The “black spider” letters are finally out. On Wednesday, after a lengthy legal battle, a limited batch of private correspondence from the heir to the British throne, Prince Charles, to government ministers was made public.

Charles has been suspected of attempting to influence political decisions. In the 27 letters, written in 2004 and 2005, he expresses disquiet at, among other things, moves to bring the use of herbal medicines and acupuncture under increased scrutiny and regulation.

We may never know what was in other letters he wrote to those in power over the years, but Charles has made no secret of his support for many aspects of complementary medicine, including perhaps the most controversial – .

Despite the absence of any evidence of effectiveness, it is still possible to obtain homeopathic treatment on the UK’s National Health Service. Yet five years ago, an official evidence check concluded that the government should stop public funding of homeopathy by the NHS. What happened? Nothing! Politicians said that , and rumour had it that had something to do with this absurd outcome.

In my role putting complementary medicine under scientific scrutiny – and generally finding it wanting – I discovered the influence Charles wields. After he complained about me to my university, there was a 13-month investigation into my behaviour. At the end, I was pronounced innocent but all my support vanished into thin air. The story is told in full in my recent memoir A żìĂš¶ÌÊÓÆ” In Wonderland.

The point is that homeopathy flies in the face of science and evidence-based medicine. One of the notions its practitioners believe is that “like cures like”. A common example is onion: it makes our eyes water, and is therefore used to treat conditions such as hay fever, which can cause runny eyes.

They do not administer pure onion to their patients; they repeatedly dilute their remedies while vigorously shaking them, a procedure which they call “potentization”. The term indicates their belief that this renders the remedies not less but more powerful. Typical remedies are thus devoid of even a single active molecule.

Unsurprisingly, the totality of the reliable evidence from clinical trials fails to show that homeopathic remedies are more effective than placebos.

Beyond the UK, national health organisations are beginning to follow this evidence. The Australian National Health and Medical Research Council recently what must be the most comprehensive, transparent and rigorous assessment of homeopathy. The panel that “homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness.”

And the looks set to follow suit. After several high-profile legal actions against manufacturers of homeopathic products, it has announced “a public hearing to obtain information and comments about the current use of human drug and biological products labeled as homeopathic, as well as the agency’s regulatory framework for such products”. If its final report is based on a rigorous, critical assessment of the best available evidence, it will inevitably confirm the Australian verdict.

Given a history of defending the indefensible, and the growing actions elsewhere, it seems all the more important that the UK finally takes action on complementary medicine based on evidence.

We should not allow ideological, anti-scientific points of view to hold sway, no matter where they come from.

Six years on, the OAM remains controversial. This is hardly surprising given
the still shaky scientific reputation of much of complementary/alternative
medicine (CAM), ranging as it does from acupuncture and visualisation to
homeopathy and spinal manipulation.

Yet CAM continues to triumph in terms of public support. Some 50 per cent of
Australians and 65 per cent of Germans use some form of CAM according to studies
published in The Lancet (vol 347, p 569) and Deutsches
Ärzteblatt (vol 94, p 1857). The budget of the OAM has increased more than
tenfold and is now some $20 million a year. The OAM also supports 11
research centres in the US, which attempt to fill the numerous gaps in our
knowledge about CAM. This autumn, the Journal of the American Medical
Association and Archives of Internal Medicine will both be
producing issues with CAM themes.

So much for the good news. The bad news is that progress in research and, in
particular, clinical trials, is dismally slow. Before anything is published, it
can take a year of planning, two years of trials, six months of
evaluation—plus another six months to get a paper into print.

There’s more. Numerous obstacles confront any scientific investigation of
CAM, especially shortages of funding and expertise. As a result, we are still
unable to answer with any confidence even such a pressing and fundamental
question as whether a particular therapy is safe. And unacceptable levels of
uncertainty still leave us unable to judge or compare the efficacy of most
complementary therapies.

For example, recent authoritative reviews published in Spine (vol
21, p 2860) have cast doubt on the notion that chiropractic is useful for low
back pain—the leading cause of absenteeism in all industrialised
countries. Only a few years ago several countries, including Britain, the US and
Canada, believed so firmly in chiropractic that they incorporated it into their
national guidelines on how best to treat low back pain. Yet although most books
on CAM would lead us to believe that chiropractic is free from risks, we cannot
put a figure on how safe it is.

In fact, a number of cases have been published in the medical literature
showing that chiropractic is associated with severe complications—even
death. Nobody can say for sure how frequently such disasters occur. Nor can we
compare the direct and indirect costs of using chiropractic to treat back
problems with more conventional approaches. And the bad news doesn’t end there.
While some American chiropractors have produced calculations that seem to imply
that the use of chiropractic may save money (Journal of Manipulative and
Physiological Therapeutics, vol 20, p 5), independent investigators usually
come to the opposite conclusion (New England Journal of Medicine, vol
333, p 913).

The ugly side of all this is the whiff of quackery, pseudoscience and
antiscience that often hovers about. A recent outbreak of hepatitis among
clients of a London acupuncture practice could be an example. The pseudosciences
rear their ugly heads when practitioners have patients take alternative
diagnostic tests that diagnose nonexistent diseases. And a widespread notion
among many CAM followers seems to be that CAM cannot and should not be submitted
to rigorous testing. That looks like antiscience standing in the way of
progress.

So what is the right way forward? Surely there is no good reason for the kind
of double standard where some treatments are not submitted for scientific
evaluation—medicine is medicine whether it is complementary or mainstream.
Evidence-based CAM must not remain a contradiction in terms. The efficacy,
safety and costs of CAM should be scrutinised just as in other fields of
medicine. This is in the long-term interests of CAM—and of the
patient.

To achieve any real understanding requires common ground, that is to say
clear definitions that are acceptable to all parties concerned. Different
countries lump different therapies under the heading of ‘complementary
medicine’, and terms like complementary, unorthodox, alternative,
unconventional vary only in nuance. Unfortunately they are all ill defined.
One practical definition is simply to describe them as medical practices
which do not conform to the standards of the medical community.

Many of these practices are well known, others are exotic or mysterious, and
some may even be dangerous. For example, recent reports warn against the use
of certain Chinese herbs which are suspected of causing severe kidney
disease, and it now seems that Lorenzo’s oil can result in a bleeding
disorder because it can cause a serious drop in the number of blood
platelets.

In the US, relaxation techniques, chiropractic and massages are the three
most popular unconventional therapies. In Britain, herbalism, homeopathy,
acupuncture and chiropractic represent the most important branches of
complementary medicine. In Germany a single plant medicine marketed to
increase cerebral circulation achieved a turnover of DM300 million (almost
ÂŁ120 million) in 1989. That country is the Eden for plant
remedies which account for 10 per cent of the national turnover of
pharmaceuticals. More exotic complementary therapies include hypnosis, faith
healing and even prayer. The only common denominator is that they all stand
outside orthodox medical thinking.

The main reason for the eviction of complementary medicine from the courses
followed by most medical schools is that they are considered to be
‘unscientific’, which is to say, their effectiveness has not been
established sufficiently. Usually they are also based on rationales, or
rather ‘philosophies’, which are out of line with accepted medical thinking.
It is the educated, affluent and middle-aged who rely most heavily on
unconventional treatments. That some individuals should prefer them to
orthodox treatments is itself something that needs careful research. Most
experts say it results from frustration with modern high-technology
medicine, with today’s GPs who often do not have enough time or empathy, and
sometimes with the hopelessness of a disease.

Patients with two categories of diseases frequently turn, with or without
the advice of their GPs, to unconventional treatments. The first is made up
of patients with self-limiting ailments like back pain, insomnia, headache,
anxiety and so on. These are common symptoms which GPs often find hard to
treat effectively. Many enthusiasts argue that in such instances
unconventional treatment can do no harm. And since the orthodox camp often
claims that most of the complaints treated by unorthodox methods are not
diseases but ‘states of reduced well-being’ which are responsive to the
placebo effect, little damage can be caused when treating such complaints
with ‘alternative’ methods.

People with malignant diseases also turn to complementary therapies. Here,
the patient’s motive may be despair. With cancer there is considerable
danger of ineffective treatment delaying or preventing effective cures.
Recent studies show that some 80 per cent of all cancer patients are aware
of alternative methods and between 10 and 60 per cent use them. But many
GPs claim that ‘miracle cancer cures’ offer no more than bogus promises, and
they angrily demand stricter regulations and a crackdown on badly trained
‘cowboy practitioners’.

The increasing interest that the medical profession is beginning to show in
some form of complementary therapy therefore comes as a surprise. In
Britain, more than a third of all GPs now get a formal training in one of
the techniques. Young doctors tend to know more about alternative
approaches than their older colleagues. One survey showed that about 80 per
cent of all trainees knew something about hypnosis and acupuncture. In
Germany, 98 per cent of the medical students believe that it would be a
sensible move to include complementary medicine in the curriculum.

Within the climate of changing attitudes, opinions are naturally divided.
Some in the orthodox camp maintain that unorthodox treatments are an attack
on scientific understanding and reasoning bordering on occultism and
obfuscation. They emphasise that the ideas behind the ‘philosophies’ of
complementary medicine are neither original nor even true. For example,
orthodox medicine recognises the interaction of body and soul, in that every
good GP tries to understand a patient’s complaint against the background of
the patient’s psychological, economical and sociological situation. However,
the idea of such an interaction is often implied to be the invention of the
alternative camp. The opinion of unorthodox circles that all states of
health and all disorders are psychosomatic is patently wrong. And the
holistic view that one’s state of health is affected by everything is a
truism which has no real medical consequences, because it does not permit
the relevant to be distinguished from the irrelevant.

But not even the sceptics can deny that complementary medicine can give the
impression of being spectacularly successful. What, for example, should one
make of a chronic migraine sufferer who has tried all the orthodox experts
and taken all the remedies the medical establishment can offer and who
finally ends up with an unorthodox practitioner and is promptly cured? Such
experiences tend to generate enthusiastic and sometimes even fanatically
convinced patients as well as therapists. Yet one has to exclude at least
two possible explanations before concluding that the unorthodox therapy did
in fact work. One is the placebo effect, which can do wonders, particularly
when combined with the levels of empathy which often come with complementary
treatments. The other is the natural history of the disease; fortunately
many symptoms disappear ‘by themselves’, and in these instances it may be
impossible to isolate what did what. The patient may well take the attitude
that it does not matter – all that counts is getting better. But it matters
immensely for society and medicine because doctors carry the heavy burden of
an ethical responsibility to find good treatments and to discard poor ones.

More and more doctors think that they have to keep an open mind. They feel
that if a particular remedy has been used empirically for many years with
apparent success, they should give it a fair trial, apply the scientific
methods of clinical pharmacology, and rigorously test whether or not it
works in a given clinical situation. This usually means running randomised
trials against placebo controls. Contrary to what is sometimes said, such
trials are feasible for most unorthodox therapies, no matter how closely the
therapy is tailored to the individual rather than to the disease. With some
complementary therapies, for example homeopathy, acupuncture or manual
therapies such as osteopathy and chiropractic, trials have been undertaken
and some show highly promising results. This, however, does not mean that
the rationales of acupuncture or homeopathy are irrefutable; it merely
suggests that the treatment is more useful than a placebo.

The history of medicine abounds with examples from which we could learn in
this somewhat confusing situation. Take, for instance, blood-letting. It was
once used indiscriminately for almost every disease. The idea behind it was
that removing blood from the body would restore the balance of the ‘four
humours’. Today we know that it was an utterly wrong concept, yet
blood-letting was reintroduced, scientifically tested and is now known to be
an effective therapy for a number of closely defined diseases. The lesson
seems to be obvious: we must not condemn a remedy purely because its
rationale does not fit the scientific model of today’s medicine.

Many countries have set up official bodies to monitor the need for further
research in complementary medicine. Pressurised by Congress, the US National
Institutes of Health have formed a working group to test complementary
methods scientifically, with an annual budget of $2 million. In
Britain, the first university chair in complementary medicine is about to
start operating at the University of Exeter. Its aim is to review and test
scientifically unorthodox methods. And in Germany, a huge government-run
study is to test the effectiveness of several unproven therapies.

It is generally agreed that there is a lack of proper scientific work. Many
experts now say that the medical profession ought to act swiftly to avoid
losing contact with what is going on outside the ivory towers of the
universities. Doctors should respond to the need of their patients for
objective information on the effectiveness of complementary medicine. The
traditional approach of treating a few patients with an unproven medicine
and seeing how they get on, must be abandoned – it is both unscientific and
unethical. To mature as a medicine, the magic in complementary therapies
must be replaced by science.

Edzard Ernst is a professor at the University Clinic for Physical Medicine
and Rehabilitation in Vienna and takes up the chair in complementary
medicine at the University of Exeter in October.