @kashfarooq and @the_beacon together sent in a second complaint with another 133 products listed. @nwoolhouseuk was still going at 1:30 in the morning, and @ScepticLetters finally finished it off at 4am.

Boots will now hopefully be held to account. For years, whether accidentally or by design, they been keeping the misleading claims they make about their products just beyond the remit of the ASA. One slip up, and with excellent teamwork we caught them out in one night with a total of 240 complaints.

The CNHC won't be publishing my complaints

Following my complaints to the CNHC about 14 reflexologists claiming to treat specific diseases without any credible evidence, you may have noticed that nothing has yet appeared on the CNHC’s decisions page.

I contacted Maggie Dunn about this matter. It appears that because my complaints were dealt with before it got through to the conduct and competence committee, they do not intend to publish the details on the web site, nor do they intend on ever naming the offending practitioners.

I do not believe that they intend to go any further than this press release published in December 2009 congratulating themselves on a job well done.

With still no clarification from the CNHC on what practitioners are allowed to claim, it seems likely that there are many more CNHC members continuing to do exactly the same with no worry about regulation.

Maybe it’s time to submit a few more complaints.

Boots avoid admitting there's nothing in it. 10:23

If you thought I'm too old for this sort of childish moron-baiting, I'm afraid you're sorely mistaken. This month I've been emailing Boots to ask how much Arnica is in one of their Arnica 30C remedies. Obviously I know the answer - there is none. Boots also know the answer.

It's quite amusing however, to see them trying to avoid giving me this answer. The email trail follows.

10:23.

---

8 January 2010 21:03

Hi,

I'm used to seeing the quantity of ingredients listed in mg rather that as "6C" or "30C" as your homeopathic remedies are labelled.

Can you clarify for me how many mg of Arnica is in one of your "Arnica 30C" tablets? I tried to work it out, but I think I got confused at some point.

Thanks,

Simon

---

11 January 2010 17:39

Dear Simon

Thank you for taking the time to email me regarding Boots Arnica 30c (item code 37-71-814) with regard to converting the content of Arnica into milligrams.

I am afraid, however, that it is not possible to convert "centesimal" (c) dilutions of Homoeopathic remedies into milligrams (mg) or micrograms (mcg).

During the manufacturing of Homoeopathic remedies the amount of Arnica is not quantified in milligrams or micrograms. Instead one drop of Arnica (or other Homoeopathic ingredient) is added to ninety-nine drops of diluent (carrier) to produce a 1 centesimal (1c) potency, which is then further diluted to produce a 6c or 30c product.

I hope that this information is of use to you.

Regards

Paul Williams MRPharmS
Medical Information (Pharmacist) Officer

---

11 January 2010 18:17

Hi,

Sorry, I'm confused by this. Surely there is a specific amount of Arnica in the pills which can be measured in mg?

If, as you suggest, that a 1C remedy is 1% Arnica then surely if it was a 100mg pill, then this would be 1mg Arnica. Why isn't this correct?

Simon

---

14 January 2010 13:27

Dear Simon

Thank you for your second e-mail regarding Boots Arnica 30c (item code 37-71-814).

Unfortunately, the amount of Arnica (or other Homoeopathic ingredient) in the drop that is then subsequently diluted with 99 drops of diluent (carrier) is not quantified in milligrams (mg) or micrograms (mcg).

Thus, although it is true to say that a 1 centesimal (1c) Homoeopathic remedy contains 1 part of Arnica, as the amount of Arnica is not initially quantified then it is not possible to convert this into milligrams (mg) or micrograms (mcg).

Therefore, with regard to Homoeopathic remedies we are not able to state the quantity of Arnica in milligrams (mg) or micrograms (mcg) for the reason outlined above.

The labelling of our products is in accordance with guidelines on the labelling of Homoeopathic remedies, which are derived from The Medicines and Healthcare Products Regulatory Agency (known as the MHRA), which is the UK medicines regulator. These guidelines state that the scientific name of the "stock" (i.e. Arnica) and centesimal dilution should be declared on the labelling.

I hope that this further information is of use to you.

Kind Regards

Paul Williams MRPharmS
Medical Information (Pharmacist) Officer
Medical Services

---

14 January 2010 15:39

Dear Paul,

Thank you for your reply, and I understand that without knowing the mass of the original drop of Arnica it would be impossible to determine the subsequent mass of Arnica in the final product. However, it should easily be possible to determine the percentage of Arnica in the final 30C remedy.

Am I correct that a 1C remedy is 1% active ingredient? That it is 99% water and 1% Arnica?

What is the percentage of Arnica in the final 30C product?

I've been trying to work this out myself, but I think I've gone wrong somewhere. This will allow me to make an approximate estimate of the number of mg of Arnica.

Many thanks for your help,

Simon

---

18 January 2010 16:29

Dear Simon

Thank you for you further e-mail regarding Boots Arnica 30c (item code 37-71-814).

I can confirm that a 1c Homoeopathic remedy comprises of 1% of the Homoeopathic ingredient i.e. Arnica and 99% of the diluent (carrier).

I can also confirm that to produce a 2c Homoeopathic remedy 1 drop of the 1c Homoeopathic dilution is then further diluted with 99 drops of diluent (carrier). This would equate to 0.01% of the Homoeopathic ingredient i.e. Arnica.

To produce a 3c Homoeopathic remedy this method of dilution is repeated with one drop of the 2c dilution and so on in order to produce a 30c Homoeopathic remedy.

The labelling of our products is in accordance with guidelines on the labelling of Homoeopathic remedies, which are derived from The Medicines and Healthcare Products Regulatory Agency (known as the MHRA), which is the UK medicines regulator. These guidelines state that the scientific name of the "stock" (i.e. Arnica) and centesimal dilution should be declared on the labelling.

I hope that this information is of use to you and is sufficient to allow you to calculate the percentage of Arnica.

If you require further support in understanding Homoeopathic remedies then you may wish to contact the supplier for this product, Nelsons, via enquiries@nelsons.net.

Regards


Paul Williams MRPharmS
Medical Information (Pharmacist) Officer

---

18 January 2010 18:02

Hi Paul,

Thanks for your reply, however I'm still having problems with my calculation. While the figures seem to make sense from a mathematical point of view, the percentage of Arnica seems to reduce fairly rapidly to seemingly absurd quantities.

As you said in your email, these products are licensed by the MHRA and of course they are sold by Boots, so I've no doubt as to their effectiveness.

So the only logical conclusion I can draw is that I've made a mess of the mathematics.

Can you confirm the answer you get for a 30C remedy?

Many thanks,

Simon

---

22 January 2010 15:37

Dear Simon

Thank you for your further e-mail regarding Boots Arnica 30 c (item code 37-71-814) with regard to calculating the percentage of Arnica.

Whilst the information about the dilutions of Homoeopathic remedies is freely available from validated reference sources, the actual percentage in a 30 c Homoeopathic remedy is not stated and, therefore, I am afraid I am unable to provide this information.

At Boots we take our responsibilities as the leading Pharmacy-led Health & Beauty retailer in the UK very seriously and as part of this we pride ourselves on being able to offer all of our customers a choice of products that support them in their day-to-day lives. We know that many people believe in the benefits of complementary medicines and we aim to offer the products we know our customers want.

I can confirm that Boots Arnica 30 c are a licensed Homoeopathic product without approved therapeutic indications. The pack is labelled in accordance with the requirements placed upon the Marketing Authorisation holder, Nelsons, by the Medicines and Healthcare Products Regulatory Agency. If you would like to contact the Marketing Authorisation holder to discuss the formulation of this product and the manufacturing process in more detail they are contactable at enquiries@nelsons.net.

Our Pharmacists are trained Healthcare Professionals and are on hand to offer advice on the safe use of complementary medicines. The Royal Pharmaceutical Society of Great Britain issues guidance to Pharmacists on the correct selling of Homoeopathy, which our Pharmacists adhere to.

I would like to conclude by confirming that Boots support the call for scientific research and evidence gathering on the efficacy of Homoeopathic medicines as this would help our patients and customers make better informed choices about using Homoeopathic medicines.

I hope that this information is of use to you.

Regards
Paul Williams MRPharmS
Medical Information (Pharmacist) Officer
Medical Services

---

23 January 2010 08:52

Hi Paul,

I get the impression that you are trying hard to avoid answering my question.

In an earlier email you say that it is possible to calculate the percentage of Arnica in a 1C and 2C remedy but then without reason you say you cannot do it for a 30C remedy. Yet in a previous email you state that the information you gave me should be sufficient for the calculation.

The problems I was having when calculating the amount of Arnica is that every time I did the maths, the result came out that there was no Arnica remaining in the 30C remedy.

This is a perfectly simple and clear question: is there any Arnica remaining in an Arnica 30C remedy?

Many thanks,

Simon

---

As yet - no response.

David Tredinnick MP Promotes Dangerous Ideas

The ability to use reason, weigh evidence and make rational decisions is an essential skill. Strongly held beliefs unsupported by evidence can cause significant damage to the deluded individual and those who surround them.

An individual approaching a homeopath for a cold remedy will probably do no more self harm than to waste their money and feed their own delusion, but the homeopath who convinces their client that they're safe to go to West Africa with nothing more than a sugar pill for malaria protection may well kill them.

But mumbo-jumbo becomes most dangerous when it is believed by those with power.

In the late 1980s, the Government launched an Aids awareness campaign warning people not to "die of ignorance". But 13 years later in South Africa, the Mbeki government was infected with the very ignorance we Brits were warned against.

Mbeki started to doubt HIV was the cause of Aids and the regime started promoting the eating of potatoes and garlic as Aids treatment while warning of the dangers of anti-retro viral drugs.

The South African government's stance is estimated by scientists to have caused the premature deaths of between 300,000 and 350,000 people, the equivalent of a 9/11-sized catastrophe once a week for two years.

Under Chairman Mao, the People's Republic of China embarked on its Great Leap Forward, combining a set of absurd pseudo-scientific farming practices with a socialist economic doctrine so daft that its flaws could have been spotted by a teenager half way through their economics GCSE.

The farming practices were devised by Trofim Lysenko, who denied many basic tenets of biology, even genetic theory.

His farming advice included ploughing to a depth of two metres, storing wet seed in snow and planting rows of seeds extremely close together under the belief they would not compete with each other.

With the expected productivity gains, they reasoned there was little need to farm much of the land. But then these expectations were not based on any kind of rational thought or evidence.

This lethal combination of nonsense-biology, nonsense-agronomy and nonsense-economics caused the greatest famine in history, with estimates of the number of deaths ranging from 15-30 million.

But you think you're probably safe, right? Our MPs place their trust in independent scientific advisers who are at the top of their profession, right? Well, no.

Should you wish to find the MP who I believe promotes some of the most scientifically illiterate and dangerous ideas in Parliament, then look no further than the Leicestershire constituency of Bosworth.

On October 14 last year, David Tredinnick, MP for Bosworth, voiced controversial ideas during a Parliamentary question. His speech included: "There are now people who teach, such as Jane Ridder-Patrick, who published A Handbook of Medical Astrology. They look at aspects of the subject and how it affects people's health. Whatever one believes personally, the issue is one that we should look into and consider."

I find it unbelievable that a democratically-elected MP seems to be suggesting we should be looking into using astrology within our system of health care.

His question also included the lines: "A number of disciplines were mentioned and I could have referred to radionics, for example, for which a double-blind trial is almost impossible, yet it is very popular because people believe that it gives them the ability to get remote healing.

"We need to think out of the box here. As with healers who can do remote healing, it is no good people saying that just because we cannot prove something, it does not work. The anecdotal evidence that it does is enormous."

Radionics is a system of healing where you take a sample of hair or blood, or even a signature and use it in what I can only describe as a kind of remote psychic healing machine.

It's the friendly but equally wacky equivalent of sticking pins into a voodoo doll. Yet it seems Mr Tredinnick is suggesting we should consider it within the NHS.

But, in my view, the most dangerous of Mr Tredinnick's suggestions concerns his promotion of homeopathy: "Attacks have also been made on the efficacy of homeopathy. A letter was sent to the World Health Organisation warning against the use of homeopathy, but it ignored the very clear randomised, double-blind trials that proved it is effective in the particular area of childhood diarrhoea on which it was criticised.

"Will the Government therefore be robust in their support for homeopathy and consider what can be done so that it is used more effectively in the health service?"

Let's put this into context. Homeopathy is best described as a magical belief system that uses chemicals at such ludicrously huge dilution levels the majority of remedies contain little but water. The implausibility of homeopathy has been already covered in my column on December 10 and I will not bore you by repeating it.

Mr Tredinnick is technically right when he says there have been double-blind trials that have come out positive. However, that is not the whole story.

The trials he refers to were all conducted by the same person. In science, repeatability is key: if other people repeat your trial and get the same results then your results are likely to be trusted. If all the trials are performed by the same person they should be treated with more skepticism. The first name on all the papers Tredinnick refers to is Jacobs J. I'm not confident in the open-minded nature of this person's experiments.

For a start, writing an article entitled "Homeopathy, not evidence-based, but now?!" seems to me to be implying a motivation to create evidence in favour, rather than simply conducting research and be led by the outcome.

What's more interesting is in 2003, Jacobs did a meta-analysis of his previous three trials. In a meta-analysis, a researcher will combine the results of several trials into one to produce more statistical power.

Of course, if you combine the results of three positive trials all done by the same person the outcome will be positive. But in total, the three trials only involved 242 children.

In the conclusion, Jacobs noted the results "suggest larger sample sizes be used in future homeopathic research to ensure adequate statistical power".

In 2006, Jacobs did just that. This time, six other researchers were involved in the trial and the number of subjects in the test was larger even than the total of the previous trials – 292 children.

The latest trial, which had the largest number of subjects, concluded: "There was no significant difference in the likelihood of resolution of diarrhoeal symptoms between the treatment and placebo groups".

Or, in other words: homeopathy does not seem to work for childhood diarrhoea.

But all Mr Tredinnick is suggesting is that we use this form of quackery to treat a bit of Delhi Belly.

Diarrhoea, according to the World Health Organisation, kills about 2.2 million people each year – most of them children.

Internationally, it is responsible for 4% of all deaths.

And by specifically mentioning the advice given out by the Worldwide Health Organisation his agenda appears to take a global perspective.

Yes, one in every 25 people worldwide will die of diarrhoea. They need the best that medical science has to offer them – which is usually simple and pretty cheap really: just a basic mix of water, salt and sugar.

But if you live in the Bosworth constituency, it seems your MP may prefer to treat these poor children with something even simpler: quackery.

Trust Boots

This is a repost of my article in the Leicester Mercury. I wanted to repost it here so I could fix the messed up text. When they copied and pasted it they lost all the formatting and most importantly the scientific notation. I've fixed it below.

“Trust Boots” is the tagline that has been offered by the high street pharmacist since 2005. According to Boots’ 2006 Corporate Responsibility Strategy, “Everything we do that builds trust is good for our business; anything which could compromise it, a risk we can't afford to take.” So have Boots shown themselves to be worthy of our trust?

On the shelves of their pharmacy on Gallowtree Gate in Leicester you will find a small section devoted to homeopathy. Many people I meet are confused about exactly what homeopathy is – some thinking it is simply a type of herbal or natural medicine.

Allow me to explain.

The first principle of homeopathy is what they call the “law of similars”. Homeopaths look for a chemical that produces a similar symptom to the disease they aim to treat. For instance, caffeine causes you to stay awake, so homeopaths may decide to use this in a remedy to treat insomnia. Another example is hay fever. Hay fever causes runny eyes and so do onions – so some homeopaths will treat hay fever with a preparation of onions. I realise that all this may sound a little bit unconventional, but please bear with me – in a moment it’s going to sound even more so.

Turning a chemical such as onion juice into a homeopathic preparation involves a process of “dilution” and “succussion”. To create the centesimal or “C” remedies they sell at Boots, the homeopath takes one drop of the chemical and mixes it with 99 drops of water (dilution). In centuries past, this was then banged against a leather covered board or book, often a bible, although in modern times the shaking is often done by machine. This shaking is called "succussion". This is now a 1C homeopathic preparation. It contains 99% water and 1% “active ingredient”.

To turn this into a 2C remedy, the process is repeated. One drop of the solution is taken from the 1C remedy is mixed with 99 drops of water and then shaken. The 2C remedy now contains 99.99% water and 0.01% “active ingredient”. Repeat the process again to create a 3C remedy at 0.0001%, and so on. Homeopaths believe that the higher the level of dilution, the more powerful the remedy.

Many homeopaths will use the solution directly, but Boots and many others prefer to sell homeopathy as pills - or pillules as they call them. One pillule is meant to contain the equivalent of one drop of homeopathic solution.

We can calculate approximately how many molecules of “active ingredient” get into the one drop that makes it into the pillule. A drop of water contains about 1,700,000,000,000,000,000,000 molecules. Scientists write this as 1.7x10²¹. That’s a 17 with 20 zeros after it. Boots sell remedies at 6C and 30C. A 6C remedy will contain around 0.0000000001% “active” ingredient – which works out at about 1.7 billion molecules of active ingredient. But what about when we dilute this further? By the time you get to 10C, there are only 17 molecules of active ingredient left. And at 11C, you only have about a one chance in 6 of finding a single molecule.

The branch of Boots on Gallowtree Gate in Leicester display a guide, provided by the manufacturer, that states a Bryonia 30C remedy “Relieves the symptoms of a dry painful cough, pressure and dehydration headaches” and that a Kali Bich 30C remedy “Soothes the symptoms of sinusitis”.

30C. I already explained that at 11C, you only have about a one in 6 chance of finding a single molecule of active ingredient. At 12C, there is only about one chance in 600 that you will find a molecule and at 13C just one chance in 60,000. By the time you get to 30C, you have more chance of winning the National Lottery jackpot five weeks in a row than you do of finding a single molecule of active ingredient.

Or think about it this way: how much water would you need to contain one molecule of active ingredient at 30C dilution? According to my calculations, the body of water would weigh 5 billion times more than the planet you are standing on. If you want that in pillule form, you'd need to buy 6x10³⁸ pillules (a 6 with 38 zeros after it). At Boots' retail prices, that would cost you 35 trillion trillion trillion pounds. That's a rather expensive molecule.

These pills do not contain any active ingredient.

To my way of thinking, homeopathy is entirely implausible, but science is incredibly open-minded to seemingly implausible ideas. Ideas such as Einstein’s theory of general relativity and quantum theory are utterly bizarre, but once they were demonstrated to be true with fair tests then scientists accepted them.

Testing for a pill is essentially simple. Take a large number of people with a particular disease and randomly divide them into two groups. Give one group the pills you want to test and the other group some placebo pills that don’t contain anything. Neither the patient nor the researchers working with them can know which patients were given which pill. After an agreed period of time count how many people in each group got better.

So what do the trials show? Actually, that’s a little complicated. Some of the poor quality trials where the patients were told which drug they were getting, or had very small sample sizes showed an effect. But those effects could easily be down to the placebo effect or random variation due to the small sample sizes.

But when the experiments are done properly with larger numbers of patients, the vast majority do not show homeopathy to be any better than a placebo. A quick search of Cochrane articles leads us to reviews of homeopathy for the treatment of dementia, chronic asthma and attention deficit/hyperactivity disorder. They all end in similar conclusions: “No evidence that homeopathy is effective in treating dementia”, “Until stronger evidence exists for the use of homeopathy in the treatment of asthma, we are unable to make recommendations about homeopathic treatment.” and “Overall the results of this review found no evidence of effectiveness for homeopathy for the global symptoms, core symptoms or related outcomes of attention deficit/hyperactivity disorder.”

But what do they tell you in Boots? When I popped into their Oadby branch and asked about homeopathic treatment, the pharmacist tried to politely steer me away from the homeopathic remedies citing the lack of evidence. Fair enough.

But a pharmacist at the Gallowtree Gate branch was not so off putting. Despite a couple of points in the conversation where I felt she certainly gave the impression that she did not believe in homeopathy, she was still happy to say things that I would never expect to come out of the mouth of professional pharmacist, by explaining that homeopaths “don't just treat the condition, they look at the whole person” and “If you want absolutely spot on accurate treatment you need to see someone who is a qualified homeopath."

Boots' professional standards director Paul Bennett was asked about homeopathy at a parliamentary science and technology sub-committee on the 25th October: "Do they work beyond the placebo effect?" He replied, "I have no evidence before me that they are efficacious and we look very much for the evidence to support that."

I think it's unlikely that Boots don't know where to look for medical evidence. So what we're being told by Boots' professional standards director is that they've looked around, found evidence - but he hasn't found any that show homeopathy to work.

He was asked to clarify with the line, "You sell them, but you don't believe they are efficacious?" He replied, "It's about consumer choice for us."

If it is about consumer choice, I personally believe that Boots should be ensuring that their consumers are properly informed to make a choice. Their labels should clearly state "the best evidence shows that these products work no better than placebos." But their labels don't say that. The information on their shelves makes claims such as "Relieves the symptoms of a dry painful cough." Selling this quackery may well be about consumer choice. Making these claims of efficacy is most certainly not.

Is this likely to lead you to “Trust Boots”?

Homeopathy Maths Quiz: My Answers

Here are the answers to my previous maths quiz. At the end, I've added some notes including an argument showing the "memory of water" idea spouted by homeopaths to be invalid.

1. What is the probability of there being a single molecule of active ingredient in a 30C homeopathic remedy? Assume no contamination and pure water.

Molar mass of water = 18.01528 grams.
1 drop of water approx = 0.05 grams.
=> 1 drop of water = 0.05/18 = 0.0027 moles
=> 1 drop of water = 6 * 10^23 (Avogadro constant) * 0.0027 = 1.66*10²¹ molecules

Number of molecules in a 30C preparation:
= 1.7x10²¹ (molecules in a drop) / 100³⁰ (level of dilution) = 1.7*10^-39

As this is less than one, it is the probability of finding a molecule.

Answer: 1.7*10^-39

2. What is the probability of winning the National Lottery 5 weeks in a row. You get one ticket per week of course.

There are 6 balls drawn out of 49 and you can pick 6 numbers.

Probability that your 1st number will match any one of the 6 drawn = 6/49
Probability that your 2nd number will match any one of the remaining 5 drawn = 5/48
Probability that your 3rd number will match any one of the remaining 4 drawn = 4/47
Probability that your 4th number will match any one of the remaining 3 drawn = 3/46
Probability that your 5th number will match any one of the remaining 2 drawn = 2/45
Probability that your 6th number will match any one of the remaining 1 drawn = 1/44

Probability that all 6 match = 6/49 * 5/48 * 4/47 * 3/46 * 2/45 * 1/44 = 7.15 x 10-8

Or, about 1 in 14 million.

Probability of winning 5 weeks in a row = (7.15x10^-8)⁵ = 1.87 x 10^-36

3. Which is more likely?

Comparing 1.7*10^-39 and 1.87 x 10^-36, you can see that winning the national lottery 5 times in a row is about 1,000 times more likely.

Unless of course, there was some contamination during the process.

4. How much would it cost to buy enough pills that you'd expect to have one molecule of active ingredient? Note: At Boots, they're about £5 for 84 pillules.

To get one molecule, you'd need 100³⁰ water molecules (10⁶⁰).

Molar mass of water = 18 grams.

10⁶⁰ molecules would therefore weigh 18x10⁶⁰/6x10²³ = 3.0 × 10³⁷ grams

One drop of water weighs approx 0.05 grams

So you'd need 3.0 × 10³⁷ / 0.05 = 6 x 10³⁸ pills

At £5 for 84, that will cost 5/84 * 6 x 10³⁸ = £3.57 * 10³⁷

A Trillion is 10¹². Trillion Trillion Trillion = 10³⁶

So that's about 35 Trillion Trillion Trillion pounds.

Other Notes

David P made a good point when he pointed out that the mother tincture may not be pure. Obviously the mathematics above assumes it is.

Another point I realised while I was doing this is that there is another argument here against the "memory of water" bollocks" spouted by homeopaths.

At 12C, there are no molecules of the mother tincture remaining. So the only molecules in the final preperation that could have been in the same mix as any of the original ingredient must come out of this mix.

So by the time you get to 24C, there are not only no molecules of original ingredient left, but there are no molecules of water that have ever been in the same mix as the original ingredient left.

Even the water has memory argument therefore breaks down at dilutions beyond 24C. At best, homeopaths would need to argue that water not only has memory, but that water is capable of passing this memory on.

Are homeopaths going to come to the conclusion that a 30C remedy works because the water contains the memory of a rumour passed on by other water molecule that remembers the mother tincture?

A quick maths quiz

Here's a quick maths quiz. Post your answers, ideally with your working and I'll be able to see how well they compare to mine.

1. What is the probability of there being a single molecule of active ingredient in a 30C homeopathic remedy? Assume no contamination and pure water.
2. What is the probability of winning the National Lottery 5 weeks in a row. You get one ticket per week of course.
3. Which is more likely?
   
4. How much would it cost to buy enough pills that you'd expect to have one molecule of active ingredient? Note: At Boots, they're about £5 for 84 pillules.

I'll post my answers tomorrow.

The CNHC wishes to place on formal record their thanks to Simon Perry

When the Complementary and Natural Healthcare Council (CNHC) decided to start letting in reflexologists, I started sending in complaints about them on the same day that they joined for claiming to treat disease with magic foot massages.

The CNHC has now upheld my complaints, asked the reflexologists to stop making unjustifiable claims, and informed me of their intention to contact all registered members to issue advice to all registered practitioners.

Oh, and they formally placed on record their thanks to me for "bringing this matter to their attention".

The CNHC’s Code of Conduct, Performance and Ethics states:

15. You must follow CNHC guidelines in relation to advertising your services
Any advertising you undertake in relation to your professional activities must be accurate. Advertisements must not be misleading, false, unfair or exaggerated. You must not claim that your personal skills, equipment or facilities are better than anyone else’s.
If you are involved in advertising or promoting any other product or service, you must make sure that you use your knowledge, healthcare skills, qualifications and experience in an accurate and professionally responsible way. You must not make or support unjustifiable statements relating to particular products or services. Any potential financial rewards to you should be made explicit and play no part at all in your advice or recommendations of products and services that you give to patients, clients and users.

The key line in that paragraph is:

You must not make or support unjustifiable statements relating to particular products or services.

Now have I missed something here? The whole point of Complementary health is that you can make claims of efficacy without justification. Don’t get me wrong, I personally believe justification to be extremely important. My point is simply that the regulatory body is exclusively for practitioners who don't share this view.

So I started my little project. By searching for practitioners on the CNHC web site each day I could find out who joined. I actually wrote a computer program to do this as it takes multiple searches to get all the results. I would then manually check their web sites to see what was being claimed. If they made any unjustifiable claims, I reported them via the CNHC’s complaints procedure. I knocked these complaints out in a few minutes – quick enough to get the point across but so hastily that I failed on my first complaint to correct a copied & pasted spelling error and even added my own grammar hiccup at the end.

The ad suggests that reflexology is suitable for treating babies with colic, IBS and arthritus. She also claims to have experience in treating fertility issues. There is no reliable evidence to suggest that reflexology is capable of treating this issues.

But even with the bad English, it was sufficient to make the point: if the CNHC is going to regulate healthcare then it needs to deal with the question of efficacy.

Yesterday I received a call from the Maggie Dunn, the CNHC’s Chief Executive Officer to update me on the status of my complaints.

The CNHC had received evidence from the practitioners to defend their claims. They had also been in touch with the Advertising Standards Agency. The investigative committee met on Tuesday 24th November to discuss the cases.

They decided that my complaints were indeed covered by paragraph 15 of the code of conduct. All fourteen of my complaints were upheld. The practitioners will now be told to stop making these claims.

Sadly however, the CNHC decided that fitness to practice was not impaired because the unjustifiable claims were not made deliberately. The CNHC has a number of “Profession Specific Boards”. Someone from the board relating to reflexology had advised the investigative committee that it is likely the practitioner had been trained to believe that they could treat these diseases.

Now while I do not find it at all surprising that the practitioner was trained this way, I still take issue with this decision. If a practitioner has undergone training that tells them they can treat specific diseases for which there is no evidence then the practitioner has not undergone proper training. An untrained or poorly trained practitioner is surely unfit to practice.

What’s more positive however, is what else the CNHC now plans to do. It makes no sense for the CNHC to allow new registrants to join, only to be immediately reported by me. Instead, I’m told, the CNHC will now look at the evidence and provide advice in advance.

The evidence review will go beyond reflexology; it will extend to all of the disciplines covered by the CNHC.

The CNHC will then be contacting all registrants to explain what they are allowed, and not allowed, to claim.

I confirmed with Maggie that this advice will not solely relate to advertising. I was told that the advice will make clear that practitioners are not permitted to make these claims within the day to day interactions with their clients.

I also expressed a concern to Maggie over the training received by the practitioners. There are undoubtedly many courses out there teaching that reflexology is an efficacious treatment for many diseases. Would the CNHC be doing anything about these courses?

Maggie told me that as a regulator, the CNHC sees it as their duty to get in contact with alternative health course providers and authors. Given the nature of my original complaint, I expect this will enforce the view that claims must be justifiable.

What would a course on reflexology consisting only of justifiable claims cover exactly? How to spell reflexology?

This is so important, and so surprising I feel I need summarise in bullet points:

• CNHC will tell practitioners to remove claims they cannot justify.
• CNHC will conduct a review of evidence base for regulated therapies.
• CNHC will contact all registrants to instruct them not to make claims without justification.
• CNHC will contact complementary health course providers and authors to instruct them not to make claims without justification.

It is my view that adhering to the CNHC’s guidelines will make it impossible to practice complementary medicine.

Could this the end of the CNHC? It would be hugely ironic if forcing its members to act ethically became the cause of its demise.

Finally, Maggie told me that the investigations committee had decided that they wished to “place on formal record their thanks to Simon Perry for bringing this matter to their attention.”

You’re welcome.

[Original] The CNHC wishes to place on formal record their thanks to Simon Perry

Having taken some very fine advice from someone I greatly respect, I now realise that this article wasn't very good. Well, it was rubbish. I've rewritten it here without taking 14 paragraphs before I get to the point - so read that one instead.

The Complementary & Natural Healthcare Council, or CNHC, started its operation of registering practitioners at the beginning of 2009. Its stated key purpose is to:

“protect the public by means of regulating practitioners on a voluntary register for complementary and natural healthcare practitioners.”

Practising evidence-based medicine has some difficult constraints. Firstly, you need to be able to show your intervention to be effective. It’s considered unethical to just make up ideas ad-hoc and market them as an effective medical intervention. Secondly, in order to avoid a repeat of the thalidomide disaster, you need to be able to demonstrate that your intervention is safe.

But all this is very difficult. It requires a lot of training. It means you can’t get your products and services to market without checking them. But what if there was a way we could avoid the hassle of checking the evidence for efficacy? What if there was a way we could practice without checking our interventions were safe? What if instead of going through the trouble of medical training, we could take a part-time evening course at a local college and be guaranteed a pass because the course content consists of no actual knowledge?

Welcome to the world of Complementary Healthcare.

Now I don’t think I’m the first person to point out that if you are going to regulate any type of healthcare, then the fundamental points you need to cover are (i) ensuring interventions work, (ii) ensuring interventions are safe, and (iii) ensuring practitioners are adequately trained.

But this is already subject to statutory regulation. It’s what we call medicine. The whole point of Complementary health is that the practitioners can’t be bothered with all that.

What on earth does the CNHC intend to regulate?

The CNHC’s Code of Conduct, Performance and Ethics states:

15. You must follow CNHC guidelines in relation to advertising your services
Any advertising you undertake in relation to your professional activities must be accurate. Advertisements must not be misleading, false, unfair or exaggerated. You must not claim that your personal skills, equipment or facilities are better than anyone else’s.
If you are involved in advertising or promoting any other product or service, you must make sure that you use your knowledge, healthcare skills, qualifications and experience in an accurate and professionally responsible way. You must not make or support unjustifiable statements relating to particular products or services. Any potential financial rewards to you should be made explicit and play no part at all in your advice or recommendations of products and services that you give to patients, clients and users.

The key line in that paragraph is:

You must not make or support unjustifiable statements relating to particular products or services.

Now have I missed something here? The whole point of Complementary health is that you can make claims of efficacy without justification. Don’t get me wrong, I personally believe justification to be extremely important. My point is simply that the regulatory body is exclusively for practitioners who don't share this view.

So I started a little project. The CNHC’s web site allows you to search for practitioners. Each day, I would look at which new practitioners had joined, check their web sites and report them if they made any unjustifiable claims. If they did, I reported them via the CNHC’s complaints procedure. I knocked these complaints out in a few minutes – quick enough to get the point across but so hastily that I failed on my first complaint to correct a copied & pasted spelling error and even added my own grammar hiccup at the end.

The ad suggests that reflexology is suitable for treating babies with colic, IBS and arthritus. She also claims to have experience in treating fertility issues. There is no reliable evidence to suggest that reflexology is capable of treating this issues.

But even with the bad English, it was sufficient to make the point: if the CNHC is going to regulate healthcare then it needs to deal with the question of efficacy.

I intended to send these in every day as new members joined. My persistence lasted about 5 days – it takes time and is very boring work. I drew it back to looking every week, but by that time there were so many members that the task of checking was daunting. In total, I think I only complained about 14 practitioners.

These were the first complaints that the CNHC has received. At this time of writing, I believe I am the only person ever to have complained to the CNHC.

Yesterday I received a call from the Maggie Dunn, the CNHC’s Chief Executive Officer to update me on the status of my complaints.

The CNHC had received evidence from the practitioners to defend their claims. They had also been in touch with the Advertising Standards Agency. The investigative committee met on Tuesday 24th November to discuss the cases.

They decided that my complaints were indeed covered by paragraph 15 of the code of conduct. All fourteen of my complaints were upheld. The practitioners will now be told to stop making these claims.

Sadly however, the CNHC decided that fitness to practice was not impaired because the unjustifiable claims were not made deliberately. The CNHC has a number of “Profession Specific Boards”. Someone from the board relating to reflexology had advised the investigative committee that it is likely the practitioner had been trained to believe that they could treat these diseases.

Now while I do not find it at all surprising that the practitioner was trained this way, I still take issue with this decision. If a practitioner has undergone training that tells them they can treat specific diseases for which there is no evidence then the practitioner has not undergone proper training. An untrained or poorly trained practitioner is surely unfit to practice.

What’s more positive however, is what else the CNHC now plans to do. It makes no sense for the CNHC to allow new registrants to join, only to be immediately reported by me. Instead, I’m told, the CNHC will now look at the evidence and provide advice in advance.

The evidence review will go beyond reflexology; it will extend to all of the disciplines covered by the CNHC.

The CNHC will then be contacting all registrants to explain what they are allowed, and not allowed, to claim.

I confirmed with Maggie that this advice will not solely relate to advertising. I was told that the advice will make clear that practitioners are not permitted to make these claims within the day to day interactions with their clients.

I also expressed a concern to Maggie over the training received by the practitioners. There are undoubtedly many courses out there teaching that reflexology is an efficacious treatment for many diseases. Would the CNHC be doing anything about these courses?

Maggie told me that as a regulator, the CNHC sees it as their duty to get in contact with alternative health course providers and authors. Given the nature of my original complaint, I expect this will enforce the view that claims must be justifiable.

But what would a course on reflexology consisting only of justifiable claims cover exactly? How to spell reflexology?

This is so important, and so surprising I feel I need summarise in bullet points:

• CNHC will tell practitioners to remove claims they cannot justify.
• CNHC will conduct a review of evidence base for regulated therapies.
• CNHC will contact all registrants to instruct them not to make claims without justification.
• CNHC will contact complementary health course providers and authors to instruct them not to make claims without justification.

It is my view that adhering to the CNHC’s guidelines will make it impossible to practice complementary medicine.

Could this the end of the CNHC? It would be hugely ironic if forcing its members to act ethically became the cause of its demise.

Finally, Maggie told me that the investigations committee had decided that they wished to “place on formal record their thanks to Simon Perry for bringing this matter to their attention.”

You’re welcome.

Edzard Ernst shows Society of Homoeopaths break their own code of conduct

In this excellent article in the BMJ, Zosia Kmietowicz interviews Edzard Ernst on the Society of Homoeopaths breaking their own code of conduct. Similar observations were made on Gimpyblog back in 2007. Apparently they didn't learn too much from that then.

Homoeopath society breaks own ethics code by making speculative claims on website, says expert Zosia Kmietowicz

The Society of Homeopaths is in breach of its own code of ethics by posting "speculative," "misleading," and "deceptive" statements on its website, claims a leading UK expert in complementary medicine.

Edzard Ernst, professor of complementary medicine at the Peninsula Medical School in Exeter, identified numerous statements on the society’s website that he claimed could be seen as contravening the code. He was writing in the International Journal of Clinical Practice (doi:10.1111/j.1742-1241.2009.02249.x).

The code of ethics, which runs to 23 pages, sets out the rules that the society expects its members to abide by. These state that advertising should not make claims to "cure named diseases" or be "false, fraudulent, misleading, deceptive, extravagant or sensational." It adds that "all speculative theories will be stated as such and clearly distinguished."

However, a review of some members’ websites showed a series of violations of the code that led Professor Ernst to scrutinise the society’s own website.

Despite there being no good clinical evidence to substantiate such claims, says Professor Ernst, the society’s website carried statements claiming that homoeopathy can help with various symptoms and illnesses, including fever, sore throat, toothache, arthritis, eczema, asthma, anxiety, insomnia, chicken pox, erectile dysfunction, and prostate problems.

"In my view, they [the statements] do ‘expressly or implicitly’ claim ‘to cure named diseases,’" writes Professor Ernst. "If this is so, they violate the SoH’s [Society of Homeopath’s] own Code of Ethics."

He concludes, "If the SoH wants its members to behave ethically it should evaluate its own website carefully and deliberate whether it is responsible for a professional organisation to make health claims which are not supported by the current best evidence."

Professor Ernst told the BMJ that advertising by members of the Society of Homeopaths "should be more than lip service to evidence based medicine, otherwise it is confusing and potentially harmful."

Paula Ross, the society’s chief executive, said she was grateful to Professor Ernst for highlighting his concerns and that the society would be investigating the concerns and making amendments "where appropriate."

BMJ 2009;339:b4605

The General Chiropractic Council is knowingly and deliberately violating its own code of practice

The General Chiropractic Council is knowingly and deliberately violating its own code of practice and continuing to mislead the very patients it is meant to protect.

My previous post detailed how the General Chiropractic Council resolved my Advertising Standards Authority complaint against them informally. I also noted that as yet, the GCC has not removed their Patient Information Leaflet from their web site.

About a week after the informal resolution was made (but before it was published), I spoke to the ASA on the telephone about the fact that they were continuing to make these unsubstantiated claims. A concerned ASA voice told me:

"We would have hoped they would have taken this down by now."

So on the 6th October I emailed the GCC to ask their intentions:

"I notice that despite your informal resolution with the ASA, that the text still appears on your patient information leaflet here: http://www.gcc-uk.org/files/link_file/WhatCanI_142_5(Web-Version).pdf

Are you intending to take down or change this leaflet?"

And on the 8th, I received a reply in the post:

I emailed the ASA by email to get their take on this:

"I contacted the GCC following my finding that they had not removed the Patient Information Leaflet from their web site. I had a rather surprising reply from them this morning. They said that they will take it down in reasonable time - and suggested that this would happen once they had taken the time to re-write the document and translate it into several languages.

This is shocking. Surely it makes sense for them to take it down now if it breaches ASA standards - or not at all if it doesn't. Surely while they are re-printing they should not be continuing to distribute the material?

Can you clarify the ASA's position on this?"

And the ASA's reply was fairly clear:

"We’d normally expect an advertiser to implement the changes as soon as is 'reasonably practicable' (bearing in mind the time involved in printing new leaflets).

However, if it’s a leaflet on a website then it should be taken down as soon as possible."

So the ASA (rather unsurprisingly) agrees with me that it is unreasonable to continue to make unsubstantiated claims solely on the grounds that you haven't got around to writing and translating anything honest yet.

Based on the informal resolution and the above text from letters and emails, I can't draw any conclusion other than:

• The Chief Executive of the GCC is fully aware that its Patient Information Leaflet violates ASA guidelines.
• The Chief Executive of the GCC is aware that this leaflet is continuing to be made available on their web site.
• The Chief Executive of the GCC is in no rush to do anything about it.

How can the GCC be expected to regulate the chiropractic profession when it knowingly and deliberately violates the very guidelines it is meant to be enforcing?

I think it's time for a complaint against the GCC itself.

Hopefully they'll take my complaint seriously, clean up the regulatory body, start properly regulating the chiropractors and move towards a future of evidence-based chiropractic.

Then I can get back to my game of World of Warcraft.

General Chiropractic Council to Change Patient Information Leaflet

My complaint to the Advertising Standards Authority about the General Chiropractic Council’s Patient Information Leaflet has now gone through the ASA’s process.

The ASA has managed to deal with my complaint as an “Informally Resolved Complaint” rather than pushing it through to a formal adjudication.

This is a very interesting outcome.

What this means is that the General Chiropractic Council has withdrawn the claims as soon as they were approached and asked the ASA’s guidance in how they can make their advertising comply. There is an important point to note here: if the General Chiropractic Council believed they had the evidence to back up the efficacy of using chiropractic as a treatment for asthma, headaches, migraine and infant colic – then they simply could have produced it.

The ASA would have assessed this for them free of charge and either upheld the complaint asking them to remove the advertising, or not upheld the complaint. There is only one reason for backing off from the complaints: the GCC must have appreciated that that they simply do not currently have the evidence.

This is a significant change, and has huge implications for the circa 600 complaints currently being handled by the GCC.

By backing off and removing their claims before the ASA investigates, the GCC is acknowledging that even their loosely worded, slightly ambiguous leaflet (text below) is in breach of ASA guidelines.

There is some evidence, though more research is needed, that you may see an improvement in some types of:
• asthma
• headaches, including migraine
and
• infant colic.

If the GCC believes this loosely worded text to be in breach of ASA guidelines, then they must also believe that every complaint made to the GCC surrounding this subject is valid.

Am I being too optimistic in anticipating a vast number of guilty verdicts against chiropractors in the forthcoming months?

It also brings up a second potentially interesting outcome. If you’ve been following this blog, you will be aware of the letter that the GCC sent to Trading Standards in defence of their members. The advice given in that letter includes the exact text within the patient information leaflet that I complained about.

Will the GCC now follow that letter up with another saying that they are now withdrawing that claim? I will be putting that question to them.

Perhaps I'm being a bit optimistic – especially considering that more than a week after agreeing to informally resolve the complaint, the patient information leaflet remains on their website in its original form.

I am now beginning work on my second ASA complaint about the same Patient Information Leaflet.

While you're in the mood for chiro woo, I highly recommend Zeno's post on his recent ASA complaint - published at the same time.

The public isn't interested in why the GCC is trying to mislead Trading Standards

I received the GCC's response to my Freedom of Information Act Inquiry yesterday evening. The GCC avoided responding to almost every point. You can read the full text of their response here and here.

Two points stand out. Firstly, I was very clear in asking for all previous versions of the document, yet they only returned the final version without specifically stating that it was the only version.

Secondly, and more interesting is their response to my request for copies of internal communications discussing the content of the letter.

The emails are considered to be exempt under S36 of the FOIA because the disclosure of the information would, or would be likely to, inhibit the free and frank exchange of views for the purposes of deliberation. The GCC considers it is important that an exchange of views can take place between relevant parties to allow for proper space for deliberation without the exchange being made public. Additionally, the GCC needs to be able to think through the implications of particular options and consider how to properly approach the trading standards offices. Consequently, the public interest test has been applied by the "qualified person" at the GCC and the decision was that the public interest in withholding the information outweighed the public interest in disclosure and therefore it was considered appropriate to rely on FOIA s36 in this case.

Now the only way I can see this inhibiting the free exchange of ideas is if those ideas are not in the public interest. If those ideas included strategies for deliberately misleading trading standards by misrepresenting evidence, then you'd expect that the free exchange of those ideas may be inhibited. But then I'd have thought that inhibiting those ideas was very strongly in the public interest.

But if the ideas exchanged were how best to represent the evidence and how important it is to be honest with trading standards, then it is important that these ideas are not inhibited. But then honest ideas that are genuinely intended to help the public are not likely to inhibited by the prospect of them being made public.

Now I am willing to accept that some of the GCC's staff may have been less than complimentary when referring to me in their internal communications. And I don't have a problem with that.

Paul Ghuman of the GCC, I make you an offer to protect your staff from embarrassment. Pop those communications over to your lawyers at Capsticks and let them know what you want to remove. Then ask them to send the censored copy to me, declaring that nothing material to the decision making process was removed.

If you'd prefer not to do this, I'll ask my MP to send the next request for information. He has been very helpful before when I have been campaigning against quackery.

His next open bureaux is at 5pm on the 18th September.

Sara Stevens and the Ultra-Woo Allergy Test

I visited Sara Stevens of "The Complementary Health Team" in Blaby back in May. I've been incredibly slow to blog this, but just realised that blogging my letter of complaint in full would be much better than writing anything new.

Enjoy!

Dear Ms Stevens,

I visited your premises in Blaby on the 7th May 2009 around 5pm for what was sold to me as an “allergy test”.

Having thought about the tests I received, I have got quite suspicious of the methods used and am not convinced that they could work.

To summarise your methods:

• You took a homeopathic preparation of an allergen and put it into my left hand.
• I held it close to my stomach and outstretched my arm.
• You pushed my arm down.
• If my arm moved easily you deduced that I was allergic or sensitive to the preparation from which the homeopathic remedy was made. If not, you deduced that I was not allergic or sensitive.

The problems I am having difficulty overcoming are as follows:

• Homeopathic solutions are typically dissolved to the point where there is none of the original substance remaining. With no substance remaining, I see no difference whatsoever between the 35 preparations you presented me with. How could this work without a chemical difference between the solutions?
• With the preparations contained within glass phials, my body did not even come into contact with the pills. How could my body produce a reaction against a chemical it did not come into contact with?
• I can find no reliable evidence to suggest that coming into contact with an allergen near your stomach reduces your strength in a different part of your body.
• You merely pushed my arm down to subjectively measure the force. This is obviously a completely inaccurate way of measuring resistive force.

To summarise, you attempted to test me for an allergy by pushing my arm down while I didn’t touch a preparation that probably contained no trace whatsoever of an allergen. What evidence do you have to demonstrate that this test actually works?

Following the allergy test, you then gave me two further “tests”. The first, you claimed, was to assess the proportion of “bad bacteria” to “good bacteria” in my body. You did this by counting in tens (0, 10, 20 etc) up to 100 while repeatedly pushing down my arm. After assessing it was weakest between the times when you said “10” and “20”; you then pushed down my arm while counting between 10 and 20. From this, you deduced that my “Candia Level” as you called it, was 14%.

What evidence do you have to demonstrate that this second test actually works?

You then carried out a further “test” to find out what “good bacteria” I needed to buy to restore the balance. You did this by repeatedly pushing down my arm whilst pointing at descriptions of bacteria in a book. You then recommended I take “acidobifidus”.

What evidence do you have to demonstrate that this third test actually works?

I’ve read a fair bit about these tests online and opinion seems to be split. Practitioners of Applied Kinesiology appear to endorse the test, while the common consensus, including all reputable scientific studies, dismiss the practice as pseudo-science with no evidence that it produces accurate repeatable results.

If you do have good evidence that this test works, could you send it to me please? If you do not, I believe that you are operating an unfair commercial practice under the 2008 consumer protection regulations and would like a full refund.

If you do not have reliable evidence for this test, I assume you will from now on comply with the 2008 consumer protection legislation and discontinue your applied kinesiology service. Can you clarify if this is the case?

Regards,

Simon Perry