The notorious tendency of pharmacist to behave like shop-keepers when it comes to the sale of bogus remedies has been the subject of this blog many times before. In my view, this is an important subject, and I will therefore continue to report about it.
On the website of the AUSTRALIAN JOURNAL OF PHARMACY (AJP), we find interesting new data on Australian pharmacists’ love affair with bogus alternative medicine. The AJP recently ran a poll asking readers: “Do you stock Complementary Medicines (CMs) in your pharmacy?” The results of this little survey so far show that 54% of all participating pharmacists say they stock CMs, including homeopathic products. About a quarter (28%) of respondents stock CMs but not homeopathic products. And 9% said they “only stock evidence-based CMs”. Three percent completely refuse to stock CMs, while 2% stock them but with clear in-store labels saying that they may not work. One person stated they stock CMs but have recently decided to no longer do so.
The President of the Pharmaceutical Society of Australia (PSA) Joe Demarte commented on these findings: “The latest survey results, showing over 40% of pharmacists are adhering to PSA’s Code of Ethics on complementary medicines, are very encouraging… However it’s disappointing that some pharmacists are still stocking homeopathy products, which are not supported by PSA’s Code of Ethics or our Position Statement on Complementary Medicines… Irrespective of the products stocked in a pharmacy, the important thing is when discussing the use of complementary medicines with consumers, pharmacists must ensure that consumers are provided with the best available information about the current evidence for efficacy, as well as information on any potential side effects, drug interactions and risks of harm… It’s important for pharmacists to provide a fair, honest and balanced view of the current evidence available on all complementary medicines,” Demarte added.
NSW pharmacist Ian Carr, who is a member of the Friends of Science in Medicine group, commented that many pharmacists may not have much choice when it comes to stocking complementary and alternative medicines. “CMs policy is not being filtered through the professional assessment of the pharmacist… It’s basically a business deal with the franchise, and as a pharmacist taking on a franchise you’ve basically got to sign those rights away about what you get to sell. Some of the chains offer basically everything that is available, no questions asked. As an independent pharmacist I am able to make my own decisions about what to stock… We’ve got a ‘de-facto’ corporatisation happening with marketing groups and franchises, and I’m concerned the government will look at this trend and ask, why are we not deregulating the industry to reflect the apparent reality of pharmacy today? We’re only playing into the hands of people who want deregulation… We should be telling people in no uncertain terms that if something is on the shelf it doesn’t mean it’s been assessed or approved by the TGA… There is no doubt that there has been a long-term relationship between the supplement industry and pharmacy. But it was also a few decades ago that researchers started applying the concept of evidence-based medicine to healthcare generally. That should have been the point where we said, ‘we’re not just going to be a conduit for your products without questioning their basis in evidence’. That’s where we lost the plot. The question now is: where do we draw that line? I’m really trying to say to my fellow pharmacists: Please let us reassess the unquestioning support of the CM industry, or we’ll all be tarred with the same brush. I and many others are concerned about – and fighting for – the reputation of the pharmacy profession.”
A BMC Complementary and Alternative Medicine survey by researchers from Alfred Hospital in Melbourne found that 92% thought pharmacists should provide safety information about CMs, while 93% thought it important for pharmacists to be knowledgeable about CMs. This shows a huge divide between what is happening in Australian pharmacy on the one side and ethical demands or public opinion on the other side. What is more, there is little reason to believe that the situation in other countries is fundamentally different.
And did you notice this little gem in the comments above? “…over 40% of pharmacists are adhering to PSA’s Code of Ethics…” – the PSA president finds this ‘VERY ENCOURAGING’.
When I saw this, I almost fell off my chair!
Does the president know that this means that 60% of his members are violating their own code of ethics?
Is that truly VERY ENCOURAGING, I ask myself.
My answer is no, this is VERY WORRYING.
A recently published study was aimed at evaluating the efficacy and safety of potentized estrogen compared to placebo in homeopathic treatment of endometriosis-associated pelvic pain (EAPP). This 24-week, randomized, double-blind, placebo-controlled trial included 50 women aged 18-45 years old with diagnosis of deeply infiltrating endometriosis based on magnetic resonance imaging or transvaginal ultrasound after bowel preparation, and score≥5 on a visual analogue scale (VAS: range 0 to 10) for endometriosis-associated pelvic pain. Potentized estrogen (12cH, 18cH and 24cH) or placebo was administered twice daily. The primary outcome measure was change in the severity of EAPP global and partial scores (VAS) from baseline to week 24, determined as the difference in the mean score of five modalities of chronic pelvic pain (dysmenorrhea, deep dyspareunia, non-cyclic pelvic pain, cyclic bowel pain and/or cyclic urinary pain). The secondary outcome measures were mean score difference for quality of life assessed with SF-36 Health Survey Questionnaire, depression symptoms on Beck Depression Inventory (BDI), and anxiety symptoms on Beck Anxiety Inventory (BAI).
The EAPP global score (VAS: range 0 to 50) decreased by 12.82 in the group treated with potentized estrogen from baseline to week 24. Group that used potentized estrogen also exhibited partial score (VAS: range 0 to 10) reduction in three EAPP modalities: dysmenorrhea (3.28;), non-cyclic pelvic pain (2.71), and cyclic bowel pain (3.40). Placebo group did not show any significant changes in EAPP global or partial scores. In addition, the potentized estrogen group showed significant improvement in three of eight SF-36 domains (bodily pain, vitality and mental health) and depression symptoms (BDI). The placebo group showed no significant improvement in this regard. These results demonstrate superiority of potentized estrogen over placebo. Few adverse events were associated with potentized estrogen.
The authors concluded that potentized estrogen (12cH, 18cH and 24cH) at a dose of 3 drops twice daily for 24 weeks was significantly more effective than placebo for reducing endometriosis-associated pelvic pain.
The study is unusual in several ways. For instance, contrary to most trials of homeopathy, its protocol had been published in ‘Homeopathy’ in August 2016. Here is the abstract:
Endometriosis is a chronic inflammatory disease that causes difficult-to-treat pelvic pain. Thus being, many patients seek help in complementary and alternative medicine, including homeopathy. The effectiveness of homeopathic treatment for endometriosis is controversial due to the lack of evidences in the literature. The aim of the present randomized controlled trial is to assess the efficacy of potentized estrogen compared to placebo in the treatment of chronic pelvic pain associated with endometriosis.
The present is a randomized, double-blind, placebo-controlled trial of a homeopathic medicine individualized according to program ‘New Homeopathic Medicines: use of modern drugs according to the principle of similitude’ (http://newhomeopathicmedicines.com). Women with endometriosis, chronic pelvic pain and a set of signs and symptoms similar to the adverse events caused by estrogen were recruited at the Endometriosis Unit of Division of Clinical Gynecology, Clinical Hospital, School of Medicine, University of São Paulo (Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – HCFMUSP). The participants were selected based on the analysis of their medical records and the application of self-report structured questionnaires. A total of 50 women meeting the eligibility criteria will be randomly allocated to receive potentized estrogen or placebo. The primary clinical outcome measure will be severity of chronic pelvic pain. Statistical analysis will be performed on the intention-to-treat and per-protocol approaches comparing the effect of the homeopathic medicine versus placebo after 24 weeks of intervention.
The present study was approved by the research ethics committee of HCFMUSP and the results are expected in 2016.
END OF QUOTE
As far as I can see, this study has no major flaws (I do not have access, however, to the full article). It seems to suggest that highly diluted homeopathic remedies are efficacious. I am aware of the fact that this will be difficult to accept for many readers of this blog.
So, what should we make of this new trial?
Should we recommend homeopathic estrogen to women suffering from endometriosis? I don’t think so. On the contrary, I recommend a healthy dose of scepticism. Clinical trials can produce false results sometimes by chance or through fraud. In any case, we hardly ever rely on the findings of a single study. The sensible course of action always is to wait for an independent replication (and, of course, study the full text of the paper).
‘Country News’ just published an article about our heir to the throne. Here is an excerpt:
The Prince of Wales has revealed he uses homeopathic treatments for animals on his organic farm at Highgrove to help reduce reliance on antibiotics, the article stated. He said his methods of farming tried wherever possible to ‘‘go with the grain of nature’’ to avoid dependency on antibiotics, pesticides and other forms of chemical intervention.
The prince made these comments to experts at a summit at the Royal Society in London as part of a global battle against the growing threat of antibiotic resistance. ‘‘In fact, it was one of the reasons I converted my farming operation to an organic, or agro-ecological, system over 30 years ago, and why incidentally we have been successfully using homeopathic — yes, homeopathic — treatments for my cattle and sheep as part of a program to reduce the use of antibiotics,’’ Prince Charles said. Calling for ‘‘urgent and coherent’’ global action, he said antibiotics were being overused. ‘‘It must be incredibly frustrating to witness the fact that, as has been pointed out by many authorities, antibiotics have too often simply acted as a substitute for basic hygiene, or as it would seem, as a way of placating a patient who has a viral infection or who actually needs little more than patience to allow a minor bacterial infection to resolve itself.’’
The prince continued: ‘‘I find it difficult to understand how we can continue to allow most of the antibiotics in farming, many of which are also used in human medicine, to be administered to healthy animals… Could we not devise more effective systems where we reserve antibiotics for treating animals where the use is fully justified by the seriousness of the illness?’’
END OF EXCERPT
Charles seems to have a few reasonable points her. Sadly he then spoils it all by not being able to resist his passion for quackery.
- Yes, we have over-used antibiotics both in human and in veterinary medicine.
- Yes, this has now gone so far that it now endangers our health.
- Yes, it is a scandal that so little has happened in this respect, despite us knowing about the problem for many years.
- No, homeopathy is not the solution to any of the above!!!
The Prince claims he has been ‘successfully using homeopathy’. This is nonsense, and he should know it. Highly diluted homeopathic remedies are pure placebos, and to use placebos for sick animals cannot be a good idea. For those who need the evidence for these (all too obvious) statements, here it is:
A recent systematic review assessed the efficacy of homeopathy in cattle, pigs and poultry. Only peer-reviewed publications dealing with homeopathic remedies, which could possibly replace or prevent the use of antibiotics in the case of infective diseases or growth promotion in livestock were included. Search results revealed a total number of 52 trials performed within 48 publications fulfilling the predefined criteria. Twenty-eight trials were in favour of homeopathy, with 26 trials showing a significantly higher efficacy in comparison to a control group, whereas 22 showed no medicinal effect. Cure rates for the treatments with antibiotics, homeopathy or placebo varied to a high degree, while the remedy used did not seem to make a big difference. No study had been repeated under comparable conditions. Consequently, the use of homeopathy cannot claim to have sufficient prognostic validity where efficacy is concerned. When striving for high therapeutic success in treatment, the potential of homeopathy in replacing or reducing antibiotics can only be validated if evidence of efficacy is confirmed by randomised controlled trials under modified conditions.
If we want to reduce antibiotics, we need to stop using them for situations where they are not necessary, and we must improve husbandry such that antibiotics are not required for disease prevention. To a large extent this is a question of educating those who are responsible for administering antibiotics. Education has to be rational and evidence-based. Homeopathy is irrational and believe-based.
Yet again, Prince Charles’ views turn out to be a hindrance to progress.
God save the Queen!
Yes, I am afraid it is Dana Ullman again!
On the last post, he commented: “If you actually think that homeopathic medicines will KILL people, then, we all must assume that you think that conventional medicines create MASS MURDERS.”
In my view, this is a sad comment indeed. It reveals that a homeopath who has, after all, been in the business for decades has really very little idea about what makes an intervention a potentially good or a bad treatment.
Is it its efficacy?
Is it its safety?
IT IS THE RATIO OF THE TWO!!!
For the Ullmans of this world, I provide two very simple examples:
- One could prevent a common cold effectively with interferon. Why don’t we do this routinely? Because the benefit would not out-weigh its harm.
- We all know that chemotherapy can have terrible adverse effects. Why do we nevertheless use it for cancer? Because the benefits of saving a life out-weigh all the significant harm chemotherapy might do.
The conclusion is simple: to be useful, a therapy must demonstrably generate more good than harm. If there is no effectiveness, the risk/benefit balance can never be positive, even if the risks are relatively small. But risk/benefit balance can still be favourable, even if the therapy causes considerable harm.
This hardly is rocket science, is it? But the Ullmans of this world do refuse to get it, and that is sad, in my view. This ignorance is the basis for the fundamentally misguided advice they issue to their patients day in, day out.
What is more, the Ullmans of this world stubbornly deny that anyone can do significant harm with homeopathic remedies; they evidently think that homeopathy cannot kill patients. Yet they are evidently wrong.
Whenever the simple rules of risk/benefit are ignored, even apparently harmless treatments, like highly diluted homeopathic remedies, can – and sadly will – kill patients.
I suspect that the Ullmans of this world are still in closed-minded denial about this point. Let me therefore quote a few of my own posts where cases of ‘death by homeopathy’ have been mentioned:
- The ‘pernicious practice of homeopathy in Australia’: ‘tolerated by authorities to avoid an inconvenient confrontation’
- The end of a free ride for homeopathy in the US
- Homeopathy cost another life … and homeopaths remain once again silent
- A further strong nail in the coffin of homeopathy
- Time for the legal profession to have a serious look at homeopathy?
I fear that the Ullmans of this world will still not be convinced. Perhaps a look at this website might do the trick? No, probably not – changing one’s mind vis a vis facts requires intelligence. They will carry on claiming that, in comparison, “conventional medicines creates MASS MURDERS”.
And this is where we go full circle and I start again explaining about the balance of risk and benefit…
GIVE ME STRENGTH!!!
Dana Ullman is an indefatigable promotor of bogus claims and an unwitting contributor of hilarity. Therefore he has become a regular feature of this blog (see for instance here, here and here). His latest laughable assertion is that lead and other poisonings can be successfully treated with homeopathy.
Just to make sure: lead poisoning is no joke. The greatest risk is to brain development in babies, where irreversible damage can occur. Higher levels can damage the kidneys and nervous system in both children and adults. Very high lead levels may cause seizures, unconsciousness and death.
In view of this, Ullman’s claim is surprising, to say the least. In order to persuade the unsuspecting public of his notion, Ullman first cites a review of basic research on homeopathy and toxins published in Human and Experimental Toxicology. “Of forty high-quality studies, 27 showed positive results from homeopathic treatment”, Ullman states.
Now, now, now Dana!
Has your mom not taught you that telling porkies is forbidden?
Or did you perhaps miss this line in the article’s abstract? “The quality of evidence in these studies was low with only 43% achieving one half of the maximum possible quality score and only 31% reported in a fashion that permitted re-evaluation of the data. Very few studies were independently replicated using comparable models.”
Hardly ‘high quality studies’, wouldn’t you agree?
But this review was of pre-clinical studies; what about the much more important clinical evidence?
Here Ullman cites one trial where a potentized homeopathic remedy, Arsenicum Album 30C, was administered to 55 people who were entered into a double-blind, placebo-controlled trial. According to Ullman, the homeopathically treated group “experienced higher excretion of arsenic in their urine for the first eleven days, compared to those given a placebo.”
Na, na, na, Dana, this is getting serious!!!
Another porky – and not even a little one.
The authors of this study clearly stated that, at the end of the 11-day RCT, there was no significant difference between the homeopathy and the placebo group: “The differences in the concentration between the two groups (drug versus placebo) were generally a little higher during the first week, but subsequently the differences were not so palpable, particularly at the 11th day.” And for those who are a bit slow on the uptake, they even included a graph that makes it abundantly clear.
The only other clinical study cited by Ullman in support of his surprising claim is a double-blind randomized trial which was conducted with 131 workers who suffered lead poisoning at the Ajax battery plant in Bauru, São Paulo State, Brazil. Subjects were prescribed homeopathic doses of lead (Plumbum metallicum 15C) or placebo which they took orally for 35 days. The results of this RCT show that homeopathy is not better than placebo.
So, we seem to have all of two RCTs on the subject (I did a quick Medline-search and also found no further RCTs), and both are negative.
Anyone who is not given to compulsive porky-telling would, I guess, conclude from this evidence that people suffering from lead poisoning should urgently see conventional experts and avoid homeopaths at all costs – not so Dana Ullman who boldly concludes his article with these words:
“As an adjunct to conventional medical treatment, professional homeopathic care is recommended for people who have been exposed (or think they have been exposed) to toxic substances… Even if you do not have a professional homeopath in your town, many homeopathic practitioners “see” their patients via Skype or do consultations over the telephone. Unlike acupuncturists, who put needles in you, or chiropractors, who adjust your spine, homeopaths are not “hands-on”: they simply need to conduct a detailed interview… If your symptoms are serious or potentially serious, it is important to see a professional homeopath and/or physician. While a homeopath will commonly prescribe a safe homeopathic dose of the toxic substance to which one was exposed, the homeopath may instead decide that a different substance more closely matches the patient’s unique symptoms…”
It takes a lot these days to make me speechless but there, Dana, you almost succeeded!
Prof Walach has featured on this blog before, for instance here, and here. He is a psychologist by training and a vocal and prominent advocate of several bogus treatments, including homeopathy. He also is the editor in chief of the journal ‘Complementary Medicine Research’ and regularly uses this position to sing the praise of homeopathy. There is a degree of mystery about his affiliation: he informed me about 10 months ago that he has left his post at the Europa Universität Viadrina, Frankfurt/Oder (“Dass ich als “ehemaliger Professor” geführt werde liegt daran, dass ich Ende Januar aufgehört habe. Meine Stelle ist ausgelaufen und ich habe
sie nicht mehr verlängert.”). Yet all, even his recent papers still carry this address.
His latest article is entitled ‘The future of homeopathy’ is no exception. It is remarkable not just because of the mysterious affiliation but also – and mostly – because of its content. Here is my translation of a brief passage from this paper [I added some numbers in square brackets which refer to footnotes below].
START OF MY TRANSLATION
It is entirely undisputed that homeopathy with its therapeutic principles runs against the mainstream of science; and in this, Weymayr  is correct. However, to build on this fact a veritable research prohibition, such as the ‘scientability-concept’ suggests, is not just wrong from a science theoretical perspective, but… also discloses a dogmatic and unscientific stance.
If we see things soberly, homeopathy is – from a science theory point of view – an anomaly: empiric data prove that effects appear regularly and more and more frequently . This is being demonstrated with meta-analyses of placebo-controlled clinical trials. And this also shows with our own provings, which conform well with the newly developed standards as well as with the newer provings. Effects are furthermore noted with such frequency in animal and plant-based studies. Contrary to often voiced statements, there are also models which produce replicated effects – for instance the model of children with ADHD which is currently being replicated. Repeatedly high quality pilot studies emerge, such as the one by Gassmann et al., which show that unexpected effects also appear with higher potencies, documented with objective methods. Homeopathy proves itself as useful in large pragmatic trials of which we, however, have far too few. And let’s not forget: homeopathy is pragmatically useful. Even though aggravations do occur occasionally during homeopathic treatments, the claim that homeopathy is dangerous is a careless interpretation of the data. 
In what way is homeopathy an anomaly? I have already years ago argued that the signature of the data does not suggest that we are dealing with a classical local effect. This would be an effect which would conform with the usual criterion of causality and would thus be stable, regular and more and more evident with improved experimentation. It is unnecessary to repeat this argument  for the purpose of this editorial. But precisely the question of the classic causal effect is the controversy. And exactly this is the issue used by the new wave of critic of homeopathy which is openly aimed at the demise of homeopathy. This situation occurs because also the homeopaths are victims of the misapprehension that homeopathy is based on a classic causal process. But this assumption is most likely wrong, and homeopaths would be well-advised on the one side to point to the empiric evidence, and on the other side to practice theoretical chastity making clear that, for the time being, we have not a clue how homeopathy functions. This is the typical situation when a scientific anomaly occurs…
My prognosis would be: if we stop to misunderstand homeopathy as a classic causal phenomenon and instead view and research it as a non-classical phenomenon, homeopathy would have a chance and science would get richer by a new category of phenomena. This approach will prompt criticism, because it renders the world more complex rather than simpler. But this cannot be changed. Perhaps a new era of therapeutics might even emerge which does not abolish the molecular paradigm but makes it appear as one of several possibilities. 
END OF MY TRANSLATION
For those of you who can read German, here is the original text with references:
Dass die Homöopathie mit ihren therapeutischen Prinzipien dem Hauptstrom der Wissenschaft immer schon zuwiderlief, ist völlig unbestritten, und darin hat Weymayr recht. Aber auf dieser Tatsache ein regelrechtes «Forschungsverbot» aufbauen zu wollen, wie es das Szientabilitätskonzept vorsieht, das ist nicht nur wissenschaftstheoretisch absolut falsch, wie wir in einer Replik gezeigt haben , sondern offenbart auch eine dogmatische und unwissenschaftliche Einstellung.
Wenn man die Sache nüchtern sieht, ist die Homöopathie – wissenschaftstheoretisch betrachtet – eine Anomalie : Empirische Daten belegen, dass immer wieder und insgesamt häufiger als zufällig erwartet Effekte auftreten. Das zeigen Meta-Analysen placebokontrollierter klinischer Studien [4,5,6]. Und das zeigt sich sowohl in unseren eigenen Arzneimittel-Prüfungen , die im Übrigen den erst neuerdings entwickelten Standards gut entsprechen , als auch in neueren Prüfungen . Auch in Tierexperimenten [10,11,12,13] und in Pflanzenstudien [14,15,16] treten Effekte in solcher Häufigkeit auf. Entgegen oft gehörten Äußerungen gibt es durchaus auch Modelle, die replizierte Effekte ergeben – etwa das Modell homöopathischer Behandlung von Kindern mit Aufmerksamkeitsdefizit-/Hyperaktivitätssyndrom [17,18], das gerade repliziert wird . Immer wieder gibt es qualitativ hochwertige Pilotstudien, wie die unlängst publizierte von Gassmann et al. , die zeigen, dass unerwartete Effekte auch unter höheren Potenzen und dokumentiert mit objektiven Methoden zu beobachten sind. Homöopathie erweist sich in großen pragmatischen Studien, von denen es allerdings viel zu wenige gibt, als nützlich [21,22,23]. Und nicht zu vergessen: Homöopathie ist pragmatisch hilfreich [24,25,26,27]. Zwar kommt es bei homöopathischer Behandlung gelegentlich zu einer Erstverschlimmerung [28,29], aber die Behauptung, Homöopathie sei gefährlich , ist eine fahrlässige Interpretation der Daten .
Inwiefern ist die Homöopathie dann eine Anomalie? Ich habe schon vor Jahren argumentiert, dass die Signatur der Daten in der Homöopathie nicht dafür spricht, dass wir es mit einem klassischen, lokalen Effekt zu tun haben . Das wäre ein Effekt, der dem gewöhnlichen Kriterium der Kausalität entspräche und somit stabil, regelmäßig und bei immer besserer Experimentierkunst immer deutlicher hervorträte. Dieses Argument jetzt wieder aufzurollen, ist im Rahmen eines Editorials müßig. Aber genau die Frage nach einem klassisch-kausalen Effekt ist letztlich der Stein des Anstoßes. Und genau diesen Anstoß nimmt nun die neue Welle der Homöopathiekritik, die erklärtermaßen auf die Abschaffung der Homöopathie abzielt, zu ihrem Anlass. Diese Situation ergibt sich, weil auch die Homöopathen dem Selbstmissverständnis aufsitzen, Homöopathie sei ein klassisch-kausaler Prozess. Das ist höchstwahrscheinlich falsch, und die Homöopathie wäre gut beraten, einerseits auf die empirischen Befunde hinzuweisen und auf der anderen Seite theoretische Enthaltsamkeit zu üben und klarzulegen, dass wir vorläufig keinerlei Ahnung haben, wie Homöopathie funktioniert. Das ist die typische Situation, wenn eine wissenschaftliche Anomalie vorliegt…
Meine Prognose wäre: Wenn wir aufhören, die Homöopathie als klassisches Phänomen misszuverstehen, und sie stattdessen als ein mögliches nichtklassisches Phänomen betrachten und beforschen, dann hat die Homöopathie eine Chance und die Wissenschaft wird um eine neue Kategorie von Phänomenen reicher. Dieser Ansatz wird Kritik hervorrufen, denn er macht die Welt eher komplexer als einfacher. Aber das lässt sich nicht ändern. Vielleicht kann sogar eine neue Ära der Therapie beginnen, die das molekulare Paradigma nicht abschafft, aber als eine von mehreren Möglichkeiten erscheinen lässt.
Rather than commenting on this text in full detail, I simply want to provide a few explanations [they refer to the numbers in square brackets inserted by me into my translation] in order to facilitate understanding. I hope, however, that my readers will comment as much as they feel like.
1) Weymayr argued that certain fields lack plausibility to a degree that they do not merit being investigated. Here is an abstract of an article by him:
Evidence-based medicine (EbM) has proved to be very useful in healthcare; thanks to its methodology the reliability of our knowledge of the benefits and harms of interventions can be assessed. This at least applies to interventions which are based on a plausible concept for their mechanism of action and which have already achieved positive effects in experiments and simple studies. However, for interventions whose concepts contradict scientific findings EbM has proved to be unsuitable; it has not been able to prevent that they are still regarded as effective amongst wide parts of the population and medical experts. Particularly homeopathy has managed to even present itself as scientifically justified by using EbM. With the aim of highlighting the speculative character of homeopathy and other procedures and of preventing EbM from getting damaged, the concept of scientability is introduced in this article. This concept only approves of clinical studies if the intervention that is to be tested does not contradict definite scientific findings.
2) A scientific anomaly is “something which cannot be explained by currently accepted scientific theories. Sometimes the new phenomenon leads to new rules or theories, e.g., the discovery of x-rays and radiation.”
3) Even a minimal amount of critical thinking leads to the conclusion that the claims made about homeopathy in this paragraph are mostly not true or exaggerated. On this blog, there is plenty of evidence to contradict Walach on all the points he made here.
4) Walach’s argument is detailed in this article:
Among homeopaths the common idea about a working hypothesis for homeopathic effects seems to be that, during the potentization process, ‘information’ or ‘energy’ is being preserved or even enhanced in homeopathic remedies. The organism is said to be able to pick up this information, which in turn will stimulate the organism into a self-healing response. According to this view the decisive element of homeopathic therapy is the remedy which locally contains and conveys this information. I question this view for empirical and theoretical reasons. Empirical research has shown a repetitive pattern, in fundamental and clinical research alike: there are many anomalies in high-dilution research and clinical homeopathic trials which will set any observing researcher thinking. But no single paradigm has proved stable enough in order to produce repeatable results independent of the researcher. I conclude that the database is too weak and contradictory to substantiate a local interpretation of homeopathy, in which the remedy is endowed with causal-informational content irrespective of the circumstances. I propose a non-local interpretation to understand the anomalies along the lines of Jung’s notion of synchronicity and make some predictions following this analysis.
5) In a nutshell, Walach seems to be saying:
- the empirical evidence for homeopathy is strong;
- nobody understands the mechanisms by which the effects of homeopathy are brought about;
- if we all claim that homeopathy is a ‘scientific anomaly’ which operates according to Jung’s notion of synchronicity, the discrepancy between strong evidence and lack of plausible explanation disappears and everyone can be happy.
This is wrong for the following reasons, in my view:
- the evidence is not strong but negative or extremely weak;
- we understand very well that the effects of homeopathy are due to non-specific effects;
- therefore there is no need for a new paradigm;
- Jung’s notion of synchronicity is pure speculation and not applicable to therapeutics.
In summary, Prof Walach would do well to stop philosophising about homeopathy, read up about critical analysis, fine-tune his BS-detector and familiarise himself with Occam’s razor.
The objective of the ‘Portland Centre for Integrative Medicine’ in Bristol, UK is to “offer an Integrative Medicine (IM) approach to healthcare that seeks to deliver the best complementary care and lifestyle approaches”. Specifically, they
- “Aim to maximise individual choice and care to improve health, wellbeing and quality of life
- Support a whole person care approach through a working collaboration between people and practitioners to improve health and well-being
- Work to raise awareness about IM and increasing the availability of quality IM services for service users and their referring clinicians
- Support ‘Self Care Strategies’ across the South West by promoting and supporting self-care and self-management of health and well-being by using healthy living solutions
- Offer a centre for academic excellence for IM education and training, research and evaluation.”
Academic excellence does not normally entail telling porkies – but the Portland Centre seems willing to make an exception for a good cause: homeopathy. At least, this is the impression I got when reading their recent post entitled HOMEOPATHY, THE FACTS (surprisingly similar title as my latest book: HOMEOPATHY, THE UNDILUTED FACTS). The 6 ‘Portland facts’ turn out to be so surprising that I could simply not resist copying them here:
START OF QUOTE
1 It’s more than just a placebo
Homeopathy has been used successfully on babies, young children and animals. In these cases, the patients have no idea what medication they are taking, so the placebo argument does not hold.
2 Homeopathy costs the NHS very little
The total amount spent on Homeopathy in the NHS is approximately £4 million per year, representing less than 1% of the total NHS budget. In contrast, the NHS spends £282 million annually on anti-depressants which one study suggests only benefit 11% of patients diagnosed with depression.
3 Homeopathy is more than a passing fad
Homeopathy has been used for over 200 years and has been available on the NHS since the health service was formed in 1948. It is an important part of the health systems in many European countries including France, Germany and Italy.
4 Homeopathy is safe
When used approximately the practice is extremely safe as it produces no dangerous side-effects and can be used in conjunction with conventional medicines. In comparison, the European Commission estimated in 2008 that adverse reactions to conventional drugs kill 197,000 EU citizens each year.
5 Many treatments have limited evidence
A clinical evidence surgery carried out by the British Medical Journal found that out of 3000 medical treatments 50% were classified as having “unknown effectiveness”.
6 In support of high dilutions
“What I can say now is that the high dilutions are right. High dilutions of something are not nothing. They are water structures which mimic the original molecules. It’s no pseudoscience. It’s no quackery. These are real phenomena which deserve further study,” Professional Luc Montagnier, French virologist and Nobel Laureate speaking in 2010.
END OF QUOTE
Regular readers of this blog will not really need any comments; in their absurdity, the 6 ‘Portland facts’ speak almost for themselves. For those who are not regulars, let me briefly add a few words (in doing so, I follow the numbering above).
1) The most comprehensive and independent review of the evidence in the history of homeopathy has failed to confirm that homeopathy has any therapeutic effects beyond placebo. This applies to kids as much as it applies to animals. Placebo effects in animals and kids are well documented.
2) Much more important than the costs of homeopathy is the fact that the continued use of homeopathy on the NHS makes a mockery of the principles of EBM. Either we believe in evidence (in which case, homeopathy has no place in the NHS), or we don’t (in which case, anything goes and we regress to the dark ages of healthcare).
3) Appeal to tradition is a classic fallacy and not an argument in support of anything.
4) Most, but not all, homeopathic remedies are safe. However, homeopaths are often very unsafe, for instance when they insist to treat life-threatening conditions with their placebos, or when they advice against vaccinating children. Conventional medicines can certainly cause harm but, on balance, they unquestionably generate more good than harm – and this is clearly not the case for homeopathy.
5) Tu quoque is another classic fallacy and no argument in favour of homeopathy. EBM is a relatively new concept and progress in conventional medicine is now breathtakingly fast. By contrast, homeopathy did not progress since the days Hahnemann invented it.
6) The appeal to authority is yet another classic fallacy. The ‘Montagnier story’ merely shows that even Nobel laureates can make foolish mistakes, particularly if they venture outside their area of expertise. Poor Montaigner lost all credibility since he embarked on high dilutions.
I hope that you had as much fun reading the ‘Portland porkies’ as I had commenting on them. I think they are hilarious, particularly if we consider that the Portland Centre is the direct successor of the Bristol Homeopathic Hospital. Here is what Wikipedia has to say about this institution:
“Bristol Homeopathic Hospital was a hospital in the city of Bristol in south-west England, specializing in homeopathic treatments. It was founded in 1852 but had a history as a dispensary dating back to 1832. It later became a National Health Service hospital.
From 1925, the hospital was based in its own building, Cotham House, in the Cotham area of Bristol. On 7 January 2013 the hospital moved operations from Cotham to the South Bristol Community Hospital. In-patient services had been provided at Cotham House until 1986, when they were moved to the Bristol Eye Hospital, with out-patients continuing at Cotham House.
Homeopathic services ceased at the Hospital in October 2015, partly in response to a campaign against the public funding of homeopathy lead by the Good Thinking Society and public figures such as Simon Singh and Edzard Ernst. University Hospitals Bristol confirmed to the Clinical Commissioning Group that it would cease to offer homeopathic therapies from October 2015, at which point homeopathic therapies would no longer be included in the contract.
Homeopathic services in the Bristol area were relocated to the Portland Centre for Integrative Medicine, described as “a new independent social enterprise.” In response to a FOI request, Bristol Clinical Commissioning Group revealed that “there are currently no (NHS) contracts for homeopathy in place with the Portland Centre.”“
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Of course, this Wiki page is slightly misleading on at least one issue (No, I don’t mean the fact that I am called a ‘public figure’ rather than a professor and expert in alternative medicine who has published more on the subject than anyone else): Hospitals are never closed in response to a campaign (as far as I know) but hospitals might get closed because of what a campaign discloses. In the Bristol case, the campaign disclosed that there is no good evidence for homeopathy (see above) and therefore no good reason to carry on wasting scarce NHS funds on it – perhaps just a slight but, I think, important difference!
Back to the 6 ‘Portland porkies’.
As we have seen, they are nowhere close to real facts – but they certainly are funny.
While studying the services offered by the Portland Centre, I found a course on ‘creative writing’. Aha, I thought, this must be the explanation: the 6 ‘Portland porkies’ are not the result of research, study or knowledge. Far from it! They clearly are the fruits of exceedingly creative writing.
So, well done Portland Centre: at least one of your aims seems to be within reach!
A recent article in the Guardian revealed that about one third of Australian pharmacists are recommending alternative medicines with little-to-no evidence for their efficacy, including useless homeopathic products and potentially harmful herbal products.
For this survey of 240 Australian pharmacies, mystery shoppers were sent in to speak to a pharmacist at the prescription dispensing counter and ask for advice about feeling stressed. The results show that three per cent of the pharmacists recommended homeopathic products, despite a comprehensive review of all existing studies on homeopathy finding that there is no evidence they work in treating any condition and that ‘people who choose homeopathy may put their health at risk if they reject or delay treatments’. Twenty-six percent of all pharmacists recommended Bach flower remedies to relieve stress. A comprehensive review of all existing studies on Bach flower remedies found no difference between the remedies and placebos. Fifty-nine per cent of people were just told the complementary and alternative product recommended to them worked, and 24% were told the product was scientifically proven, without any evidence being provided to them.
Asked about these findings, Dr Ken Harvey, a prominent Australian expert, said they demonstrated that some pharmacists were failing in their professional duty to consumers. “Pharmacists are giving crazy advice, and it is dangerous in some cases,” he said. “My view is that pharmacists, if they are going to sell these products, need to have a big shining sign over the shelves of the complementary and alternative medicine section that says ‘these products have not been assessed by the government regulators to see if they work, please talk to pharmacist’.Pharamacists are giving poor advice and they clearly have a conflict of interest,” Harvey said.
If you had hoped that in other countries pharmacists behave more responsibly, I must disappoint you. The information available shows that, when it comes to alternative medicine, pharmacists across the globe act much more like shop-keepers than like health care professionals. They are in the habit of putting profit before their duty to abide by the rules of evidence-based practice. And, in doing do, they violate their own ethical codes so regularly that I ask myself why they bothered to even implement one.
On this blog I have written so often about this issue that one could come to the conclusion that I have a bee under my bonnet:
- Pharmacists: to sell quackery means you are quacks – or have I got that wrong?
- Pharmacists must use their professional judgement to prevent the supply of homeopathic remedies
- A pharmacist’s defence of homeopathy
- When will pharmacists finally stop selling homeopathic remedies?
- The homeopathic emergency kit: it must be good, it’s recommended by pharmacists
- Why do pharmacists sell bogus medicines?
- Pharmacists should finally get their act together…or lose credibility
The truth, however, is not that I am the victim of a bee.
The truth is that this is a very important public health issue.
The truth is that pharmacists show little signs of even trying to get to grips with it.
The truth is that pharmacists who sell bogus medicines put profit before professional ethics.
The truth is that such behaviour is not that of health care professionals but that of shop-keepers.
The truth is that I intend to carry on reminding these pharmacists that they are behaving like charlatans.
The British Homeopathic Association (BHA) is a registered charity founded in 1902. Their objectives are “to promote and develop the study and practice of homeopathy and to advance education and research in the theory and practice of homeopathy…” and their priority is “to ensure that homeopathy is available to all…” The BHA believes that “homeopathy should be fully integrated into the healthcare system and available as a treatment choice for everyone…”
This does not bode well, in my view. Specifically, it does not seem as though we can expect unbiased information from the BHA. Yet, from a charity we certainly do not expect a packet of outright lies – so, let’s have a look.
The BHA have a website (thank you Greg for reminding me of this source; I have long known about it and used it often for lectures when wanting to highlight the state of homeopathic thinking) where they provide “THE EVIDENCE FOR HOMEOPATHY“. I find the data presented there truly remarkable, so much so that I present a crucial section from it below:
START OF QUOTE
The widely accepted method of proving whether or not a medical intervention works is called a randomised controlled trial (RCT). One group of patients, the control group, receive placebo (a “dummy” pill) or standard treatment, and another group of patients receive the medicine being tested. The trial becomes double-blinded when neither the patient nor the practitioner knows which treatment the patient is getting. RCTs are often referred to as the “gold standard” of clinical research.
Up to the end of 2014, a total of 104 papers reporting good-quality placebo-controlled RCTs in homeopathy (on 61 different medical conditions) have been published in peer-reviewed journals. 41% of these RCTs have reported a balance of positive evidence, 5% a balance of negative evidence, and 54% have not been conclusively positive or negative. For full details of all these RCTs and more in-depth information on the research in general, visit the research section of the Faculty of Homeopathy’s website. Also, see 2-page evidence summary with full references.
END OF QUOTE
But is it true?
Let’s have a closer look at the percentage figures: according to the BHA
- 41% of all RCT are positive,
- 5% are negative,
- 54% are inconclusive.
These numbers are hugely important because they are being cited regularly across the globe as one of the most convincing bit of evidence to date in support of homeopathy. If they were true, many more RCT would be positive than negative. They would, in fact, constitute a strong indicator suggesting that homeopathic remedies are more than placebos.
One does not need to look far to find that these figures are clearly not correct! To disclose the ‘mistake’, we do not even need to study any of the 104 RCTs in question, we only need to straighten out the BHA’s ‘accounting error’ and ask: what on earth is an ‘inconclusive’ RCT?
A positive RCT obviously is one where homeopathy generated better outcomes than the placebo; similarly a negative RCT is one where the opposite was the case; in other words, where the placebo generated better outcomes than homeopathy. But what is an ‘inconclusive’ RCT? It turns out that, according to the BHA, it is one where there was no significant difference between the results obtained with placebo and homeopathy.
Yes, you understood correctly!
Outside homeopathy such RCTs are categorised as negative studies – they fail to show that homeopathy out-performs placebo and therefore confirm the null-hypothesis. An RCT is a test of the null-hypothesis (the experimental treatment is not better than the control) and can only confirm or reject this hypothesis. Certainly finding that the experimental treatment is not better than the control is not inconclusive bit a confirmation of the null-hypothesis. In other words it is a negative result.
So, let’s look at the little BHA – statistic again, and this time let’s do the accounting properly:
- 41% of all RCTs are positive,
- 59% are negative.
This means that, according to this very simplistic method, the majority of RCTs is negative. I say ‘very simplistic’ because, for a proper analysis of the trial evidence, we need to account, of course, for the quality of each trial. If the quality of the positive RCTs is, on average, less rigorous than that of the negative RCTs, the overall result would become yet more clearly negative. Most assessments of homeopathy that consider this essential factor do, in fact, confirm that this is the case.
Once all this has been analysed properly, we still have to account for factors like publication bias. Negative trials get often not published and therefore the overall picture gets easily distorted and generates a false-positive image. At the end of a sound evaluation along these lines, the result would fail to show that homeopathy differs from placebo.
Regardless of all these necessary and important considerations, the BHA website then tells us that the RCT method is problematic when it comes to testing homeopathy: “The RCT model of measuring efficacy of a drug poses some challenges for homeopathic research. In homeopathy, treatment is usually tailored to the individual. A homeopathic prescription is based not only on the symptoms of disease in the patient but also on a host of other factors that are particular to that patient, including lifestyle, emotional health, personality, eating habits and medical history. The “efficacy” of an individualised homeopathic intervention is thus a complex blend of the prescribed medicine together with the other facets of the in-depth consultation and integrated health advice provided by the practitioner; under these circumstances, the specific effect of the homeopathic medicine itself may be difficult to quantify with precision in RCTs.”
What are they trying to say here?
I am not sure.
Are they perhaps claiming that, even if an independent scientist disclosed their ‘accounting error’ and demonstrated that, in fact, the RCT evidence fails to support homeopathy, the BHA would still argue that homeopathy works?
I think so!
It looks to me that the BHA is engaged in the currently popular British past-time: THEY WANT THE CAKE AND EAT IT.
All this is more than a little disturbing, and I think it begs several questions:
- Is this type of behaviour in keeping with the charitable status of the BHA?
- Does it really ‘promote and develop the study and practice of homeopathy and to advance education and research’?
- Is it not rather unethical to mislead the public in such a gross and dishonest fashion?
- Is it not fraudulent to insist on false accounting?
I would be interested to get your views on this.
Homeopathy is never far from my mind, it seems. and this is reflected by the many posts on the subject that I continue to publish. Homeopaths get more than a little irritated by what they see as my ‘obsession’ with their beloved therapy. They thus try anything – yes, I mean anything – to undermine my credibility. One very popular way of doing this is to claim that I am sitting in the ‘ivory tower’ of academia and have no real inkling of the life on the ‘coal face’ of healthcare.
Because this is an argument that I find difficult to counter – I have indeed not routinely seen patients for over 20 years! – I was immensely pleased to read this article by an Australian GP. I take the liberty of quoting a section from it below:
START OF QUOTE
…An intricate web of lies protects the pernicious practice of homeopathy in Australia. Homeopathy is one of the most widespread disciplines of alternative medicines, with an estimated one million Australian consumers. It’s very popular. It also doesn’t work. At all. No better than a sugar pill, anyway. Turns out, vials of homeopathic remedies are chemically indistinguishable from water. Numerous international investigations and a scientific review of over 1800 studies by the National Medical Health Research Council could not be clearer: there is zero evidence that homeopathy is an effective treatment for medical conditions.
And yet the practice of homeopathy in Australia goes largely unchecked. The industry is overwhelmingly self-regulated by its own board, lending it an undue air of legitimacy. Meanwhile homeopaths advertise their ability to treat everything from autism to haemorrhoids with near impunity. Most obscenely, homeopathic therapies attract rebates under private health insurance policies that are funded by public taxes.
The justifications for allowing homeopathy are convoluted. One of the most common defences is that if the remedies truly are ineffective vials of water, then they are harmless. This is perhaps the most toxic myth about these therapies. Giving people a false cure for real symptoms is dangerous, because it delays correct diagnosis and treatment.
As a general practitioner I have observed the consequences of this in practice, seeing patients of homeopaths with conditions ranging from undiagnosed autoimmune disorders to mistreated blood pressure. These experiences mirror more notorious incidents – one West Australian coronial inquest in 2005 revealed a case where a homeopath treated rectal cancer, leading to the patient’s death. In 2009, a nine-month-old child with severe eczema was treated by her homeopath father who was later found guilty of manslaughter by denying her conventional medical care.
These are the kind of horror stories that prompt bureaucracies into symbolic action. Enter the Victorian Health Complaints Commission: a brand new watchdog unveiled last week to reign in, as Premier Daniel Andrews called them, “dodgy health providers”. The idea is that “health service providers” in Victoria, whether officially registered or not, will have to follow a general code of conduct. Included in this category are all homeopaths, and practitioners of other completely debunked practices such as reiki and iridology. The idea seems good on paper. The new code demands practitioners are truthful about their treatments, and act in the patient’s best interest. But here’s the catch – the commission will only take action on complaints lodged against individual practitioners.
This system is clearly geared towards only chasing a handful of rogue practitioners. But the problem isn’t a few rogue practitioners – it’s entirely rogue industries. The discipline of homeopathy, by its very nature, is untruthful.
Perhaps we can begin by following the lead of the United States, where the Federal Trade Council has ruled that homeopathic medicine labels must state that there is no scientific evidence backing homeopathic health claims. You have to admit, it’s bold stuff. It leaves our ACCC looking quite impotent. Real change requires the kind of courage that is in short supply.
That’s what it comes down to – cowardice. Homeopathy, along with an array of debunked complementary and alternative health disciplines, are tolerated by authorities to avoid an inconvenient confrontation. They let it slide to avoid upsetting delusional practitioners, misinformed customers, and anyone profiting from the practice. The presence of disproved medicines has insidiously embedded itself so deeply into our culture that curtailing a false cure is a huge political risk. So the status quo prevails, lest we rock the boat. Never mind that it’s heading straight down a waterfall.
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This clearly is a deeply felt and well-expressed article. It reiterates what we have regularly been trying to get across on this blog. But it is much better than anything I could ever contribute to the subject; it comes from someone who encounters the ‘pernicious practice of homeopathy’ on a regular basis and who knows about the harm it can do.
All I need to add is this: WELL DONE DOCTOR VYOM SHARMA!