THE DESKTOP GUIDE TO COMPLEMENTARY AND ALTERNATIVE MEDICINE

The aim of this desktop guide, possibly the first of its kind to appear in this country, is – I quote - to turn the spotlight of scientific enquiry and thorough research onto 64 kinds of complementary and alternative therapies, assessing them on the basis of evidence, not opinion, and weighing up their benefits and risks. Its editor, Professor Edzard Ernst, is the Director of the Department of Complementary Medicine at the University of Exeter, where his three associate editors also work under him.

From the academic and publishing aspect the book is impeccable extensively researched, and reviewed by international experts. In clear, well laid-out sections it deals with the main areas of complementary and alternative medicine, such as diagnostic methods, therapies, herbal and non-herbal medicines, and conditions ranging from AIDS to tinnitus. It's also easy to use and pleasant to handle. So far, so good. But that's where the good things end.

Having worked my way through the book, I got the impression that Prof. Ernst's attitude to his subject is negative, fault-finding and patronising. His is the conservative Cartesian approach well known from allopathic medicine which regards body and mind as two separate entities, notwithstanding the findings of psycho neuro-immunology, and the growing acceptance of holism in medicine. His interest is centred on scientific rigour and hard evidence, and of course there is nothing wrong with either, provided that the rigour doesn't turn into rigidity and the emerging evidence is presented fairly and without negative bias. And this is where the book falls down.

Let me explain. Each therapy and remedy is presented with its background, traditional concepts, scientific rationale, and the conditions it is frequently used for. Then comes the clinical evidence, based on randomized clinical trials (RCTs) or controlled clinical trials (CCTs). Next, under the heading of "Risks" we get contraindications, precautions/warnings, adverse effects, interactions and quality issues, important details any conscientious practitioner must possess. However, the concluding Risk-benefit assessment, the raison d'etre of this work, manages to put down the therapy or remedy, even if a sufficient number of RCTs or CCTs have produced favourable results. There is no out-of-hand dismissal, only the subtle suggestion that the subject under review isn't particularly useful. This is done with carefully chosen phraseology, famously described by Alexander Pope as "Damn with faint praise", easily missed in the wealth of material on offer.

"Conclusion uncertain due to unclear statistics", we read. Or, although the most rigorous RCTs come out in favour of cranberry juice against urinary infections, "Due to the poor quality of these studies, the authors question the reliability of these findings." Peppermint oil for irritable bowel syndrome has been shown to have positive effects, but "the evidence is not convincing. The possibility of adverse effects exists, which may outweigh any possible benefits" (added emphasis). And again, "Methodological limitations of the primary data" or "Due to weaknesses in study design" crop up whenever a scientifically respectable review shows positive results.

Considering that in his preface Prof. Ernst came out strongly in favour of evidence-based, as opposed to opinion-based conclusions, it's surprising that he uses vague opinions against clinical evidence supplied by reliable sources.

However, that's not the only surprise. Amazingly diet, nutritional medicine, vitamins, minerals and lifestyle advice don't figure in the book, because, according to Prof. Ernst, they are more mainstream than complementary and alternative (CAM) therapies. Where on earth is the evidence for that? The average GP's knowledge of these very subjects, the truly avant-garde tools of prevention and healing, is infinitesimal, and the lethal awfulness of hospital food proves the medical profession's profound ignorance of the importance of nutrition. While that state of affairs persists, food as medicine remains firmly on the CAM side of the watershed.

The only reference I found to diet was in connection with the CAM approach to cancer prevention. Although a big British study has shown that vegetarians fared much better than meat-eaters in cancer death rate and general mortality, all we are told is that strict vegetarianism can lead to malnutrition: "Sensible advice therefore could be to reduce meat (particularly red meat) consumption without pursuing a strict vegetarian diet." One can't help wondering whether Prof. Ernst knows the difference between vegetarian and vegan, or whether he has the faintest idea about the huge healing potential of a good organic vegetarian regime.

Some other warnings are equally bizarre. Bach flower remedies "contain alcohol", Autogenic Training may cause "unusual sensations in the body", learning the Alexander Technique "requires commitment and a great deal of practice by the student" (so does learning to play the piano), Music Therapy "should not exceed 90 dB, as this may lead to hearing impairment". Herbal medicines fail the safety requirements, because many are contaminated with chlorinated pesticides, insecticides and herbicides (just like many non-organic fruits and vegetables at the greengrocers). But the recurring, all-embracing indirect risk of all CAM therapies seems to be that treatment by practitioners without medical training may delay conventional diagnosis or treatment. In other words, like it or not, CAM is here as a "strong consumer-driven movement", but it can never claim equality with orthodox medicine.

Having explored CAM therapies over many years, I felt that what this prodigiously researched and lucidly presented material lacked were the very things that made CAM different from orthodox medicine, namely its spirit of enquiry and its acknowledgement of the non-material factors of health, healing and human life. I had to work my way to P.395, to a chapter entitled "Why Patients Use Complementary and Alternative Medicine", to find some comfort. There, among possible factors contributing to CAM use I found philosophical congruence between the principles of certain therapies and patients' beliefs, the spiritual dimension, emphasis on holism, an active role for the patient and natural treatments. An American study is quoted which lists CAM's association with nature, the long intellectual traditions and sophisticated philosophies of many therapies, and the acceptance of spirituality as reasons for its attraction. The role of the therapeutic relationship is also emphasized. At the risk of being accused of feminist bias, I must add that this chapter was written by the only female member of the team.

To be fair to Prof. Ernst, he admits that "some forms of CAM are frequently supported by evidence and therefore do have a role in modern health-care." It's rather a pity that he does so in a brief, easy-to-miss postscript on P. 423.

His book appears at a time when conventional medicine is in a multi-faceted crisis, the profession has lost its halo, a high proportion of hospital patients suffer from iatrogenic, i.e. doctor-induced illness, a sizeable chunk of the population is growing obese and accordingly sick, and the NHS can't cope. It is the moment when anything that might open up different paths and strive to heal our many ills through alternative methods should be examined with more goodwill, more imagination, and less insistence that doctor knows best. After all, if he or she did, patients wouldn't vote with their feet, the use of CAM in developed countries wouldn't grow by leaps and bounds, and the US Government wouldn't spend ever-increasing sums - 68.5 million dollars in 1999 - on new centres for Complementary and Alternative Medicine. The times they are certainly a-changing.

Unfortunately this book will do more harm than good to the better understanding and wider application of complementary and alternative medicine. The overworked GP, confronted with a well-informed patient requesting a certain non-conventional treatment will quickly glance at its risk-benefit assessment, find a typically downbeat conclusion ("the evidence is not sufficiently strong to allow any firm recommendation") and dismiss the whole idea. My only hope is that there will be enough physicians who recognize the negative drift of much of the Desktop Guide, just as this not medically qualified reviewer has done, and decide for themselves how far they accept its conclusions.