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  • 1135THE LANCET


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    Searching for alternatives:loser pays

    Some conventional doctors have made it their mission tofight alternative medicine. To them, what is taught in theivory university tower is the only truth, almost by definition."Listen", they argue, "you may feel better after seeing yourfavourite charlatan, but the benefit of his interventions, ifany, is non-specific." At best, they say, alternativepractitioners can be considered masters of placebo therapy.Few patients, however, care about the scientificclassification of their improvement (spontaneous, placebo,or biomedical). They continue to choose the treatment thatthey expect to give them the best overall benefit.

    It is always important to optimise placebo effects, in anykind of medicine. But has mainstream medicine somethingextra to offer over alternative medicine? The answer to thatquestion must come mainly from clinical research.

    Searching the literatureThe method with the greatest impact for showing clinical

    efficacy is the controlled trial. To the surprise of people whoprefer the debate to study of what has been published, thereare many reports of controlled trials of alternative therapies.Sometimes these publications are difficult to trace.Computer databases are biased towards conventionalmedicine because many established journals are reluctant toprint the evidence--especially when it is positive. On theother hand, we also get a biased overview if research initiatedby supporters of alternative medicine is not published whenthe results are disappointing.My experience with alternative researchers is that many

    are honest people and welcome any effort to dig up the greyliterature. Sometimes one finds promising data. Theliterature on ginseng, for instance, which cannot be found on

    ADDRESSES- Department of Epidemiology, University ofLimburg, PO Box 616, 6200 MD Maastricht, Netherlands(Prof P. Knipschild, MD).

  • 1136 THE LANCET

    Medline, shows that it is a helpful tonic for elderly patientswho lack vitality.l Ginkgo biloba has been extensivelystudied in many trials in Germany and France; it seems towork against what the Germans call a TK/eMM.otM(cerebral insufficiency).2 But how many in theAngloamerican rampart of science read foreign languages?

    HomoeopathyLet me give one illustration of how exhaustive an

    alternative literature search can be. People from mydepartment rolled up their sleeves to look for researchpapers on the effectiveness of homoeopathy. The DutchMinistry of Public Health funded the enterprise.A Medline/Embase search (till 1991) gives 18 published

    reports of controlled trials on homoeopathy. Stepwisechecking the references in these publications yields 28 more.If you stop here, you miss more than half of all studies.3We continued browsing through many alternative

    journals, including homoeopathic journals. Our rummagein congress reports and doctoral theses in specialisedlibraries in Paris, Hamburg, London, and Glasgow was veryrewarding. Many homoeopathic companies offered help.We wrote to well-known investigators working on thissubject and sometimes paid them a visit. It was importantthat they felt comfortable discussing homoeopathy with us,so our meetings were often held in good restaurants! Weheard details of their studies that were not published andreceived other reports that were still confidential. Ourjourney into homoeopathy produced a pile of more than 100controlled studies. Our subsequent meta-analysis showed,to our astonishment, beneficial effects for homoeopathy inmany (but not all) well-performed trials."

    Lately, we have collected many efficacy studies on alltypes of alternative treatments. Many of these studies are notvery convincing becaus