Dr David L. J. Freed, MB, MD, MIBiol
In 1984 I saw a 30-year old nurse who was suffering inexplicable paroxysmal tachycardiae (racing of the pulse). Her cardiologist had fitted her with an ‘intelligent’ electronic pacemaker which would switch in within seconds to abort each attack, but she still got these attacks, causing much fear and suffering. I advised avoidance of tea and coffee and the problem disappeared forever, making the expensive pacemaker unnecessary. Such cases are commonplace for members of the British Society for Ecological Medicine (BSEM), doctors who are interested in allergy, toxicology, nutritional and environmental influences on health. We consider ourselves to be, and align ourselves with, scientists rather than doctors (although we are doctors), being affiliated to the Institute of Biology rather than to any medical Royal College.
That may surprise you because in principle all medical doctors are scientists, Medicine being a form of applied biology. But in practice Medicine and Science make uneasy bedfellows and this unease arises from several sources.
1) We doctors like people to think we know what we’re talking about, and may indeed be so convincing that we convince ourselves too. Because other people’s lives depend on it, we have a big emotional stake in being right, and are uncomfortable with the thought that much is still unknown. Scientists, on the other hand, are perfectly comfortable with the unknown as it is their bread and butter. When scientists disagree there is no more at stake than their next grant applications, whereas medical disputes grow extra bitter because of each side’s conviction (as you will shortly see) that the other chap is damaging innocent lives.
2) Science does not in itself make its practitioners haughty (in fact the contrary if done with honesty), whereas medicine does. Much of the reason for that, I think, is that our clients obediently undress at our request while we remain clothed, and lie down while we remain standing. Having observed and handled their naked flesh we then proceed to discuss their intimate bodily functions with our colleagues at the bedside, over the patient’s head both figuratively and literally. Once you have examined princes and archbishops in their underpants the world never looks quite the same again (especially for a young healthy doctor unaware of his own vulnerability).
3) Taken together with doctors’ exaggerated reverence for Authority (a remnant of our monastic origins, I suppose) it becomes very easy for us doctors to start believing that we know everything that we need to know, and that makes us unreasonably unreceptive to new ideas.
“Respectable Medicine”, runs the conventional dogma, “is based on scientific evidence, whereas Alternative Medicine is not” - but we of the BSEM have refused to comply. We have taken the methods of Science from under the noses of ‘respectable’ doctors (principally the prospective double-blind trial and the double-blind challenge) and have used them to validate methods and phenomena that at first sight appear implausible, indeed distinctly “alternative”. Ironically, we (along with surprisingly many complementary medical procedures) are now supported by as good or better scientific trials than much of conventional medicine, although the mechanisms may not be as well elucidated. Ironically, the subsequent debate has forced some conventional medics into a public defence of prejudice, using elegant witty prose as a substitute for objective evidence [1,2].
Certainty, in our area of biology (and I dare say in most), is a rare commodity. Instead, when we observe what appears to be a phenomenon of Nature, we calculate the probability (p) that it is actually due to random chance. If that probability is very low (the usual criterion is less than 5%) we conclude that this is indeed (probably) a genuine phenomenon. The “p value” can never reach zero, but the closer it gets, the more likely that conclusion is to be true.
The bedrock of Science is this: (i) before expending effort on explaining a phenomenon, it is always worthwhile determining as rigorously as possible that there is actually a phenomenon to explain. But once having done that, then (ii) however unexpected and counter-intuitive the finding, that finding must for practical purposes be considered true, albeit with the eternal proviso that the current evidence could in principle be overturned by stronger, as-yet-undiscovered, evidence to the contrary (all scientific “knowledge” is to some extent provisional). Once having determined the existence of the phenomenon, we can then turn our attention to trying to explain it - there must be an explanation although it may be elusive.
Just as physicists were forced by the evidence to accept relativity and quantum mechanics, even though it stood conventional physics on its head, so too biologists. When you are forced into a corner, and a decision has to be made, and the experimental results indicate something that you cannot believe, the scientist has no choice but to follow the scientific results (remember, scientists are not believers – at best we concede, if forced by the evidence, the probability that something is true). All paradigm-shifting discoveries - discoveries that changed people’s thinking - were made thus. And this is the nub of all our disagreements with conventional doctors.
Broadly speaking, the contentious issues between us and our conventional colleagues are four-fold, as follows:
Nosology Based on double-blind challenge studies that yield p>0.5 values, we accept the existence of conditions that conventional doctors don’t, as follows:
(a)adverse reactions to traces of chemical pollutants, at ambient dose levels insufficient to upset healthy people,
and therefore reminiscent of and sometimes loosely referred to as “allergic” reactions,
(b)a generalised form of this condition termed Multiple Chemical Sensitivity (MCS), which can be severely
incapacitating and leads to the derisory epithets sometimes employed by the popular media (“total allergy syndrome” etc),
(c)allergy to or intolerance of foods, and inhalants both natural and artificial, as causative factors in a much
wider range of illnesses than conventionally thought including rheumatoid disease, migraine and Crohn’s disease.
Conventional doctors manage these conditions with drugs and sometimes surgery while we prefer to use dietary
and environmental manipulations, sometimes ridiculously simple as in the case we began with.
(d)We also recognise provisionally (based on listening to patients, the oldest clinical science of all)
the existence of food addictions (and not just to chocolate and caffeine) and the related phenomenon
of ‘masked allergy’, which is a ‘reaction’ that makes the sufferer feel transiently better, while at the
same time causing illness in the longer term (just as an alcoholic feels transiently better after a drink).
This last however cannot realistically be investigated by double-blind challenge, and can therefore never be
more than a tentative diagnosis.
Treatment Methods We recognise as valid any relevant method that is evidence-based, i.e. supported by conventional prospective double-blind trials, using the conventional standard of p>0.05. In particular these methods include two new allergy desensitisation methods, neutralisation and enzyme-potentiated desensitisation [3]. True, these methods are difficult to believe, and our ‘traditional’ opponents find them so unbelievable that they require far higher standards of evidence (i.e. far lower p values) than they require for a new drug. One internationally-respected immunologist once confessed frankly to me at a coffee break that “however the strong the evidence becomes, I will never be able to believe it!”
I admit I also don’t believe it sometimes, in spite of the fact that I see the efficacy of these methods daily, because they bear little resemblance to the immunology we studied at medical school and they threaten to force open our minds to natural phenomena that Science doesn’t yet know about. When I saw the first papers describing double-blind trials of neutralisation [3] I felt the world lurching. But try as I could I could rarely find flaws in the studies. What could I do? In practice a scientist has no choice but to make his decisions on the basis of the p value, not on prejudice or clinical impression – even though some medics apparently feel that they possess a Higher Truth unfettered by nasty earthy things like scientific evidence.
Diagnostic Methods In this respect we tend (perhaps surprisingly) to be less credulous than our conventional colleagues, regarding a test which is 75% accurate (i.e.yielding the wrong result in a quarter of cases) as unreliable. Sadly, few tests for allergy in current use – orthodox or heterodox - achieve even that degree of reliability. Although this figure is based on numerous scientific studies [4], few medics appear to be aware of it and allergists are still to be found who will inform a patient, because of a negative test result, that he/she is not allergic. To my mind this practice verges on criminal, as it leads to unfair suspicions of psychogenesis or malingering (see below). And this leads us to the biggest area of contention, namely the venerable
“Mind versus body” debate. What do you do when a patient complains of medically-inexplicable symptoms and tells a story you find hard to believe? Condemn the patient to a lifetime of disbelief, humiliation and tranquillisers on the grounds that he (more often she) is imagining it? Our members see thousands of such patients and we can often restore them to health by simple dietary or lifestyle manipulations. Having thus saved numerous genuine sufferers from being drugged into submission (the “psychiatric dustbin”), most of us are slow to attribute inexplicable symptoms to the notional and usually unprovable states of hypochondria, somatism or malingering. Sometimes this is our Achilles heel as we can be misled by the occasional plausible liar. But such frauds are far fewer than most doctors think, and are vastly outnumbered by genuinely ill people, mismanaged by doctors who thought they knew everything.
As you see, medical disputes can get bitter. Small wonder that conventional medics hate us – a hatred which in this country is further fuelled by the fact that most of our members, rugged individualists, practise mainly in the private sector. Private medical practitioners are always suspected (sometimes probably fairly) of cutting ethical corners for the sake of money though I have yet to meet such a person in this speciality. Scientists, on the other hand, welcome us with open arms, as we discovered to our delight when, cap in hand, we first sought affiliation to the Institute of Biology. The IoB headquarters in those days was an imposing Edwardian building in Kensington just like a Royal College, and its Royal Charter is equally as impressive. Its officers have the same sober suits and regal gravitas, and our late President Keith Eaton and I were both half-expecting to be patronised and fobbed-off as we would have been by any Royal College. After years of being spat upon by our professional colleagues, the intelligent and thoughtful hearing we received from IoB Chief Executive Professor Alan Malcolm made us feel refreshingly human.
References
1)Skrabanek P. Demarcation of the absurd. Lancet 1986, i: 1960-1
2)cf Pearson, 1987: “It is a misunderstanding of the nature of statistical testing to assume that it
must be true if one can somehow calculate a ‘p value’ with lots of noughts…… Neither has it been proven to
my satisfaction that Santa Claus does not exist, but as I get older I become more suspicious of free offers.”
(Pearson DJ. commentary. In Dobbing J (ed) Food Intolerance. Baillière Tindall, London, 1987,
p 172, para 3).
3)Anthony H, Birtwistle S, Eaton K, Maberly J. (1997) Environmental Medicine in Clinical Practice.
BSAENM Publications, Southampton, ISBN 0 9523397 2 2. pp 227-238.
4)Freed DLJ, Waickman FJ, 2002. Laboratory diagnosis of food intolerance. In Brostoff J, Challacombe SJ (eds),
Food Allergy and Intolerance, Saunders, London, pp 837-856.
Acknowledgements
This essay has been 37 years in the writing, all of them in medical allergy practice and many of them as a Lecturer in Immunology at Manchester University. Several of the ideas and sometimes the phrases are borrowed, particularly from Tom Beswick, Keith Eaton, Ronnie Finn, George Hearn, Stephen Seely, Bob Stoddart and Geoff Taylor but also from many others, to all of whom my grateful thanks. Alec Adcock, Peter Elwood and Margaret Moss helped me improve the manuscript.
I must also acknowledge David Pearson, my colleague and intellectual sparring-partner since the days when we both trained in Geoff Taylor’s laboratory. Predictably we came to occupy opposite poles of the “allergy debate”, and his good-natured criticisms (which I regret to say I did not always take in the spirit they were intended) have helped sharpen my thinking for over three decades. Apologies and good wishes to him.
