Wheat and chaff in alternative medicine 1
SIR—Kahn (March 15, p 812) regards the fact that I wrote the foreword for a book on the scientific basis of homoeopathy to be evidence of bias. If the director of research of the largest public-sector hospital in Europe devoted to any other specialty wrote the foreword to a book on research in that specialty, would he construe it as a bias? I think not. Kahn goes on to make an unreferenced attack on a clinical trial in which I was principal investigator2 and characterises homoeopathy as quackery and himself as a fearless crusader against it. The evidence does not support Kahn. Two overviews, including one by an expert group supported by the European Commission, found that the clinical evidence is positive. The expert group identified 184 clinical trials of homoeopathy, and concluded that the results of its meta-analysis were unlikely to be due to publication bias.3,4 Meanwhile, the public is voting with its feet: sales of homoeopathic medicine are growing at 15% every year in the UK and even more rapidly in the USA.5 If Kahn expects to be taken seriously as a commentator in this area of rapidly growing scientific and public interest, he will need to show more respect for science and less for conspiracy theories. Peter Fisher Royal London Homoeopathic Hospital NHS Trust, London WC1N 3HR, UK
Kahn MF. Wheat and chaff in alternative medicine. Lancet 1997; 349: 812. Fisher P, Greenwood A, Huskisson EC, Turner P, Belon P. Effect of homoeopathic treatment on fibrositis (primary fibromyalgia). BMJ 1989; 299: 365–66. Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homoeopathy. BMJ 1991; 302: 316–23. Boissel JP, Ernst E, Fisher P, Fülgraff G, Garattini S, de Lange de Klerk E. Overview of data from homoeopathic medicine trials: report on the efficacy of homoeopathic interventions over no treatment of placebo. In: Report of Homoeopathic Medicine Research Group. Brussels: European Commission, 1996. Fasihi A. Complementary medicine, volume 1. London: Financial Times Pharmaceuticals and Healthcare Publishing, 1996.
SIR—On reading Kahn’s1 review of my book Homeopathy, a frontier in medical science, I was surprised both by the title, Wheat and chaff in alternative medicine (where the reviewed book would be the chaff), and by the general tone of the criticism. Kahn complains of “a bias of the authors” and accuses me of belonging to a “semi-official group” of people who “support the validity of homoeopathic concepts . . . under the combined pressure of manufacturers
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and alternative-medicine apologists”. I am described as one of the “obvious advocates of homoeopathy” and my theories are dismissed as “mixed up with philosophical considerations not quite different from what Hahnemann wrote 200 years ago”. These assertions are untrue. I am a research scientist with a background in haematology and cell biology. My coauthor is a medical doctor, whose specialty is clinical biology and who is an expert on homoeopathic drugs. Our book is explicitly a first and tentative synthesis of knowledge originating from apparently different and opposing fields. The only “philosophical” section of the book refers to the widely accepted theories of Thomas Kuhn and Karl Popper, and the old vitalism of Hahnemann is explained in scientific terms. Kahn is wrong to assume that researchers working in this field are supporters of homoeopathy and sponsored by drug companies. We, and many other scientists, do not support homoeopathy, but investigate it, and this makes a great difference. Of course we need financial support for our research and have to work with manufacturers, but this pressure is no different from that exerted by any drug manufacturer over medical scientists working in other, more conventional, specialties. Kahn says we do not reference “all” refutations. Our book is not intended as a complete reference, nor is it a metaanalysis of clinical trials. On the contrary, the book contains a detailed (even if not complete) account of research conducted in this field to date. Our book does, in fact, contain a list of 500 bibliographical citations and we explain in much detail that the research is still provisional and preliminary: “To be able to draw firm conclusions as to the efficacy of a specific treatment in a specific disease, the main clinical trials published to date would need to be repeated by independent groups” (p 55). Finally, Kahn’s declaration that he is a “dedicated opponent of quackery in all its forms” shows the “author bias” in the review of our book. Your readers could easily be misled into believing that my book belongs to quackery, but since I am a dedicated opponent of prejudice and censorship in science, I would recommend the book as a stimulus for one’s critical judgment. Paolo Bellavite Istituto di Chimica e Microscopia Clinica, Ospedale Policlinico, University of Verona, 37134 Verona, Italy
Kahn MF. Wheat and chaff in alternative medicine. Lancet 1997; 349: 812.
Elderly pilots SIR—A person who applies for an aeronautical pilot’s licence, or its renewal, must undergo a medical examination by a physician to assess his or her physical and mental aptitude. In France, the medical-aptitude norms are defined by the decree of Oct 2, 1992, which was an amendment to the decree of Dec 2, 1988.1 But these norms will soon be replaced by stricter European the Joint Aviation norms:2 Requirements and Flight Crew Licensing, developed by the Joint Aviation Authorities. In view of these changes, the aptitude of pilots older than 65 years should be reassessed. In the Nord region of France, 19 voluntary non-professional pilots (aged 66–75 years) gave their consent to undergo a medical examination in accordance with the present decree. The examination was systematically completed by a paraclinical examination that will be made compulsory from July 1, 1998, if the European standardisation projects are adopted. These examinations are: an electrocardiogram, an audiogram, and basic haematological tests. Such rigorous examination ensures that many previously undetected offences to the legislation are brought to the fore. Of the 19 French pilots, only one met the criteria for physical and mental aptitude. Among the other 18 pilots, some showed one or more grounds for total or temporary inaptitude. Three pilots were declared totally inapt because of ophthalmological (one case), cardiovascular (one case), and cardiological and neurological (one case) problems. 15 pilots proved temporarily inapt—ie, inapt until the problem was stabilised by surgical or medical treatment and their aptitude was confirmed by the specialist. The 15 patients had cardiovascular, digestive, endocrinological, ophthalmological, otorhinolaryngological, or genitourinary disorders.3,4 These findings underline the importance of a thorough medical examination of pilots by authorised If the European doctors.5 standardisation revisions of the statutory decree on the physical and mental aptitude of non-professional technical pilots are adopted and implemented, the safety of pilots who wish to continue flying over the age of 65 and their passengers will be improved. At present, we can only advise especial vigilance during the medical examination of pilots aged over 65. Luc Devianne, *Bernard Frigard, M C Pivion Centre de Gériatrie, Rue Salvader Allendé, 59290 Wasquehal, France
THE LANCET 1 2
OACI. Manuel de médecine aéronautique civile, 2nd edn, 1985. Colin J, Auffret R, Bergot G. Médecine Aérospatiale Société Française de Médecine Aérospatiale Expansion Scientifique Française, 1990. Gourbat JP, Martel V. Comment décider de l’aptitude au vol aéronautique? AMC Pratique 1995; 4: 10. Bourgneres F. Difficultés de l’expetise du médecin agréé en ophtalmologie. Médecine Aéronautique et Spatiale 1995; 133: 19–22. Bulletin d’Information des Médecins Agréés, no 6. Octobre 1995. Edité par le Conseil Médical de l’Aéronautique Civile.
Conquering poliomyelitis in India
Number of cases
SIR—On Dec 7, 1996, and Jan 18, 1997, the Indian government conducted national poliomyelitis immunisation days. 121 million children aged under 5 years were targeted to receive oral poliovirus vaccine on each of these days. 117·4 million children were immunised on Dec 7, and 127·3 million on Jan 18. This figure exceeded the previous year’s effort when 93 million children aged under 3 years were immunised on Jan 29, 1996, representing at that time the largest single-day immunisation event ever.1 This record-breaking success required extensive planning and coordination by the government and partner agencies, including WHO, United Nations Children’s Fund, Rotary International, Danish International Development Agency, British Overseas Development Agency, Japanese International Cooperation Agency, Centers for Disease Control and Prevention in Atlanta, USA, and the US Agency for International Development. The total cost, not including operational costs covered by state governments, was about US$45·7 million. Over 2·6 million health workers and volunteers staffed more than 650 000 vaccination posts nationwide. Between 1995 and 1996, the number of poliomyelitis cases reported in India fell by 68%, from 3142 to 1005 (figure). India has consistently reported more than 50% of the world’s poliomyelitis cases, so the success of the
1200 1000 800 600 400 200 0 1994
Reported cases of paralytic poliomyelitis in India between Jan 1, 1994, and Feb 28, 1997 Arrows=national immunisation days.
national immunisation days in India is critical for the worldwide polio-eradication initiative.2 Improving surveillance of acute flaccid paralysis and wild poliovirus is needed to evaluate accurately the impact of the immunisation days. To that end, field surveillance for vaccine preventable diseases is being accelerated in 1997 by the implementation of a national plan of action which includes nationwide retraining of state and district immunisation officers, procedures for reporting, investigation, and monitoring cases of acute flaccid paralysis, and the expansion of the Indian polio laboratory network from five to eight laboratories. *Kaushik Banerjee, Jon Andrus, Gary Hlady Ministry of Health and Family Welfare, Nirman Bhavan, New Delhi; *Regional Office for South-East Asia, WHO, New Delhi, India 11002; and WHO’s Country Office for India, New Delhi
WHO. National immunization days: India. Wkly Epidemiol Rec 1996; 22: 169–71. Andrus JK, Banerjee K, Hull BP, Smith JC, Mochny I. Polio eradication in the World Health Organization South-East Asia region by the year 2000: midway assessment of progress and future challenges. J Infect Dis 1997; 175 (suppl 1): S89–96.
The when and how of advocacy SIR—I cannot agree with the ideas expressed in your March 29 editorial.1 I can understand the desire behind it— the desire for a better world—but to suggest that one should set aside normal scepticism or fail to point out the limits of one’s data to achieve this is surely to abandon the whole enterprise of science. For if one has to misrepresent one’s case in order to persuade others of something that is believed to be desirable, one has to ask on what grounds this view is held. Perhaps it is a sincere ideological belief, held as a result of one’s own moral framework. History is full of examples, however, of such opinions being subsequently shown to be false or causing immense harm. The Lancet, like most other biomedical journals, roundly condemns scientific fraud, and yet in many cases this may be no more than scientists putting aside their normal scepticism to present results that show something they sincerely believe to be true. Scientists’ strength is their integrity, and they, more than anyone else, should take great care to separate their work, which they can be (reasonably) impartial about, and their concerns as a human being and a member of society. The deliberate
amalgamation of these two functions, even if done with the best of intentions, can only lead to a decrease in the standing of the scientific community. Alison Round Department of Public Health Medicine, North and East Devon Health Authority, Ex eter EX 1 1PQ, UK
Editorial. The when and how of advocacy. Lancet 1997; 349: 891.
Do not go flying in short sleeves SIR—I woke up in a hotel bed (single), unaware of time, the day after a 14 h two-stop flight from northern Scandinavia to southern California. When I picked up the toothbrush to clean my teeth, I felt a strange numbness in my right thumb and forefinger. Did I have a headache or neck pain? No. Had I carried exceptionally heavy luggage the day before? No. Any fever or malaise? None. After 5 days of hectic impressions of tumour-suppressor genes, chromosomal rearrangements, loss of heterozygosity, and hecatombs of posters on p53, cytokines, and cyklins, I still had this enervating numbness in my right thumb and forefinger. Was my balance affected? Any signs of early dementia, or other defects? None. My finger went straight to my nose when I kept my eyes closed. On the return flight, I sat by the left window again, with a marvellous view of the polar night sky, northern lights, and the comet, and Boccherini, Borodin, and Ravel on the headsets. And all the time a heavy stream of air filtered down from the ceiling. I had to seek support from my left hand when I drank my coffee. Then I remembered from my practice a youngster who presented with a peripheral facial paralysis after a day of intense snow scootering with cold draught. On consulting Lord Brain’s Diseases of the nervous system, radial palsy seemed the most likely diagnosis and prognosis is good. I am looking forward to being able to play the piano again. Torgny Rasmuson Department of Oncology, Umeå University Hospital, S-901 85 Umeå, Sweden
DEPARTMENT OF ERROR Vaccine failures after primary immunisation with Haemophilus influenzae type-b conjugate vaccine without booster—In this article by Booy and colleagues (April 26, p 1197–202), the heading for the second column of table 1 should read “Number of previous doses of tetanus toxoid”.
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