Edzard Ernst and Simon Singh

Nature magazine raised concern that the dogmatism of Edzard Ernst and Simon Singh "mirrors that of the proponents of alternative therapies, leaving each position as entrenched as ever." Yet, if the analysis by Nature had probed deeper, it would have uncovered logical fallacies and fundamental errors in reasoning which render the book Trick or Treatment? unhelpful at best - and at worst, a dangerous obfuscation to medical progress in tackling chronic lifestyle diseases. 

Note that both Simon Singh and Edzard Ernst are champions for the group ''Sense About Science''. An investigation by The Times revealed that Sense About Science took donation money from Coca-Cola, and then failed to disclose conflicts of interest when casting doubt on the negative health effects of sugar. Sense About Science - the group which helped bolster the writing careers of Simon Singh and Edzard Ernst - is little more than a lobby group for industry interests. Links:

1.    https://www.thetimes.co.uk/article/charity-cast-doubt-on-sugar-deaths-but-failed-to-reveal-coca-cola-link-36d3pjq6zlk

2. https://theintercept.com/2016/11/15/how-self-appointed-guardians-of-sound-science-tip-the-scales-toward-industry/

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I will succinctly outline the three core problems in Ernst's and Singh's reasoning:

1. The Straw Man. Before putting pen to paper, Ernst and Singh commit a classic Straw Man fallacy by constructing and defining ''the problem'' which they believe exists - and then spending the rest of the book burning down this Straw Man. Ernst and Singh are free to criticise alternative medicine as much as they want - but they don't get to define it. Yet, this is precisely what they do - ignorantly restricting the definition of alternative medicine according to their own - misguided - conception of it, presuming everyone else in the world defines it in the same way, and then proceeding from there.  

According to Ernst and Singh, the test of alternative medicine boils down to using single herbs, single supplements, or single therapy modalities (e.g. acupuncture) and comparing their efficacy in RCTs (randomly controlled trials) to placebo or proven pharmaceutical drug treatments. Firstly, serious and respected alternative health practitioners would never consider treating a chronic disease (e.g. type-2 diabetes, heart disease, depression, or IBS) using one single herb, or one single supplement, or one single therapy. The best alternative and integrative health doctors (whose standard Ernst and Singh should use as the benchmark to honestly test the claims of alternative medicine) would use a wide range of treatment modalities in combination. Ernst and Singh might protest that you cannot compare the efficacy of 1 drug to a protocol of, say, 50 alternative treatment modalities in combination - which could include: optimum and targeted diet regime, supplementation with key vitamins, minerals and phyto-nutrients (including hormesis-inducing compounds like sulforaphane and NMN (see David Sinclair)), hot and cold therapies (saunas and the Wim Hoff therapies), periodic fasting, psychotherapy, mindfulness and breathing techniques, relaxation and massage, exercise regimes, photo-therapy and sound therapies... and a whole raft of others, even including emotional work with psychedelic substances. 

But, why not? The only thing that matters is outcome for the patient. One alternative treatment might not be as effective as one drug, but how would 50 alternative treatments administered concurrently compare with one drug? Ernst and Singh might raise the issue of cost - but you could provide as many alternative treatments to match the cost of the one mainstream treatment afforded on the NHS. Some drugs or therapies on the NHS cost £50,000 per year. That's a lot of alternative treatments. 

The issue of a ''fair'' trial is a Red Herring. RCTs are flawed by design in this respect, because they work best when testing one drug or treatment against another (or placebo) - and this only serves to betray the absurd reductionism and bias which forms the philosophical bedrock of mainstream medicine. Furthermore, the fact that 50 drugs or conventional treatment modalities couldn't possibly be combined due to toxic overload means that conventional treatments are self-exclusory from being tested in outcome trials against more balanced, integrated approaches. 50 herbs and lifestyle strategies - even supplements(!) - could be added to someone's health protocol - but this simply is not possible for mainstream treatments -  it would be fatal due to additive side effects, interactions, and contraindications. Thus, pharmaceutical drugs perform best in very simplistic (and short-term) side-by-side RCTs, and that is why there is a strong and stubborn incentive for the drug industry and the ideology of the biomedical model to limit comparisons with alternative approaches to the randomly controlled trial - the so-called ''gold standard''.  

Ernst and Singh might dish out the usual slogan of ''alternative medicine which works is just called medicine''. But this would be dishonest. Dogmatic skeptics are loath to consider food or lifestyle initiatives as medicine (even though the definition of medicine clearly states prevention as one of its core tenets). And, indeed, if Ernst and Singh can't bring themselves to broaden their definition of medicine to encompass its entire - and legal - definition, then this only serves to substantiate the fact that their book is premised on a Straw Man - i.e. their limited and misguided view of what actually constitutes an alternative approach to mainstream medicine as practiced today. For the record - all of the approaches outlined in the third paragraph are within the remit of alternative approaches to medicine. Ernst and Singh don't intelligently define their terms, nor do they clearly outline their goals, at the beginning - and so their criticism is unscientific and essentially meaningless.  

To reiterate, there is a strong ideological incentive for RCTs to remain the standard ''gold standard'' test in medicine. One-on-one, drugs might well out-perform alternative modalities in the treatment of conditions of chronic disease, but a cross-over point would rapidly be reached in outcome trials between drugs and stacked alternative approaches due to drug side-effects, interactions, and contraindications - not to mention cost, as well as other negative externalities - such as opportunity cost to the patient.     

2. In their derision of many alternative remedies and therapies for ''not being better than placebos'', Ernst and Singh make a fundamental error. They assume a standard placebo effect size, and then compare treatment effectiveness to this unquantified and nebulous ''placebo effect''. In truth, placebo effects vary from the very weak to the very strong. Pharmaceutical drugs are tested against one of the weakest placebos - a ''dummy'' pill, whereas acupuncture treatment is tested against one of the strongest forms of placebos - a sham acupuncture treatment! Ernst and Singh are correct that acupuncture does no better than placebo in randomly controlled trials, but the placebo which acupuncture is being tested against is a very strong form of placebo - i.e. all the adornments and ritual of an elaborate healing treatment, deep care and attention from the practitioner, and the physical and tactical sense that the patient is really getting the acupuncture needles inserted as would happen in a genuine treatment. There is no other way to control for placebo in acupuncture trials without having the patient experience the entire acupuncture ritual itself - minus the actual acupuncture pins. So what we're left with is a treatment which works no better than itself, i.e. placebo! In other words, in order for Ernst and Singh to have considered this scientifically, they should have quantified the placebo effect strength of acupuncture - and compared this effect to the clinical effect of a pharmaceutical drug regularly used to treat a same condition. But they didn't do that.  

So, there is the possibility that a treatment modality from alternative medicine (e.g. acupuncture) that works no better than placebo could actually have an equal or bigger clinical effect than a drug that has been shown to work better than placebo. This is because the drug was tested against a relatively weak placebo, whilst the alternative treatment modality was tested against a strong placebo. 

And, of course, the strong placebo effects from many alternative treatment modalities could have additive effects to produce significant clinical effects - with none of the downsides of side-effects associated with pharmaceutical drugs. On this point of side effects, Ernst and Singh don't factor in the negative impact of side effects on the overall, long-term, effectiveness of mainstream pharmaceutical drugs. If they did, the case for alternative medicine just becomes stronger. 

3. Finally, the overarching problem with Ernst's and Singh's critique is that it lacks systems-thinking and depth of vision - i.e. it is ultimately a superficial, naïve, and unintelligent analysis which doesn't see the wood for the trees. As alluded to in the first point, Ernst and Singh embark on the intellectual trick of tackling the problem they themselves believe exists. Whilst Ernst and Singh erroneously believe that the problem boils down to the lack of efficacy of ''one alt-med herb or treatment VS one drug in RCTs'', the best alternative and integrative medical practitioners would - together with suggesting many treatments and health strategies to be used in combination - base their approach in the much deeper philosophical position of arguing from first principles in evolutionary biology (which would provide logical evidence for innovations in thinking around diet and health strategies such as sauna, cold therapy, and intermittent fasting); they would inculcate a sense of self-ownership, sovereignty, and personal responsibility regarding health; they would re-structure our medical system to be a genuine health-care system - rather than a disease-care system - and they would seek to re-orientate and enable social systems to prioritise and seek value and joy in healthy living. 

All these tenets and vision constitute the bedrock of best practice in alternative and integrative medicine. And that is the standard to which Ernst and Singh should have made their comparisons. Best practice in medicine isn't fixed - it depends on the specific ailment or prevailing set of diseases ailing society. Where infectious diseases were once rampant, the biggest problems today are chronic health conditions caused by poor lifestyle. Those who inspire people to change their lifestyle habits - be it a doctor, a Yoga teacher, a herbalist, or a politician - are those who effect the greatest medical impact. 

In an age of type-2 diabetes, heart disease, and cancers (around 50% of which are preventable), the old biomedical model becomes increasingly redundant, and scientists like Ernst and Singh naively conflate consensus and monopolisation of treatment with best practice. Just as they are not free to define alternative medicine and then burn down their Straw Man, Ernst and Singh are not free to pick and choose the diseases which alternative medicine doesn't offer much help, and then denigrate the entire field on that basis. In the name of intellectual honesty, epidemiological evidence - and good medicine - Ernst and Singh must consider the biggest diseases. Against these, alternative and integrative approaches to healthcare often far outperform conventional treatments - both in terms of absolute efficacy, and as a function of cost.  

In other words, Ernst and Singh haven't done a cost-benefit-analysis (CBA) of conventional and alternative treatments - even though decisions by national health services (e.g. the NHS in the UK) need to factor in cost into the equation to get an overall picture of a treatment's efficacy. Sadly, CBAs by the NHS don't sufficiently factor in externalities such as side effects and opportunity costs to the patient (including a reliance on drug prescriptions inculcating in the patient a lack of autonomy and self-ownership over their own health). And, worse yet, RCTs - or the so-called ''gold-standard'' in medicine which Ernst and Singh use as their benchmark for evidence of efficacy - don't factor in either CBA or the externalities of side effects and opportunity cost (among many others)! 

Yet bizarrely, Ernst and Singh are eager to factor in externalities from alternative medicine, such as obscure and rare side effects, and infections caused from acupuncture treatment - even though these are NOT the systemic and routine side effects as seen from the use of pharmaceutical drugs. This approach clearly betrays an implicit bias toward conventional medical treatment. Their blindness to the systemic problems in conventional medicine is bizarre given the published statistics on iatrogenic death in mainstream medicine - which is the third biggest killer in the US, accounting for up to 200,000 deaths annually. It could be argued that mainstream medicine is actually the leading cause of death in the western world - (given the prevalence of chronic disease from lifestyle factors) - simply because medicine shows extreme negligence in prioritising prevention of such diseases. Further, the BMJ found in its analysis of 2,500 common medical treatments only 36% are 'beneficial' or 'likely to be beneficial'. A Cochrane review came to a similar finding. Given all of the above, it is clear that Ernst and Singh have constructed an erroneously-high baseline for the effectiveness of mainstream medicine - and it is this false baseline which they pit alternative medicine against. 

Ernst and Singh sought to ''put alternative medicine on trial'', but if they were being objective, it should have been mainstream medicine they put on trial first.   

Over long-enough time scales (e.g. the length of a human life) - and factoring in additive effects of using many alternative approaches in combination and the negative externalities of conventional drugs and treatments - mainstream medicine becomes less and less viable. But, of course, Ernst and Singh don't adopt this longitudinal, nuanced, and systems-thinking approach. 

Excluding infectious diseases - which has never been the remit of best practice in alternative and integrative healthcare practitioners - there is an inverse correlation between medical treatment and health / longevity in developed nations. This might seem counterintuitive at first, but it becomes more obvious when we consider that chronic disease from poor lifestyle is the leading cause of premature death in the western world. Logically then, on a population level, the more you take care of your health and wellbeing, the less medical intervention you will need during your life. The healthiest people in the world don't live the longest because of modern medicine, but in spite of it. Ernst and Singh might appeal to outliers to evidence things one way or another, but this isn't how epidemiological evidence works in medicine. 

So - all in all - a poor effort from Ernst and Singh. They failed to abide by a cardinal rule in argumentation and science; which is to clearly define your terms first, and to outline the desired outcomes for society as a whole - not your own.