MD, PhD, FMedSci, FSB, FRCP, FRCPEd

homeopathy

There are dozens of observational studies of homeopathy which seem to suggest – at least to homeopaths – that homeopathic treatments generate health benefits. As these investigations lack a control group, their results can be all to easily invalidated by pointing out that factors like ‘regression towards the mean‘ (RTM, a statistical artefact caused by the phenomenon that a variable that is extreme on its first measurement tends to be closer to the average on its second measurement) might be the cause of the observed change. Thus the debate whether such observational data are reliable or not has been raging for decades. Now, German (pro-homeopathy) investigators have published a paper which potentially could resolve this dispute.

With this re-analysis of an observational study, the investigators wanted to evaluate whether the observed changes in previous cohort studies are due to RTM and to estimate RTM adjusted effects. SF-36 quality-of-life (QoL) data from a cohort of 2827 chronically diseased adults treated with homeopathy were reanalysed using a method described in 1991 by Mee and Chua’s. RTM adjusted effects, standardized by the respective standard deviation at baseline, were 0.12 (95% CI: 0.06-0.19, P < 0.001) in the mental and 0.25 (0.22-0.28, P < 0.001) in the physical summary score of the SF-36. Small-to-moderate effects were confirmed for most individual diagnoses in physical, but not in mental component scores. Under the assumption that the true population mean equals the mean of all actually diseased patients, RTM adjusted effects were confirmed for both scores in most diagnoses.

The authors reached the following conclusion: “In our paper we showed that the effects on quality of life observed in patients receiving homeopathic care in a usual care setting are small or moderate at maximum, but cannot be explained by RTM alone. Due to the uncontrolled study design they may, however, completely be due to nonspecific effects. All our analyses made a restrictive and conservative assumption, so the true treatment effects might be larger than shown.” 

Of course, the analysis heavily relies on the validity of Mee and Chua’s modified t-test. It requires the true mean in the target population to be known, a requirement that seldom can be fulfilled. The authors therefore took the SF-36 mean summary scores from the 1998 German health survey as proxies. I am not a statistician and therefore unable to tell how reliable this method might be (- if there is someone out there who can give us some guidance here, please post your comment).

In order to make sense of these data, we need to consider that, during the study period, about half of the patients admitted to have had additional visits to non-homeopathic doctors, and 27% also received conventional drugs. In addition, they would have benefitted from:

  • the benign history of the conditions they were suffering from,
  • a placebo-effect,
  • the care and attention they received
  • and all sorts of other non-specific effects.

So, considering these factors, what does this interesting re-analysis really tell us? My interpretation is as follows: the type of observational study that homeopaths are so fond of yields false-positive results. If we correct them – as the authors have done here for just one single factor, the RTM – the effect size gets significantly smaller. If we were able to correct them for some of the other factors mentioned above, the effect size would shrink more and more. And if we were able to correct them for all confounders, their results would almost certainly concur with those of rigorously controlled trials which demonstrate that homeopathic remedies are pure placebos.

I am quite sure that this interpretation is unpopular with homeopaths, but I am equally certain that it is correct.

Continuing on the theme from my previous post, a website of a homeopath (and member of the UK ‘Society of Homeopaths’) caught my attention. In in it, Neil Spence makes a wide range of far-reaching statements. Because they seem rather typical of the claims made by homeopaths, I intent to scrutinize them in this post. For clarity, I put the (unaltered and unabbreviated) text from Neil Spence’s site in italics, while my own comments are in Roman print.

The holistic model of health says all disease comes from a disturbance in the vitality (life force) of the body. The energetic disturbance creates symptoms in the mind, the emotions and the physical body. Each patient has their own store of how this disturbance in vitality came about and each person has individual symptoms.

What is a ‘holistic model of health’, I wonder? Holism in health care means to treat patients as whole individuals which is a hallmark of any good health care; this means that all good medicine is holistic.

Holism and vitalism are two separate things entirely. Vitalism is the obsolete notion of a vital force or energy that determines our health. ‘Disturbances in vitality’ are not the cause of illness.

We will attempt, as far as possible, to treat the whole person and to change the conditions that created your susceptibility to cancer.

Much of the susceptibility to cancer is genetically determined and cannot be altered homeopathically.

Using Homeopathy to treat people with cancer

Homeopathic treatment can help someone with cancer. It can also be helpful for people who have a history of cancer in their family or have cared for a relative or friend with cancer. There are a number of methods of using homeopathic remedies to help people with cancer.

There is no good evidence that homeopathic remedies are effective for cancer patients or their carers.

Constitutional treatment: Treat the person who suffers the illness. A constitutional homeopathic remedy suits your nature as a person and its symptom picture reflects the unique expression of your symptoms. It can arouse the bodyʼs natural ability to heal itself and this can have profound benefits. It is appropriate if your vitality is strong.

There is no evidence that constitutional homeopathic treatments increase the body’s self-healing ability.

Stimulate the immune system to fight cancer: Remedies can be used to help the body fight the cancer, using specific homeopathic remedies called nosodes. A second treatment may be used to support the weakened organ. This method is most useful for people who are not using chemotherapy or radiotherapy.

There is no evidence that nosodes or other homeopathic remedies have any effect on the immune system ( – if they did, they would be contra-indicated for people suffering from auto-immune diseases).

Support the failing organs and the functions of the body that are not working: Remedies can be used to support weakened organs; to help with appetite; to help sleep and to treat sleep disturbances; to reduce the toxic symptoms; to help the body eliminate toxins. These treatments are helpful to people undergoing chemotherapy or radiotherapy.

For none of these claims is there good evidence; they are pure fantasy. The notion that homeopathy can help eliminate toxins is so wide-spread that it merits a further comment. It would be easy to measure such a detoxifying effect, but there is no evidence that it exists. Moreover, I would question whether, in the particular situation of a cancer patient on chemotherapy, a hastened elimination of the toxin (= chemotherapeutic agent) would be desirable; it would merely diminish the efficacy of the chemotherapy and reduce the chances of a cure.

Treat the pain: Homeopathic remedies can be very effective in aiding pain control. Remedies such as calendula can be effective in situations of intractable pain. If the cancer is at the terminal stage, remedies can be used to increase the quality of life. These remedies are palliative and can assist the patient keep mentally and emotionally alert so they can have quality time with loved ones.

Where is the evidence? Pain can obviously be a serious problem for cancer patients, and the notion that calendula in homeopathic dilutions reduces pain such that it significantly improves quality of life is laughable. Conventional medicine has powerful drugs to alleviate cancer pain but even they sometimes do not suffice to make patients pain-free.

Homeopathy in conjunction with other therapies

When a patient chooses to use chemotherapy or radiotherapy to treat their cancer the homeopath will prescribe remedies to support the body and ease the side-effects. Remedies can also be very useful after surgery to encourage the body to heal and allow greater mobility at an early stage.

Again no good evidence exists to support these claims – pure fantasy.

Other therapies can complement homeopathy but the homeopath will advise that you do not use every therapy just because they are available. It may be better to choose two or perhaps three main approaches to improving your health and ensure each one has positive effects that suit you very well.

Is he saying that cancer patients are best advised to listen to a homeopath rather than to their oncology-team? Is he encouraging them to not use all possible mainstream options available? If so, he is most irresponsible.

Each person will have different needs. It is always appropriate to change your diet. Nutritional and dietary advice is of the utmost importance to support the bodyʼs healing process. Cancer has many symptoms of disturbed metabolism and a poor diet has often contributed to the disturbance in the body that allowed the cancer to flourish. It is essential to remedy this situation. Nutritional advice puts you back in charge of your body; with good homeopathic treatments this provides the basis for improving your health.

Dietary advice can be useful and is therefore routinely provided by professionals who understand this subject much better than the average homeopath.

CONCLUSION

The thought that some cancer patients might be following such recommendations is most disturbing. Advice of this nature has doubtlessly the potential to significantly shorten the life and decrease the well-being of cancer patients. People who recommend treatments that clearly harm vulnerable patients are charlatans who should not be allowed to treat patients.

Even relatively well-informed people tend to think that homeopathy might be quirky and useless but, so what, it cannot do any harm. This is perhaps true for the homeopathic remedies but it does certainly not apply to the homeopaths. As soon as there is a public health problem, homeopaths claim that their approach offers a solution – never mind the evidence to the contrary. Just look at what they presently try to sell us in terms of cold and flu treatments!

The often criminal fight of homeopaths against public health is nowhere clearer than with their never-ending propaganda against the most successful public health measure in the history of medicine, immunisation. Some professional organisations of homeopathy have issued politically correct statements about this and thus feel they are out of the firing line. But, as far as I can see, most homeopaths are against vaccinations. Their arguments are wilfully misguided; here are just a few examples:

  • It is well known that measles is an important development milestone in the life and maturing processes in children.  Why would anybody want to stop or delay the maturation processes of children and of their immune systems?
  • Homoeopathy offers an option for disease prevention and cure.  There is scientific evidence in favour of homoeopathy for prevention of diseases.
  • Seek out homeopathic, osteopathic, naturopathic, or Chinese medical constitutional treatment to boost your child’s immune system and help them be as healthy as they can be.
  • If your children do get sick, use homeopathy to help their immune system get over it. Homeopathy is very effective in epidemics of acute illness. Either see a homeopath, buy a book on homeopathic acute care, or take a class on acute homeopathic prescribing.
  • It is possible to prevent post-vaccination damage by giving the homeopathic dilution of the vaccine shortly before and    after the vaccination in the C200 dilution.
  • there are many recorded cases of people making dramatic  recoveries with homeopathic medicines following a bad reaction to a  vaccination. Expert advice from a registered homeopath is usually  required.
  • As you would keep your children away from toxic chemicals in the environment as much as possible, inform yourself about the toxicity of the solutions that are being injected into their bloodstream. It’s up to you to find the information: no one loves your children the way you do.

If you think I cherry-picked these quotes, you are mistaken. I simply used the citations as they appeared on my computer screen after a simple Google search. You might try this yourself because there are hundreds, if not thousands more to be discovered.

A typical and interesting example of a homeopathic anti-vaccinationist is Oksana Frolov, D.Hom. graduate of Saint Petersburg, Russia, I.P.Pavlov State Medical University, General Medicine, and graduate of Los Angeles School of Homeopathy. She states that, although I do hold a medical degree, I am not a licensed medical health provider in the United States. As a homeopathic practitioner, I will provide you with the treatment which is alternative or complementary to healing arts that are licensed by the State of California. On her blog, she provides detailed advice for people who might be uncertain whether to vaccinate their children: immunisation… can cause some very serious side effects including permanent brain damage, epilepsy, autism, and mental retardation. With so many vaccinations being required, doctors often have to administer several shots at a time, which can often result in a disaster.  Vaccines, along with the elements that are supposed to create the antibodies, also contain mercury, aluminum, formaldehyde, animal tissue, animal blood, human cell from aborted babies, potatoes, yeast, lactose, phenol, antibiotics and unrelated species of germs that inadvertently get into the vaccines. Do you really want all this to be injected into your child just to prevent him or her from having a chicken pox? Vaccines are said to work by stimulating the body to produce antibodies, which are supposed to protect us from an invasion of harmful germs. Childhood diseases, such as measles, mumps, rubella and chicken pox, affect the immune system in a way that makes most people immune to them for the rest of their lives. Vaccinations, on the other hand, create an artificial immunity that wears off and allows the person to catch the disease later in life….

Homeopathy has proved to be very effective in treatment of childhood diseases, as well as other infections. From its earliest days, homeopathy has been able to treat epidemic disease, such as cholera, typhus, yellow fever, and diphtheria, with a substantial rate of success, when compared to conventional treatments. 

Doctors who practice homeopathy usually claim that only non-medically qualified homeopaths hold such deranged views. Dr Frolov shows us that this assumption is clearly not true. In my experience, most homeopaths, medical or not, advise their patients against immunizations or are at least very cagey about this subject in order to raise doubts in concerned parents. Professional organisations of homeopaths usually hide behind some powerless statement in favour of informed choice; yet they must be well-aware that many of their members fail to abide by it. And what do they do about it? Nothing!

Yes, I am afraid the fight of many homeopaths against public health is active, incessant and often criminal. Of course, they do not for one second believe that they are doing anything wrong; on the contrary, they are convinced of their good intentions. As Bert Brecht once wrote, THE OPPOSITE OF GOOD IS NOT EVIL, BUT GOOD INTENTIONS.

A recent interview on alternative medicine for the German magazine DER SPIEGEL prompted well over 500 comments; even though, in the interview, I covered numerous alternative therapies, the discussion that followed focussed almost entirely on homeopathy. Yet again, many of the comments provided a reminder of the quasi-religious faith many people have in homeopathy.

There can, of course, be dozens of reasons for such strong convictions. Yet, in my experience, some seem to be more prevalent and important than others. During my last two decades in researching homeopathy, I think, I have identified several of the most important ones. In this post, I try to outline a typical sequence of events that eventually leads to a faith in homeopathy which is utterly immune to fact and reason.

The epiphany

The starting point of this journey towards homeopathy-worship is usually an impressive personal experience which is often akin to an epiphany (defined as a moment of sudden and great revelation or realization). I have met hundreds of advocates of homeopathy, and those who talk about this sort of thing invariably offer impressive stories about how they metamorphosed from being a ‘sceptic’ (yes, it is truly phenomenal how many believers insist that they started out as sceptics) into someone who was completely bowled over by homeopathy, and how that ‘moment of great revelation’ changed the rest of their lives. Very often, this ‘Saulus-Paulus conversion’ relates to that person’s own (or a close friend’s) illness which allegedly was cured by homeopathy.

Rachel Roberts, chief executive of the Homeopathy Research Institute, provides as good an example of this sort of epiphany as anyone; in an article in THE GUARDIAN, she described her conversion to homeopathy with the following words:

I was a dedicated scientist about to begin a PhD in neuroscience when, out of the blue, homeopathy bit me on the proverbial bottom.

Science had been my passion since I began studying biology with Mr Hopkinson at the age of 11, and by the age of 21, when I attended the dinner party that altered the course of my life, I had still barely heard of it. The idea that I would one day become a homeopath would have seemed ludicrous.

That turning point is etched in my mind. A woman I’d known my entire life told me that a homeopath had successfully treated her when many months of conventional treatment had failed. As a sceptic, I scoffed, but was nonetheless a little intrigued.

She confessed that despite thinking homeopathy was a load of rubbish, she’d finally agreed to an appointment, to stop her daughter nagging. But she was genuinely shocked to find that, after one little pill, within days she felt significantly better. A second tablet, she said, “saw it off completely”.

I admit I ruined that dinner party. I interrogated her about every detail of her diagnosis, previous treatment, time scales, the lot. I thought it through logically – she was intelligent, she wasn’t lying, she had no previous inclination towards alternative medicine, and her reluctance would have diminished any placebo effect.

Scientists are supposed to make unprejudiced observations, then draw conclusions. As I thought about this, I was left with the highly uncomfortable conclusion that homeopathy appeared to have worked. I had to find out more.

So, I started reading about homeopathy, and what I discovered shifted my world for ever. I became convinced enough to hand my coveted PhD studentship over to my best friend and sign on for a three-year, full-time homeopathy training course.

Now, as an experienced homeopath, it is “science” that is biting me on the bottom. I know homeopathy works…

As I said, I have heard many strikingly similar accounts. Some of these tales seem a little too tall to be true and might be a trifle exaggerated, but the consistency of the picture that emerges from all of these stories is nevertheless extraordinary: people get started on a single anecdote which they are prepared to experience as an epiphanic turn-around. Subsequently, they are on a mission of confirming their new-found belief over and over again, until they become undoubting disciples for life.

So what? you might ask. But I do think this epiphany-like event at the outset of a homeopathic career is significant. In no other area of health care does the initial anecdote regularly play such a prominent role. People do not become believers in aspirin, for instance, on the basis of a ‘moment of great revelation’, they may take it because of the evidence. And, if there is a discrepancy between the external evidence and their own experience, as with homeopathy, most people would start to reflect: What other explanations exist to rationalise the anecdote? Invariably, there are many (placebo, natural history of the condition, concomitant events etc.).

Confirmation bias

Epiphany-stuck believers spends much time and effort to actively look for similar stories that seem to confirm the initial anecdote. They might, for instance, recommend or administer or prescribe homeopathy to others, many of whom would report positive outcomes. At the same time, all anecdotes that do not happen to fit the belief are brushed aside, forgotten, supressed, belittled, decried etc. This process leads to confirmation after confirmation after confirmation – and gradually builds up to what proponents of homeopathy would call ‘years of experience’. And ‘years of experience’ can, of course, not be wrong!

Again, believers neglect to question, doubt and rationalise their own perceptions. They ignore the fact that years of experience might just be little more than a suborn insistence on repeating one’s own mistakes. Even the most obvious confounders such as selective memory or alternative causes for positive clinical outcomes are quickly dismissed or not even considered at all.

Avoiding cognitive dissonance at all cost

But believers still has to somehow deal with the scientific facts about homeopathy; and these are, of course, grossly out of line with their belief. Thus the external evidence and the internal belief would inevitably clash creating a shrill cognitive dissonance. This must be avoided at all cost, as it might threaten the believer’s peace of mind. And the solution is amazingly simple: scientific evidence that does not confirm the believer’s conviction is ignored or, when this proves to be impossible, turned upside down.

Rachel Roberts’ account is most enlightening also in this repect:

And yet I keep reading reports in the media saying that homeopathy doesn’t work and that this scientific evidence doesn’t exist.

The facts, it seems, are being ignored. By the end of 2009, 142 randomised control trials (the gold standard in medical research) comparing homeopathy with placebo or conventional treatment had been published in peer-reviewed journals – 74 were able to draw firm conclusions: 63 were positive for homeopathy and 11 were negative. Five major systematic reviews have also been carried out to analyse the balance of evidence from RCTs of homeopathy – four were positive (Kleijnen, J, et al; Linde, K, et al; Linde, K, et al; Cucherat, M, et al) and one was negative (Shang, A et al). It’s usual to get mixed results when you look at a wide range of research results on one subject, and if these results were from trials measuring the efficacy of “normal” conventional drugs, ratios of 63:11 and 4:1 in favour of a treatment working would be considered pretty persuasive.

This statement is, in my view, a classic example of a desperate misinterpretation of the truth as a means of preventing the believer’s house of cards from collapsing. It even makes the hilarious claim that not the believers but the doubters “ignore” the facts.

In order to be able to adhere to her belief, Roberts needs to rely on a woefully biased white-wash from the ‘British Homeopathic Association’. And, in order to be on the safe side, she even quotes it misleadingly. The conclusion of the Cucherat review, for instance, can only be seen as positive by most blinkered of minds: There is some evidence that homeopathic treatments are more effective than placebo; however, the strength of this evidence is low because of the low methodological quality of the trials. Studies of high methodological quality were more likely to be negative than the lower quality studies. Further high quality studies are needed to confirm these results. Contrary to what Roberts states, there are at least a dozen more than 5 systematic reviews of homeopathy; my own systematic review of systematic reviews, for example, concluded that the best clinical evidence for homeopathy available to date does not warrant positive recommendations for its use in clinical practice.

It seems that, at this stage of a believer’s development, the truth gets all too happily sacrificed on the altar of faith. All these ‘ex-sceptics’ turned believers are now able to display is a rather comical parody of scepticism.

The delusional end-stage

The last stage in the career of a believer has been reached when hardly anything that he or she is convinced of resembles reality any longer. I don’t know much about Rachel Roberts, and she might not have reached this point yet; but there are many others who clearly have.

My two favourite examples of end-stage homeopathic delusionists are John Benneth and Dana Ullman. The final stage on the journey from ‘sceptic scientist’ to delusional disciple is characterised by an incessant stream of incoherent statements of vile nonsense that beggars belief. It is therefore easy to recognise and, because nobody can possibly take the delusionists seriously, they are best viewed as relatively harmless contributors to medical comedy.

Why does all of this matter?

Many homeopathy-fans are quasi-religious believers who, in my experience, have degressed way beyond reason. It is therefore a complete waste of time trying to reason with them. Initiated by a highly emotional epiphany, their faith cannot be shaken by rational arguments. Similar but usually less pronounced attitudes, I am afraid, can be observed in true believers of other alternative treatments as well (here I have chosen the example of homeopathy mainly because it is the area where things are most explicit).

True believers claim to have started out as sceptics and they often insist to be driven by a scientific mind. Yet I have never seen any evidence for these assumptions. On the contrary, for a relatively trivial episode to become a life-changing epiphany, the believer’s mind needs to be lamentably unscientific, unquestioning and simple.

In my experience, true believers will not change their mind; I have never seen this happening. However, progress might nevertheless be made, if we managed to instil a more (self-) questioning rationality and scientific attitudes into the minds of the next generations. In other words, we need better education in science and more training of critical thinking during their formative years.

I have been challenged by homeopaths! Not again you might think, but this one is quite interesting.

Some time ago, I gave an interview in which I stated that, for a while, I had assumed homeopaths to be just a little over-enthusiastic but, over the years, I have come to the conclusion that many of them are lying outright (the interview is in German, and I used the term “luegen wie gedruckt”). Predictably, this has prompted fierce opposition from homeopaths who objected to my claim and demand proof of this statement.

So, here I will try to provide some evidence – only SOME because there is far too much for a short post of this nature. To get started, I quickly googled ‘homeopathy’ and, impressively, the very first site already provided me with the following quotes:

Homeopathy is extremely effective.

Homeopathy is completely safe.

Homeopathy is natural.

Homeopathy is holistic.

None of these statements is true; and if they are not true, they must be lies (defined as “an untrue or deceptive statement deliberately used to mislead“)! Yes, I don’t mean errors, I do mean deliberate lies.

In fact, if we want to find proof for my statement ‘MANY HOMEOPATHS LIE OUTRIGHT’, we are spoilt for choice. For instance, any homeopath who mis-quoted the so-called ‘Swiss report’ on homeopathy as being an official document of the Swiss government even when its true nature had been disclosed over and over again, was clearly telling lies; and Dana Ullman must be the undisputed champion in this respect.

But there is more – much, much more! Homeopaths who promote their placebos as a cure of AIDS or cancer or any other serious disease are not just lying, they are endangering the health of millions. If anyone wants to read about individual homeopaths or organisations that have issued lies, I recommend reading this site which provides plenty of names and interesting links.

I think, I can stop here – but I do invite readers to post their own examples of ‘homeopathic lies’ in the comments below.

Sorry homeopaths, but you did ask for it!

Irritable bowel syndrome (IBS) is common and often difficult to treat – unless, of course, you consult a homeopath. Here is just one of virtually thousands of quotes from homeopaths available on the Internet: Homeopathic medicine can reduce Irritable Bowel Syndrome (IBS) symptoms by lowering food sensitivities and allergies. Homeopathy treats the patient as a whole and does not simply focus on the disease. Careful attention is given to the minute details about the presenting complaints, including the severity of diarrhea, constipation, pain, cramps, mucus in the stools, nausea, heartburn, emotional triggers and conventional laboratory findings. In addition, the patient’s eating habits, food preferences, thermal attributes and sleep patterns are noted. The patient’s family history and diseases, along with the patient’s emotions are discussed. Then the homeopathic practitioner will select the remedy that most closely matches the symptoms.

Such optimism might be refreshing, but is there any reason for it? Is homeopathy really an effective treatment for IBS? To answer this question, we now have a brand-new Cochrane review. The aim of this review was to assess the effectiveness and safety of homeopathic treatment for treating irritable bowel syndrome (IBS). (This type of statement always makes me a little suspicious; how on earth can anyone truly assess the safety of a treatment by looking at a few studies? This is NOT how one evaluates safety!) The authors conducted extensive literature searches to identify all RCTs, cohort and case-control studies that compared homeopathic treatment with placebo, other control treatments, or usual care in adults with IBS. The primary outcome was global improvement in IBS.

Three RCTs with a total of 213 participants were included. No cohort or case-control studies were identified. Two studies compared homeopathic remedies to placebos for constipation-predominant IBS. One study compared individualised homeopathic treatment to usual care defined as high doses of dicyclomine hydrochloride, faecal bulking agents and a high fibre diet. Due to the low quality of reporting, the risk of bias in all three studies was unclear on most criteria and high for some criteria.

A meta-analysis of two studies with a total of 129 participants with constipation-predominant IBS found a statistically significant difference in global improvement between the homeopathic ‘asafoetida’ and placebo at a short-term follow-up of two weeks. Seventy-three per cent of patients in the homeopathy group improved compared to 45% of placebo patients. There was no statistically significant difference in global improvement between the homeopathic asafoetida plus nux vomica compared to placebo. Sixty-eight per cent of patients in the homeopathy group improved compared to 52% of placebo patients.

The overall quality of the evidence was very low. There was no statistically significant difference between individualised homeopathic treatment and usual care for the outcome “feeling unwell”. None of the studies reported on adverse events (which, by the way, should be seen as a breech in research ethics on the part of the authors of the three primary studies).

The authors concluded that a pooled analysis of two small studies suggests a possible benefit for clinical homeopathy, using the remedy asafoetida, over placebo for people with constipation-predominant IBS. These results should be interpreted with caution due to the low quality of reporting in these trials, high or unknown risk of bias, short-term follow-up, and sparse data. One small study found no statistically difference between individualised homeopathy and usual care (defined as high doses of dicyclomine hydrochloride, faecal bulking agents and diet sheets advising a high fibre diet). No conclusions can be drawn from this study due to the low number of participants and the high risk of bias in this trial. In addition, it is likely that usual care has changed since this trial was conducted. Further high quality, adequately powered RCTs are required to assess the efficacy and safety of clinical and individualised homeopathy compared to placebo or usual care.

THIS REVIEW REQUIRES A FEW FURTHER COMMENTS, I THINK

Asafoetida, the remedy used in two of the studies, is a plant native to Pakistan, Iran and Afghanistan. It is used in Ayurvedic herbal medicine to treat colic, intestinal parasites and irritable bowel syndrome. In the ‘homeopathic’ trials, asafoetida was used in relatively low dilutions, one that still contains molecules. It is therefore debatable whether this was really homeopathy or whether it is more akin to herbal medicine – it was certainly not homeopathy with its typical ultra-high dilutions.

Regardless of this detail, the Cochrane review does hardly provide sound evidence for homeopathy’s efficacy. On the contrary, my reading of its findings is that the ‘possible benefit’ is NOT real but a false positive result caused by the serious limitations of the original studies. The authors stress that the apparently positive result ‘should be interpreted with caution’; that is certainly correct.

So, if you are a proponent of homeopathy, as the authors of the review seem to be, you will claim that homeopathy offers ‘possible benefits’ for IBS-sufferers. But if you are not convinced of the merits of homeopathy, you might suggest that the evidence is insufficient to recommend homeopathy. I imagine that IBS-sufferers might get as frustrated with such confusion as most scientists will be. Yet there is hope; the answer could be imminent: apparently, a new trial is to report its results within this year.

IS THIS NEW TRIAL GOING TO CONTRIBUTE MEANINGFULLY TO OUR KNOWLEDGE?

It is a three-armed study (same 1st author as in the Cochrane review) which, according to its authors, seeks to explore the effectiveness of individualised homeopathic treatment plus usual care compared to both an attention control plus usual care and usual care alone, for patients with IBS. (Why “explore” and not “determine”, I ask myself.) Patients are randomly selected to be offered, 5 sessions of homeopathic treatment plus usual care, 5 sessions of supportive listening plus usual care or usual care alone. (“To be offered” looks odd to me; does that mean patients are not blinded to the interventions? Yes, indeed it does.) The primary clinical outcome is the IBS Symptom Severity at 26 weeks. Analysis will be by intention to treat and will compare homeopathic treatment with usual care at 26 weeks as the primary analysis, and homeopathic treatment with supportive listening as an additional analysis.

Hold on…the primary analysis “will compare homeopathic treatment with usual care“. Are they pulling my leg? They just told me that patients will be “offered, 5 sessions of homeopathic treatment plus usual care… or usual care alone“.

Oh, I see! We are again dealing with an A+B versus B design, on top of it without patient- or therapist-blinding. This type of analysis cannot ever produce a negative result, even if the experimental treatment is a pure placebo: placebo + usual care is always more than usual care alone. IBS-patients will certainly experience benefit from having the homeopaths’ time, empathy and compassion – never mind the remedies they get from them. And for the secondary analyses, things do not seem to be much more rigorous either.

Do we really need more trials of this nature? The Cochrane review shows that we currently have three studies which are too flimsy to be interpretable. What difference will a further flimsy trial make in this situation? When will we stop wasting time and money on such useless ‘research’? All it can possibly achieve is that apologists of homeopathy will misinterpret the results and suggest that they demonstrate efficacy.

Obviously, I have not seen the data (they have not yet been published) but I think I can nevertheless predict the conclusions of the primary analysis of this trial; they will read something like this: HOMEOPATHY PROVED TO BE SIGNIFICANTLY MORE EFFECTIVE THAN USUAL CARE. I have asked the question before and I do it again: when does this sort of ‘research’ cross the line into the realm of scientific misconduct?

Some sceptics are convinced that, in alternative medicine, there is no evidence. This assumption is wrong, I am afraid, and statements of this nature can actually play into the hands of apologists of bogus treatments: they can then easily demonstrate the sceptics to be mistaken or “biased”, as they would probably say. The truth is that there is plenty of evidence – and lots of it is positive, at least at first glance.

Alternative medicine researchers have been very industrious during the last two decades to build up a sizable body of ‘evidence’. Consequently, one often finds data even for the most bizarre and implausible treatments. Take, for instance, the claim that homeopathy is an effective treatment for cancer. Those who promote this assumption have no difficulties in locating some weird in-vitro study that seems to support their opinion. When sceptics subsequently counter that in-vitro experiments tell us nothing about the clinical situation, apologists quickly unearth what they consider to be sound clinical evidence.

An example is this prospective observational 2011 study of cancer patients from two differently treated cohorts: one cohort with patients under complementary homeopathic treatment (HG; n = 259), and one cohort with conventionally treated cancer patients (CG; n = 380). Its main outcome measures were the change of quality life after 3 months, after one year and impairment by fatigue, anxiety or depression. The results of this study show significant improvements in most of these endpoints, and the authors concluded that we observed an improvement of quality of life as well as a tendency of fatigue symptoms to decrease in cancer patients under complementary homeopathic treatment.

Another, in some ways even better example is this 2005 observational study of 6544 consecutive patients from the Bristol Homeopathic Hospital. Every patient attending the hospital outpatient unit for a follow-up appointment was included, commencing with their first follow-up attendance. Of these patients 70.7% (n = 4627) reported positive health changes, with 50.7% (n = 3318) recording their improvement as better or much better. The authors concluded that homeopathic intervention offered positive health changes to a substantial proportion of a large cohort of patients with a wide range of chronic diseases.

The principle that is being followed here is simple:

  • believers in a bogus therapy conduct a clinical trial which is designed to generate an apparently positive finding;
  • the fact that the study cannot tell us anything about cause and effect is cleverly hidden or belittled;
  • they publish their findings in one of the many journals that specialise in this sort of nonsense;
  • they make sure that advocates across the world learn about their results;
  • the community of apologists of this treatment picks up the information without the slightest critical analysis;
  • the researchers conduct more and more of such pseudo-research;
  • nobody attempts to do some real science: the believers do not truly want to falsify their hypotheses, and the real scientists find it unreasonable to conduct research on utterly implausible interventions;
  • thus the body of false or misleading ‘evidence’ grows and grows;
  • proponents start publishing systematic reviews and meta-analyses of their studies which are devoid of critical input;
  • too few critics point out that these reviews are fatally flawed – ‘rubbish in, rubbish out’!
  • eventually politicians, journalists, health care professionals and other people who did not necessarily start out as believers in the bogus therapy are convinced that the body of evidence is impressive and justifies implementation;
  • important health care decisions are thus based on data which are false and misleading.

So, what can be done to prevent that such pseudo-evidence is mistaken as solid proof which might eventually mislead many into believing that bogus treatments are based on reasonably sound data? I think the following measures would be helpful:

  • authors should abstain from publishing over-enthusiastic conclusions which can all too easily be misinterpreted (given that the authors are believers in the therapy, this is not a realistic option);
  • editors might consider rejecting studies which contribute next to nothing to our current knowledge (given that these studies are usually published in journals that are in the business of promoting alternative medicine at any cost, this option is also not realistic);
  • if researchers report highly preliminary findings, there should be an obligation to do further studies in order to confirm or refute the initial results (not realistic either, I am afraid);
  • in case this does not happen, editors should consider retracting the paper reporting unconfirmed preliminary findings (utterly unrealistic).

What then can REALISTICALLY be done? I wish I knew the answer! All I can think of is that sceptics should educate the rest of the population to think and analyse such ‘evidence’ critically…but how realistic is that?

According to its authors, this RCT was aimed at investigating the 1) specific effect of individualized homeopathic Q-potencies compared to placebo and 2) the effect of an extensive homeopathic case taking (case history I) compared to a shorter, rather conventional one (case history II) in the treatment of acute major depression. In particular the second research question is intriguing, I think – so let’s have a closer look at this trial.

The study was designed as a randomized, partially double-blind, placebo-controlled, four-armed, 2×2 factorial trial with a 6-week study duration. A total of 44 patients were randomized (2∶1∶2∶1 randomization: 16 homeopathic Q-potencies/case history I, 7 placebo/case history I, 14 homeopathic Q-potencies/case history II, 7 placebo/case history II). Because of recruitment problems, the study was terminated prior to full recruitment, and was thus underpowered for the pre-planned confirmatory hypothesis testing. Exploratory data analyses showed heterogeneous and inconclusive results with large variance. The mean difference for the Hamilton-D after 6 weeks was 2.0 (95%CI -1.2;5.2) for Q-potencies vs. placebo, and -3.1 (-5.9;-0.2) for case history I vs. case history II. Overall, no consistent or clinically relevant results between homeopathic Q-potencies versus placebo and homeopathic versus conventional case taking were observed. The frequency of adverse events was comparable for all groups.

The conclusions were remarkable: although our results are inconclusive, given that recruitment into this trial was very difficult and we had to terminate early, we cannot recommend undertaking a further trial addressing this question in a similar setting.

Alright, the authors encountered problems in recruiting enough patients and they therefore decided to stop the trial early. This sort of thing happens. Most researchers would then not publish any data at all. This team, however, did publish a report, and the decision to do so might be perfectly fine: other investigators might learn from the problems which led to early termination of the study.

But why do they conclude that the results were INCONCLUSIVE? I think the results were not inconclusive but non-existent; these were no results to report other than those related to the recruitment problems. And even if one insists on presenting outcome data as an exploratory analysis, one cannot honestly say they were INCONCLUSIVE, all one might state in this case is that the results failed to show an effect of the remedy or the consultation. This is far less favourable for homeopathy than stating the results were INCONCLUSIVE.

And why on earth do the authors conclude “we cannot recommend undertaking a further trial addressing this question in a similar setting”? This does not make the slightest sense to me. If the trialists encountered recruitment problems, others might find ways of overcoming them. The research question asking whether the effects of an extensive homeopathic case taking differ from those of a shorter conventional one seems important. If answered accurately, it could disentangle much of the confusion that surrounds clinical trials of homeopathy.

I have repeatedly commented on the odd conclusions drawn by proponents of alternative medicine on the basis of data that did not quite fulfil their expectations, and I often ask myself at what point this ‘prettification’ of the results via false positive conclusions crosses the line to scientific misconduct. My theory is that these conclusions appear odd to those capable of critical analysis because the authors bend over backwards in order to conclude more positively than the data would seem to permit. If we see it this way, such conclusions might even prove useful as a fairly sensitive ‘bullshit-detector’.

I am delighted to report that my invitation to contribute AT FAPs was successful! Some readers did indeed cotton on and submitted their funny satire and bizarre absurdities – oddly enough, they are all homeopathic by nature. If you like to know more about the idea of AT FAPs, please see here. And do not forget: if you want me to continue with this feature, keep your alt med satire coming!

AT FAP No 4 (sent in by an anonymous reader)

You’ve heard or Gerson but now we can reveal Dyson therapy!

The well established and long-proven facts of homeopathy – that like cures like, ultra diluted solutions of nothing are incredibly potent medicines, Hahnemann can’t be wrong etc. have, of course revolutionised our world view.  Nothing substantial had changed in homeopathy for 200 years, until now!  Vacuous homeopaths have now discovered an amazing breakthrough- Dyson therapy. After extensive research one afternoon, they have made a breakthrough that will rock the world and clean your carpet.

Some homeopaths believe that ultra diluted water contains silica that is remarkably similar to that found in the glass vessels it is prepared in. Vacuous homeopaths have found a way to reduce the content of the water still further, indeed eliminate it completely!

Using the principle of like cures like, a material is chosen for its powerful homeopathic effects,  and ground up in a small amount of water and/or alcohol until it turns into a paste or solution. Now here’s the science bit- it is then smeared on the floor. After being allowed to dry for precisely 3.4 minutes (trust us) it is then vacuumed up! This amazing breakthrough allows the nano-bollock essence of the material to be firmly trapped within the vacuum cleaner, but here is the genius part-as air is drawn over it the nano-bollock material is infinitely diluted. No need for complicated machines you can do this yourself at home. Vacuous homeopaths have found that the vacuum cleaner has to be tapped on the floor during the process, or for a far more potent effect on the head of a sceptic (we call this concussion). It has to be tapped a precise number of times, the number is decided by the current cost in pence of a avocado pear, this in scientific terms is known as the avocado number  -trust us it works!

We now have a homeopathic remedy inside the cleaner. The patient takes a tube from the cleaner applies it to their mouth * and vacuums out all those nasty miasmas  whilst simultaneously increasing the potency of the homeopathic preparation by yet further dilution.  But that’s not all! Dyson therapy removes harmful mercury vapour from your fillings, this is truly miraculous.

Until now vacuous homeopaths have argued that homeopathy  has no side effects effects. Sceptics have argued this is because it contains nothing does nothing and is worth nothing. Vacuous homeopaths have now found side effects, after all when you prepare the ultimate vacuum potencies we are dealing with the strongest medicine in the universe. Side effects include blisters of the lips and mouth, ruptured lungs and feelings of intense stupidity.

* Some experiments with Dyson therapy have been abandoned due to penile injury, but an exciting new avenue of research – anal Dyson therapy is being intensively studied, this combined with coffee enemas is an exciting new wake up call for homepathy. So far results have shown that homeopaths are full of shit.

Disclaimer: I do not own shares in Dyson, and am in no way associated with the company – Big Pharma wouldn’t let me. Other brands of vacuum cleaner are available.

AT FAP No5 (sent in by Norbert Aust)

German scientist succeeded in creating the ultimate homeopathic remedy: Vinum Christi C200! This remedy combines strong beliefs and ancient wisdom from christianity with the more recent scientific achievements of current homeopathy.

Details on the procedure are not clear yet, but the scientist (name known to the edotor) succeeded in building an entanglement with the the molecules of Our Lord’s last goblet of wine that today can be found in any glass of water. By banging his head on the wall he could successfully succuss just these molecules and could build a very powerful mother tincture. Further potentization yielded a very strong remedy, much more powerful than any of the current homeopathic alcoholic dilutions. It took only one tiny drop of this solution to turn a bottle of Scotch whisky into a very efficacious tincture outperforming any of our Lord’s wines or what you would expect of todays wines. In fact, the proving got a little out of control, but the effects could be witnessed nevertheless. It seems a perfect medicine for headaches, vertigo, nausea, general pain and feeling of being sick, difficulties in eye focus and speech, turns of general love and hate of the world in total. Many more symptoms expected to be found in further provings.

The scientist – after he recovered fronm the proving – made it a point, that the preparation of the mother tincture requires much experience and personality. The beginner might well end up entangled with the wrong molecules in his glass of water (like the donkey’s first pee after he carried our Lord to Jerusalem), which may lead to unpredictable results when proving the final compound.

Adress any inquiries for marketing of this medicine to the editor who will forward it to the scientist.

A recent article  by a South African homeopath promoted the concept of homeopaths taking over the role of primary care practitioners. His argument essentially was that, in South Africa, homeopaths are well trained and thus adequately equipped to do this job responsibly. Responsibly, really? You find that hard to believe? Here are the essentials of his arguments including all his references in full. I think they are worth reading.

Currently, the Durban University of Technology (DUT) and the University of Johannesburg (UJ) offer degree’s in homoeopathy. This involves a 5-year full-time theoretical and practical training course, followed by a Master’s level research project. After fulfilment of these criteria, a Master’s Degree in Technology (Homoeopathy) is awarded. The course comprises of a strong core of medical subjects, such as the basic sciences of Anatomy, Physiology, Medical Microbiology, Biochemistry and Epidemiology, and the clinical sciences of Pathology and Diagnostics. This is complemented with subjects in Classical, Clinical and Modern Homoeopathy and Homoeopharmaceutics4,5

By law, any person practicing homoeopathy in South Africa must be registered with the Allied Health Professions Council of South Africa (AHPCSA). This is essential, as the Council ensures both medical and homoeopathic competency of practitioners, and that the activities of registered practitioners are closely monitored by the Professional Board. The purpose of the AHPCSA is to ensure that only those with legitimate qualifications of a high enough standard are registered and allowed to practice in South Africa, thus protecting the public against any fraudulent behaviour and illegal practitioners. Therefore, in order to ensure effective homoeopathic treatment, it is essential that any person wishing to prescribe homoeopathic medicine or practice homoeopathy in South Africa must be registered as a Homoeopathic Practitioner with the Allied Health Professions Council of South Africa. This includes conventional Medical Practitioners (dual registration is allowed for Medical Practitioners with both the Health Professions Council and AHPCSA)6,  as homoeopathy requires several years of training in order to apply effectively in clinical practice… 

Registration with the Council affords medico-legal rights similar to those of a medical professional, where treatment is limited to the scope of homoeopathic practice. Thus a homoeopath is firstly a trained diagnostician, and with successful registration with the Council, obtains the title Doctor. A homoeopath is trained and legally obliged to conduct a full medical history, a comprehensive clinical examination, and request further medical investigations, such as blood tests and X-rays, in order to fully assess patients. This is coupled with the ability to consult with specialist pathologists and other medical specialists when necessary, and refer a patient to the appropriate practitioner if the condition falls outside the scope of homoeopathic practice. A homoeopath may also legally issue a certificate of dispensation (‘Doctor’s note’) with appropriate evidence and within reason, and is deemed responsible for the diagnosis and treatment of patients under their care6. A homoeopath is not trained or licensed in any form of surgery, specialist diagnostics (e.g. colonoscopy or angiograms), cannot prescribe prescription medication and is not lawfully allowed to conduct intra-venous treatment of any kind. However, a registered homoeopath is licensed to use intra-muscular homoeopathic injectables in the treatment of various local or systemic complaints when necessary.

Conventional (allopathic) medicine generally targets specific biochemical processes with mostly chemically synthesised medication, in an attempt to suppress a symptom. However, in doing so, this usually negatively affects other biochemical reactions which results in an imbalance within the system. Homoeopathy, by contrast, seeks to re-establish a balance within the natural functioning of the body, restore proper function and results in the reduction or cessation of symptoms.  Homoeopathy therefore enables the body to self-regulate and self-heal, a process known as homeostasis that is intrinsic to every living organism.

Conventional medical treatment is by no means risk free. Iatrogenic (medically induced) deaths in the United States are estimated at 786 000 per year, deaths which are considered avoidable by medical doctors7,8. These figures put annual iatrogenic death in the American medical system above that of cardiovascular disease and cancer as the leading cause of death in that country9, a fact that is not widely reported! South African figures are not easily available, but it is likely that we have similar rates. Although conventional medications have a vital role, are sometimes necessary and can of-course be life-saving, all too often too many patients are put on chronic medication when there are numerous effective, natural, safe and scientifically substantiated options available….

According to the World Health Organisation (WHO), homeopathy is the second largest system of medicine in the world, and world-wide use continues to grow in developed and developing nations10. Homoeopathy is widely considered to be safe and effective, with both clinical and laboratory research providing evidence for the efficacy of homoeopathy11. As the range of potential conditions that homoeopathy can treat is almost limitless, and that treatment is not associated with adverse reactions, homoeopathy should be considered a first-line therapy for all ages. As homoeopaths in South Africa are considered primary health care practitioners, if a conventional approach is deemed necessary, and further diagnostics are required, your practitioner will not hesitate to refer you to the appropriate health care practitioner. Homeopathy is also used alongside conventional medicine and any other form of therapy, and should be seen as ‘complementary’ medicine and not ‘alternative’ medicine.

 

Conclusion

Homoeopathy is an approach that is widely considered to be safe, and when utilised correctly, can be effective for a wide range of conditions. As a primary health care practitioner, a homoeopath is able to handle all aspects of general practice and family health care, including diagnostics, case management and referral to other practitioners or medical specialists. A registered homoeopath is legally responsible to ensure the adequate treatment of their patients, and is accountable for all clinical decisions and advice. A registered homoeopath understands the role of conventional medicine, and will refer to the appropriate specialist in cases that fall outside the legal scope of practice.

 

 

References

1. http://homeopathyresource.wordpress.com/what-is-homeopathy (accessed 31 March 2010)

2.  Bloch R, Lewis B. Homoeopathy for the home. Cape Town, South Africa: Struik Publishers: 2003

3. http://www.dut.ac.za/site/awdep.asp?depnum=22609 (accessed 1 April 2010)

4. http://dutweb.dut.ac.za/handbooks/HEALTH%20Homoeopathy.pdf (accessed 1 April 2010)

5. http://www.uj.ac.za/EN/Faculties/health/departments/homeopathy/coursesandprogrammes/undergraduate/Pages/default.aspx (accessed 1 April 2010)

6. http://www.ahpcsa.co.za/pb_pbhnp_homoeopathy.htm (accessed 6 April 2010)

7. Starfield, B. Is US Health Really the Best in the World? JAMA 2000; 284(4).

8. Null G, Dean C, et al. Death by Medicine. Nutrition Institute of America 2003. 9. http://www4.dr-rath-foundation.org/features/death_by_medicine.html (accessed 7 April 2010)

10. http://ukiahcommunityblog.wordpress.com/2010/03/04/worldwide-popularity-grows-for-homeopathy-alternative-medicine/#comments (accessed 7 April 2010)

11. http://liga.iwmh.net/dokumente/upload/556c7_SCIEN_FRA_2009_final_approved.pdf (accessed 7 April 2010)

I found this article extremely revealing and scary. It gives us an important glimpse into the way some or perhaps even most homeopaths think. They clearly believe that:

1) Their training is sufficient for them to become competent primary care professionals, i.e. clinicians who are the first port of call for sick people  to be diagnosed and treated effectively.

2) Homeopathy is scientifically proven to be efficacious for an ‘almost limitless’ range of conditions. Interestingly, not a single reference is provided to support this claim. Nevertheless, homeopath believe it, and that seems to be enough.

3) Homeopaths seem convinced that they perfectly understand real medicine; yet all they really do is to denounce it as one of the biggest killer of mankind.

4) The fact that homeopaths cannot prescribe real medicine is not seen as a hindrance to their role as primary care practitioner; if anything, homeopaths consider this to be an advantage.

5) Homeopaths view registration with some sort of governing body as the ultimate legitimation of their trade. Once such regulatory measures are in place, the need to support any of their claims with evidence is nil and void.

This article did remind me of the wry statement that ‘HOMEOPATHY IS TO MEDICINE WHAT THE CARPET INDUSTRY IS TO AVIATION’. Homeopaths truly live on a different planet, a planet where belief is everything and responsibility is an alien concept. I certainly hope that they will not take over planet earth in a hurry. If I imagine a world where homeopaths dominate primary care in the way it is suggested in this article, I start having nightmares. It seems to me that people who harbour ideas of this type are not just deluded to the point of madness but they are a danger to public health.

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