MD, PhD, FMedSci, FSB, FRCP, FRCPEd

patient choice

You probably remember: the US Federal Trade Commission’s (FTC) has issued a statement announcing that unsupported claims for homeopathic remedies will be no longer allowed. Specifically, they said that, in future, homeopathic remedies have to be held to the same standard as other medicinal products. In other words, American companies must now have reliable scientific evidence for health-related claims that their products can treat specific conditions and illnesses.

Now the AMERICAN INSTITUTE OF HOMEOPATHY (AIH) has published a rebuttal. It is hilarious and embarrassing in equal measure. Here it is in full (I have only omitted their references – they can be seen in the linked original –  and added footnotes in bold square brackets with my very short comments):

START OF QUOTE

November 30, 2016

The American Institute of Homeopathy applauds the Federal Trade Commission’s (FTC) goal of protecting the American public from false advertising claims, but in a recent circumstance we believe the FTC has overstepped its jurisdictional bounds and promulgated false information in what appears to be a bid to restrict health care choices [1] available to the American public.

In Response to the recent Enforcement Policy Statement1 and a Consumer Information Blog,2 both issued by the FTC on November 15, 2016, the American Institute of Homeopathy registers our strong concern regarding the content of the following inaccurate statements:

  1. “Homeopathy… is based on the view that disease symptoms can be treated by minute doses of substances that produce similar symptoms…”

Homeopathy is not based on a “view” or an opinion. It is based on reliable, reproducible, clinically acquired, empiric evidence [2] gathered through two centuries of corroborated data, assisted by thousands of practitioners worldwide [3], demonstrating the actions of different medicinal substances in living systems, aka: the science of homeopathy. In fact, the homeopathic scientific community were pioneers of the modern scientific method including the widespread adoption of blinded and placebo controlled studies in 1885 [4], decades before conventional medicine.3

Homeopathy is not based on a theory or on conjecture, but on principles that have been confirmed by long-studied clinical data, meticulously gathered and analyzed over many years [5].

  1. “Many homeopathic products are diluted to such an extent that they no longer contain detectable levels of the initial substance.”

While the dilution and succussion process of formulating homeopathic medicines does reduce the concentration (and the toxicity) of the original substances, detectable amounts of these materials remain quantifiable in the form of nanoparticles [6] dispersed throughout.4 Multiple independent laboratories, worldwide have confirmed that these nanoparticles persist,5 and that they are biologically active.6 Many other homeopathic products (particularly those sold OTC and described as “low potency”) have dilute amounts of the original substance [7] that remain chemically detectable by straightforward titration.

  1. “…homeopathic product claims are not based on modern scientific methods…”

This statement is false and misleading. The active ingredients within most OTC homeopathic products have hundreds or thousands of case reports from physicians who have used these medicines [8]. These reports of direct clinical experiences establish a collective, real-world dataset that demonstrates which conditions have been observed to respond to treatment. Such historical data is similar to the types of information used to demonstrate effectiveness for many conventional OTC medicines on the market today [9].

The Homeopathic Pharmacopeia Convention of the United States (HPCUS) maintains a formulary describing the appropriate manufacturing standards for homeopathic medicines [10]. Every homeopathic manufacturer member of the American Association of Homeopathic Pharmacists in good ethical standing complies with both manufacturing and labeling standards set by the HPCUS. Consumers should be cautious when using any products that are not distinguished by conformance with “HPUS” on the label.

  1. “…the case for efficacy is based solely on traditional homeopathic theories…”

This statement is false. Neither homeopathy nor homeopathic efficacy is based on any theories. Efficacy for various homeopathic medicines has been established by scientifically reproducible clinical empiric research evidence [11] and cured patient cases followed over many years [12]. Homeopathy is an evidence-based medical subspecialty rooted in patient care.

  1. “…there are no valid studies using current scientific methods showing the product’s efficacy.”

While this statement may have limited accuracy with respect to some OTC products, it is false and misleading with respect to most homeopathic medicines listed in the Homeopathic Pharmacopeia of the United States. Hundreds of state-of-the-art double-blinded, randomized, placebo-controlled studies, many in peer-reviewed journals, demonstrate the superior efficacy of homeopathic medicines in a wide range of conditions, including asthma,7 depression and anxiety,8 chronic illness,9 allergic rhinitis,10 hypertension,11 headaches/migraines,12 sepsis,13 mild traumatic brain injury,14 otitis media,15 cancer,16 and many other conditions [13]. The American Institute of Homeopathy maintains and continually updates an extensive database, available free to the public, with over 6,000 research articles [14].17

Multiple meta-analyses published in peer reviewed medical journals that conclude that homeopathic medicine effects are superior to placebo [15] and that additional study of this therapeutic system is warranted.18,19,20,21,22,23  To that end, we encourage the National Institutes of Health to reverse their current position of blocking funding for homeopathic trials.24

  1. “…marketing claims that such homeopathic products have a therapeutic effect lack a reasonable basis and are likely misleading…”

The conclusion of whether a product has a “reasonable basis” is entirely irrelevant if that product has demonstrable clinical effectiveness. The important question, when it comes to homeopathy, is whether it is effective in clinical settings, not whether it has a “reasonable basis” for how it works. The mechanism by which homeopathy works differs from conventional medicines [16], but this fact does not make these products “misleading”.

Several recent class-action lawsuits brought against homeopathic manufacturers confirm that marketing practices were neither deceptive nor misleading [17].25

The FTC’s inability to formulate a reasonable basis for why homeopathic medicines work should not enter into any governmental enforcement policy statement. The FTC is not a medical organization, lacks expertise in interpreting scientific research [18], and is not qualified to make any comment on the validity of any field of medicine. To be less misleading, the FTC should exclude opinions from its policy statements.

  1. “Homeopathy: Not backed by modern science”

Homeopathy, as a system of medicine, does not fall under the purview of the FTC. Therefore, the FTC has been reckless in expressing an opinion of this magnitude. In this situation, the FTC’s comments can only be construed as being prejudicially biased and intentionally discriminatory against homeopathy. Such statements cause unwarranted harm to public trust and damage to a respected traditional system of medicine in the United States [19].

The American Institute of Homeopathy strongly objects to the FTC’s characterization of the entire field of homeopathic medicine as being without scientific evidence of efficacy. These comments are unqualified and wholly lacking in merit. The release of this Enforcement Policy Statement serves only to align the FTC with several recently released scientifically fraudulent [20] reports by a variety of pseudoscientists [21] and lowers the credibility of this valued consumer protection agency.

This type of misinformation should be embarrassing to a government organization striving to be nonpartisan and objective. The FTC owes an apology to the American Institute of Homeopathy as well as the many consumer groups that look toward this agency for fair and accurate information.

END OF QUOTE

My comments:

1 In healthcare, choice must be restricted to treatments which demonstrably generate more good than harm.

2 The AIH seems to be unaware of the difference between the nature of evidence, anecdote and experience.

3 Fallacy – appeal to popularity.

4 The first randomized, placebo-controlled study of homeopathy was, in fact, published in 1835 – its results were negative.

5 Fallacy – appeal to tradition.

6 The nano-particle explanation of homeopathy is but a theory (at best).

7 Fallacy – appeal to tradition.

8 Fallacy – appeal to authority.

9 Really? Which ones? Examples would help, but I doubt they exist.

10 The proper manufacturing of nonsense must still result in nonsense.

11 See footnote number 2

12 Fallacy – appeal to tradition.

13 For all of these conditions, the totality of the reliable evidence fails to demonstrate efficacy.

14 In this context, only clinical trials are relevant, and their number is nowhere near 6,000.

15 Most of the independent systematic reviews fail to be positive.

16 The mechanism is well-known and is called ‘placebo-effect’.

17 Many class actions also went against the manufacturers of homeopathic preparations.

18 I assume they ‘bought in’ the necessary expertise.

19 Surely, the damage is only to the cash-flow of firms selling bogus products.

20 Really? Name the report you libel here or be quiet!

21 Name the individuals you attack in this way or be quiet!

I must say, I had fun reading this. In fact, I cannot remember having seen a document by an organisation of healthcare professionals which was so embarrassingly nonsensical that it becomes comedy gold. If one of my PhD students, for instance, had submitted such drivel, I would have had no choice but to fail him or her.

Having said that, I need to stress to the AIH:

FULL MARKS FOR AMUSEMENT!!!

 

Homeopathic remedies are being marketed and sold as though they are medicines, yet highly diluted preparations contain nothing and do nothing. This means consumers are constantly mislead into believing that they are drugs. This situation seems to be changing dramatically in the US, and hopefully – led by the American example – elsewhere as well.

It has been reported that the US Federal Trade Commission issued a statement which said that, in future, homeopathic remedies have to be held to the same standard as other medicinal products. In other words, American companies must now have reliable scientific evidence for health-related claims that their products can treat specific conditions and illnesses.

The ‘Enforcement Policy Statement on Marketing Claims for Over-the-Counter (OTC) Homeopathic Drugs’ makes it clear that “the case for efficacy is based solely on traditional homeopathic theories and there are no valid studies using current scientific methods showing the product’s efficacy.”

However, an [over-the-counter] homeopathic drug claim that is not substantiated by competent and reliable scientific evidence might not be deceptive if the advertisement or label where it appears effectively communicates that: 1) there is no scientific evidence that the product works; and 2) the product’s claims are based only on theories of homeopathy from the 1700s that are not accepted by most modern medical experts. In other words, if no evidence for efficacy exists, companies must advertise this fact clearly on their labelling, and also disclose that claims are today rejected by the majority of the scientific community. Failure to do this will be considered a violation of the FTC Act.

“This is a real victory for reason, science, and the health of the American people,” said Michael De Dora, public policy director for The Center for Inquiry in a statement issued in response to the new act. “The FTC has made the right decision to hold manufacturers accountable for the absolutely baseless assertions they make about homeopathic products.”

The new regulation will make sure that customers are informed explicitly about whether the product they purchase at a pharmacy has any scientific basis. This is important because homeopathic remedies aren’t just ineffective, but they can be dangerous too. The FDA is currently investigating the deaths of 10 babies who were given homeopathic teething tablets that contained deadly nightshade.

“Consumers can’t help but be confused when snake oil is placed on the same pharmacy shelves as real science-based medicine, and they throw away billions of dollars every year on homeopathy based on its false promises,” said De Dora. “The dangers of homeopathy are very real, for when people choose these deceptive, useless products over proven, effective medicine, they risk their health and the health of their families.”

These are clear words indeed; the new regulation is bound to make a dramatic change for homeopathy in the US. The winner will undoubtedly the consumer who can no longer be so openly and shamelessly misled as before. The FTC has set an example for other national regulators who will hopefully follow suit.

I have published many articles on the risks of various alternative treatments (see for instance here, here, here, here, here and here) – not because I am alarmist but because I have always felt very strongly that, for a researcher into alternative medicine, the most important issue must be to make sure users of these therapies are as safe as possible. Usually I differentiated between direct and indirect risks. The former relate to the risks of the treatment and include, for instance, liver damage caused by a herbal remedy or stroke due to neck manipulation. The latter are mainly due to the poor, often irresponsible advice given by many therapists.

A recent article adopted the same terminology when reviewing the risks of alternative medicine specifically for cancer patients. As the indirect risks are often neglected, I will here quote the relevant section of this paper in full:

…Health care physicians and oncology experts have an ethical responsibility to initiate the communication regarding the use of complementary therapies with cancer patients. However, according to data obtained from this literature review, oncology doctors and physicians will discuss complementary therapies only when a patient him/herself raises this issue within a consultation. This passive attitude was linked to a lack of sufficient scientific evidence for positive outcomes of complementary therapies found in high quality randomized controlled trials (RCTs). Oncology nurses, on the other hand, sometimes actively promote complementary modalities that they find to correspond with their vision of holistic care.

According to the included studies, complementary providers often differ from conventional health care providers in their understanding of treatment concepts, philosophies and diagnostic procedures. This leads to different models of disease causality (cells, blood, nerves vs. energy, vital force, meridians) and treatment philosophy (reductionism vs. holism). As many complementary providers are philosophically oriented towards personal and spiritual growth, patients may feel guilty if the disease continues to advance despite the patients’ best spiritual and mental efforts. According to Broom and colleagues, such philosophies may also give patients false hope of recovery.

Another indirect risk connected to the combination of conventional and complementary treatment in cancer care is the lack of regulation and standardized education in many countries. Currently, there are, for example, no standard training requirements for complementary providers working in cancer care or any other health care setting in the EU. According to Mackareth et al., complementary providers in England need specific training to learn how to practice safely.

Moreover, there is a need for common medical terminology to bridge the communication gap between health care providers working outside the conventional health care system. Common medical terminology may reduce the existing communication gap between conventional and complementary providers about mutual patients. To minimize communication gap between physicians, oncology experts and complementary providers, a medical complementary record should include a treatment plan with conventional and complementary diagnosis, explanation of terminology, possible treatment interactions, description of the complementary treatment plan and goals. If possible, the quality of any complementary supplement given should be reported.

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As I said, I find it important to discuss the indirect risks of alternative medicine, and I am therefore pleased that the authors of this article addressed them. At the same time, I find their text remarkably tame.

Why are they not more open and forceful about what, after all, amounts to a serious public health issue? The answer might be simpler than expected: most of them are affiliated with the ‘National Research Center in Complementary and Alternative Medicine (NAFKAM), UiT The Arctic University of Norway, Tromsø, Norway’. Could it be that open warnings about outright quackery is not what suits this unit?

So, what might be an open and frank approach to discussing the indirect risks of alternative medicine? In my view, it should make several points abundantly clear and transparent:

  • Alternative practitioners (APs) are usually not trained to advise patients responsibly, particularly in cases serious disease.
  • The training of APs is often inadequate and sometimes resembles more to brain-washing than to proper education.
  • Consequently, APs often woefully over-estimate what their therapy can achieve.
  • The patients of APs are often desperate and ready to believe even the tallest tales.
  • APs have a huge conflict of interest – in order to make a living they need to treat as many patients as possible and are therefore not motivated to refer them to more suitable care.
  • APs are frequently in denial when it comes to the risks of their treatments.
  • APs are not educated such that they understand the full complexities of serious illness.
  • As a result, APs far too often misguide their patients to make tragically wrong choices thus putting their health at serious risk.
  • In most countries, the regulators turn a blind eye to this huge problem.

These are by no means trivial  points, and they have nothing to do with a ‘turf war’ between conventional and alternative medicine. They relate to our ethical duty to keep our patients as safe as we can. It has been estimated that, in oncology alone, 1 – 5% of deaths are due to patients opting to have alternative instead of conventional treatments. This amounts to an unbearably high absolute number of patients dying prematurely due to the indirect risks of alternative medicine.

It is high time, I think, that we tackle this issue systematically and seriously.

Bogus claims of alternative therapists are legion, particularly in homeopathy. But bogus claims are neither ethical nor legal. Homeopathy works for no human condition, and therefore any medical claim made for homeopathy is unethical, false, misleading and illegal.

This is not just my view (after studying the subject for more than two decades) but also that of the UK regulators. In case you doubt it, please read the full notice which the UK ‘Advertising Standards Authority’ has just published (dated 29/9/2016):

This week, our sister organisation, the Committee of Advertising Practice (CAP) Compliance team has written to homeopaths across the UK to remind them of the rules that govern what they can and can’t say in their marketing materials, including on their websites.

Homeopathy is based on the principle of treating like with like; in other words a substance which causes certain symptoms can also help remove those symptoms when it is diluted heavily in water before being consumed. Practitioners believe that this stimulates the body to heal itself. However, to date, despite having considered a body of evidence, neither us nor CAP has seen robust evidence that homeopathy works. Practitioners should therefore avoid making direct or implied claims that homeopathy can treat medical conditions.  

We have no intention of restricting the ability of practitioners to advertise legitimate and legal services, nor do we seek to restrict the right of individuals to choose treatment. However, when advertisers make claims about these products or services, in all sectors, they must hold appropriate evidence to back up those claims. If they do not, then we have a responsibility to intervene to protect consumers by ensuring that those ads are amended or withdrawn.

If you are a practicing homeopath, please ensure that you carefully read CAP’s advice and guidance. It includes a non-exhaustive list of the types of claims you can and can’t make. You will then need to make changes, as necessary, to your marketing materials, including on your website, if you have one. 

Further guidance can be found on the Society of Homeopaths’ website. We have worked closely with the Society over the course of the last year, to help them produce detailed guidance to support their members.

If you are a homeopath but have not received a letter from us, please download a copy here, together with supporting FAQs about Advertising Regulation.

I think this notice speaks for itself. All I want to add at this stage is my hope that UK homeopaths comply asap to avoid getting penalised and – much more importantly – to avoid continuing to mislead consumers.

In a recent PJ article, Michael Marshall from the ‘Good Thinking Society’ asked “WHY ON EARTH IS THE NHS SPENDING EVEN A SINGLE PENNY ON HOMEOPATHY?”. A jolly good question, given the overwhelmingly negative evidence, I thought  – but one that must be uncomfortable to homeopaths. Sure enough, a proponent of homeopathy, Jeanette Lindsay from Glasgow, has objected to Marshall’s arguments in a short comment which is a fairly typical defence of homeopathy; I therefore take the liberty of reproducing it here (the 12 references in her text were added by me and refer to my footnotes below):

I wonder if people such as Michael Marshall (The Pharmaceutical Journal 2016;297:101), who would refuse [1] patients the option of NHS homeopathic treatment, have considered the plight of people failed by evidence-based medicine ? [2] Where are those with chronic, disabling conditions to turn when the medicines available on the NHS do not work, or worse, are positively harmful? [3]

Take the instance of a woman with multiple drug allergies who has no means of treating her severe inflammatory arthritis and no suitable analgesia. [4] It has been demonstrated that disease states with immune system involvement are particularly susceptible to the placebo effect but how does one induce this? Current thinking precludes treatment with placebo medicines but it so happens that homeopathic remedies would appear, from the results of clinical trials [5], to be a good substitute. [6] Used properly, there is a good chance that in this case homeopathic treatment may achieve a real therapeutic effect. [7]

Patients who cannot tolerate allopathic [8] treatment do not just go away because they cannot take the prescribed medicine. [9] They suffer and surely deserve a better range of options [10] than those provided by the current obsession with evidence-based medicine. [11] The availability of homeopathic treatment is important and should not be denied until better alternatives become commonplace. [12]

[1] Michael Marshall does not ‘refuse’ homeopathy on the NHS; that is not in his power. He merely questions whether NHS funds should not be spent on treatments that demonstrably do more good than harm.

[2] I am sure he as carefully considered such patients.

[3] Depending on the exact circumstances, such patients have many options: for instance, they could change their physician, have their diagnosis re-considered, or try a non-drug treatment.

[4] An allergy to one drug is rarely (I would even say never) associated with allergies to all drugs for any given condition. Even if this were the case, there are several non-drug treatments for arthritis or other diseases.

[5] I think this is fantasy; there is no good evidence from clinical trials to show that homeopathy is efficacious for either inflammatory or degenerative arthritis.

[6] Is this an admission that homeopathic remedies are placebos?

[7] I am not aware of sound evidence to support this statement.

[8] ‘Allopathic’ is a derogatory term introduced by Hahnemann to defame conventional medicine.

[9] I have never seen a patient who could not tolerate any prescription medicine. I suspect this is fantasy again.

[10] Patients deserve the optimal therapy available for their conditions – that is a therapy that demonstrably generates more good than harm. Homeopathy is clearly not in this category.

[11] An obsession? Yes, perhaps it is an obsession for some dedicated healthcare professionals to provide the best possible treatments for their patients. But the way it is put here, it sounds as though this was something despicable. I would argue that such an ‘obsession’ would be most commendable.

[12] For practically all conditions, symptoms, illesses and diseases that afflict mankind, better alternatives than homeopathy have been available since about 150 years.

It seems to me that Jeanette Lindsay has been harshly disappointed by conventional medicine. Perhaps this is why, one day, she consulted a homeopath and received the empathy, understanding and compassion that she needed to get better. Many homeopaths excel at these qualities; and this is the main reason why their patients swear by them, even though their remedies are pure placebos.

My advice to such patients is: find a physician who has time, empathy and compassion. They do exist! Once you have found such a doctor, you can benefit from the compassion and empathy just as you may have benefitted from the homeopath’s compassion and empathy. But in addition to these benefits (and contrary to what you got from your homeopath), you will also be able to profit from the efficacy of the treatments prescribed.

To put it simply: homeopaths can help patients via non-specific therapeutic effects; responsible physicians can help patients via non-specific therapeutic effects plus the specific effects of the treatments they prescribe.

 

According to Wikipedia, Swiss state insurance funding of homeopathy and four other alternative therapies had been withdrawn after a review in 2005, and a 2009 referendum vote called for state backed health insurance to once more pay for these therapies. In 2012 the Swiss government reinstated them for a trial period until 2017, pending an independent investigation of the efficacy and cost-effectiveness of the therapies. The rules for the registration of homeopathic remedies without a concrete field of application are more liberal in Switzerland than they are in member countries of the EU. For homeopathic medicines based on well-known low-risk substances, Swissmedic, the regulatory authority, offers inexpensive registration by means of a simplified electronic registration procedure.

Several weeks ago, I have commented on the remarkable position of alternative medicine in Switzerland. Now this website offers further information specifically on homeopathy in Switzerland:

According to a report jointly issued by the Swiss Federal Health Office and the Swiss State Secretariat for Economic Affairs (SECO), the annual expenses for homeopathic treatments and medications in Switzerland amount to roughly CHF 50 million and CHF 31 million, respectively. These numbers seem impressive, particularly if we consider how little each homeopathic remedy costs and how ineffective it is.

But the argument that homeopathy somehow defies scientific testing does not seem to die. For instance, SantéSuisse, the umbrella organisation of health insurers, argues that standardised methods used to test conventional treatments cannot be applied to homeopathy. “It would be unfair to homeopathy if we borrowed the methodologies from conventional therapeutic options when evaluating its effectiveness. The potential risk is that these systematic and internationally accepted methods of biomedical science go against the underlying principles of homeopathy,” said SantéSuisse spokesman Christophe Kämpf. I am afraid, he is talking complete tosh – and he should, of course, know better.

The Swiss Federal Health Office admitted in its press release at the end of March that “no evidence has so far been found to prove that complementary and alternative therapies”, including homeopathy, meet the standard criteria for “effectiveness, appropriateness, and costs.” And a Swiss health office spokesman, Daniel Dauwalder, explained that the decision “reflected the will of the people” in a 2009 referendum. “The health insurance system will cover the cost of alternative therapies according to the principle of trust,” Dauwalder explained. He added that, if the standards of effectiveness, suitability and economy are called into question, SantéSuisse have the right to deny payment.

The core of the issue centres on the questions

  • How to ensure that the physical conditions of patients will not be compromised by unqualified, self-proclaimed clinicians?
  • How can health insurers deal with the potential challenges?

The truth is, alternative treatments will not be unconditionally covered by the basic insurance policies which every Swiss resident must have. Only the costs of treatments administered by certified medical doctors will be considered. Otherwise, the costs incurred can only be reimbursed, if the person insured has purchased supplementary health coverage.

END OF QUOTE

That, however, does not mean that only doctors can practice homeopathy in Switzerland. Lay-homeopaths do exist in the form of Heilpraktiker. While it is true that the national health insurance only covers the treatment by medical doctors, some private health insurances also cover homeopathy by Heilpraktiker.

All this is very different from what some enthusiasts report about homeopathy in Switzerland. Probably the best example for someone obscuring the truth is (yet again) Dana Ullman who stated that “the Swiss government has determined that the very small doses commonly used in homeopathic medicine are both effective and cost-effective.” Little wonder, I might add, because Dana Ullman also keeps on referring to “a remarkable report on homeopathic medicine conducted by and for the government of Switzerland”. He does so despite having been told over and over again that the report in question is firstly utterly unreliable and secondly not by the Swiss government.

Why this odd insistence on disseminating wrong information? Is it because it is good for business, or because homeopaths are not capable of learning (otherwise they would not be homeopaths), or both?

A survey published in 2011 showed that one-third of Danish hospitals offered alternative therapies. In total, 38 hospitals offered acupuncture and one Eye Movement Desensitization and Reprocessing Light Therapy. The most commonly reported reason for offering CAM was “scientific evidence”.

Many readers of this blog might be amazed with both the high level of alternative medicine presence in Danish hospitals and the notion that this was due to ‘scientific evidence’. A recent article provides even more surprises about the Danish alternative medicine scene.

It revealed that 8 out of 10 Danes are interested in using some form of alternative medicine…Some 67 percent of Danes say the national healthcare system should be more open to alternative healing practices, such as homeopathy, acupuncture or chiropractic, and 60 percent would like to see these treatments covered by the public health insurance system. More than half of the 6,000 respondents believe alternative therapies can be just as effective as traditional medicine.

Charlotte Yde, the chairwoman at Sundhedsrådet, which is the umbrella organisation for alternative practitioners in Denmark, contends many Danes feel frustrated because they cannot freely discuss alternative treatment with their doctors. Alternative treatment researcher Helle Johannessen agrees that Danish doctors should openly discuss alternative medicine options with patients. “In other European countries doctors use alternative treatment to a much greater extent than doctors in Denmark,” Johannessen told DR. “[International experience] shows that some forms of alternative therapy can improve quality of life and reduce anxiety and nausea in cancer patients.”

This, it seems to me, is little more than a bonanza of fallacious thinking and misleading information.

  • The notion that popularity of a therapy has anything to do with its usefulness is a classical fallacy.
  • The notion that belief determines efficacy (More than half of the 6,000 respondents believe alternative therapies can be just as effective as traditional medicine.) or vice versa is complete nonsense.
  • The notion that many Danes … cannot freely discuss alternative treatment with their doctors is misleading: patients can discuss what they feel like with whom they feel like.
  • The notion that in other European countries doctors use alternative treatment to a much greater extent than doctors in Denmark is also misleading: there are many European countries where LESS alternative therapies are being paid for via the public purse.
  • Finally, the notion that that some forms of alternative therapy can improve quality of life and reduce anxiety and nausea in cancer patients – even if it were correct – does not mean that ALL alternative therapies are efficacious, safe, or cost-effective.

Who cares about Denmark?

Why should this be important?

Well, the Danes might care, and it is important because it provides an excellent example of how promoters of bogus treatments tend to argue – not just in Denmark, but everywhere. Unfortunately, politicians all too often fall for such fallacious notions. For them, a popular issue is a potential vote-winner. Within medical systems that are notoriously strapped for money, the looser will inevitably be optimal healthcare.

MORE than £150,000 was spent by NHS Grampian on homeopathic treatments last year. Referrals to homeopathic practitioners cost £37,000 and referrals to the Glasgow Homoeopathic Hospital cost £7,315 in 2014-15. In view of the fact that highly diluted homeopathic remedies are pure placebos, any amount of tax payers’ money spent on homeopathy is hard to justify. Yet an NHS Grampian spokeswoman defended its use of by the health board with the following words:

“We have a responsibility to consider all treatments available to NHS patients to ensure they offer safe, effective and person-centred care. We also have a responsibility to use NHS resources carefully and balance our priorities across the population as well as individuals. We also recognise that patient reported outcome and experience measures are valued even when objective evidence of effectiveness is limited. Homeopathy can be considered in this arena and we remain connected with the wider debate on its role within the NHS while regularly reviewing our local support for such services within NHS Grampian.”

Mr Spence, a professional homeopath, was also invited to defend the expenditure on homeopathy: “When a friend started talking to me about homeopathy I thought he had lost his marbles. But it seemed homeopathy could fill a gap left by orthodox medicine. Homeopathy is about treating the whole person, not just the symptoms of disease, and it could save the NHS an absolute fortune. If someone is in a dangerous situation or they need surgery then they need to go to hospital. It’s often those with chronic, long-term problems where conventional treatment has not worked that can be helped by homeopathy.”

What do these arguments amount to, I ask myself.

The answer is NOTHING.

The key sentence in the spokeswomen’s comment is : “patient reported outcome and experience measures are valued even when objective evidence of effectiveness is limited.” This seems to admit that the evidence fails to support homeopathy. Therefore, so the argument, we have to abandon evidence and consider experience, opinion etc. This seemingly innocent little trick is nothing else than the introduction of double standards into health care decision making which could be used to justify the use of just about any bogus therapy in the NHS at the tax payers’ expense. It is obvious that such a move would be a decisive step in the wrong direction and to the detriment of progress in health care.

The comments by the homeopath are perhaps even more pitiful. They replace arguments with fallacies and evidence with speculation or falsehoods.

There is, of course, a bright side to this:

IF HOMEOPATHY IS DEFENDED IN SUCH A LAUGHABLE MANNER, ITS DAYS MUST BE COUNTED.

These days, I spend much of my time in France (my wife is French), and one striking thing about this country is the popularity of homeopathy. For instance, it is hard to find a pharmacy where the pharmacist does not approach you trying to sell you a homeopathic remedy for your health problem. But, of course, this is all far too anecdotal. The question therefore is, are there any reliable data on France’s usage of homeopathy?

The answer is YES: the aim of this new paper was to analyse data on medicines, prescribers and patients for homeopathic prescriptions that are reimbursed by French national health insurance.

The French national health insurance databases were used to analyse prescriptions of reimbursed homeopathic drugs or preparations in the overall French population, during the period July 2011-June 2012.

The results show that a total of 6,705,420 patients received at least one reimbursement for a homeopathic preparation during the 12-month period. This number equates to 10.2% of the French population, with a predominance in females (68%) and a peak frequency observed in children aged 0-4 years (18%). About one third of patients had only one reimbursement, and one half of patients had three or more reimbursements.

The cost of all homeopathic treatments prescribed during the 12-month period was approximately €279 million (based on the retail price). The observed mean reimbursement rate was 34%. This cost corresponded to nearly €98 million for the French national health insurance and amounted to 0.3% of France’s total drug bill. The most commonly prescribed stock was ‘Arnica montana’, followed by ‘Influenzinum’, Ignatia amara’ and ‘Gelsemium sempervirens’.

A total of 120,110 healthcare professionals (HCPs) prescribed at least one homeopathic drug or preparation. They represented 43.5% of the overall population of HCPs, nearly 95% of general practitioners, dermatologists and pediatricians, and 75% of midwives. Homeopathy accounted for 5% of the total number of drug units prescribed by HCPs. Conventional medicines were co-prescribed with 55% of homeopathic prescriptions.

From these data, the authors concluded that many HCPs occasionally prescribe reimbursed homeopathic preparations, representing however a small percentage of reimbursements compared to allopathic medicines. About 10% of the French population, particularly young children and women, received at least one homeopathic preparation during the year. In more than one half of cases, reimbursed homeopathic preparations are prescribed in combination with allopathic medicines.

So, my impression that homeopathy is much more popular in France than elsewhere was not entirely correct. Like in most other countries, it is used by a minority; but this minority is fairly vocal and gets plenty of press coverage. When discussing homeopathy with friends in France, I have regularly discovered that they have very little understanding about what homeopathy is truly about; they seem to favour it because it is heavily advertised as a harmless solution to benign health problems. In no other country have I seen regular TV commercials for homeopathy! The ones who earn by far the most from this is, of course, the pharmacist – in France, homeopathic products can only be found in pharmacies!

Seen from this angle, the French usage of homeopathy is a triumph of profit over reason: the two most popular preparations (Arnica and Influenzinum) are not just not evidence-based (like all other homeopathic remedies), they have been shown in systematic reviews not to work better than placebos.

The task of UK Clinical Commissioning Groups (CCGs) is to ensure NHS funds are spent as effectively and responsibly as possible. This is particularly important in the current financial climate, as NHS budgets are under enormous pressure. For that reason, The Good Thinking Society (GTS, a pro-science charity) invited Liverpool CCG to reconsider whether the money (~ £ 30,000 pa) they spend on homeopathy represents good service to the public. Recently the CCG agreed to make a fresh decision on this contentious issue.

The GTS would prefer to see limited NHS resources spent on evidence-based medicine rather than on continued funding of homeopathy which, as readers of this blog will know, has repeatedly failed to demonstrate that it is doing more good than harm. It is encouraging to see Liverpool CCG take a first step in the right direction by agreeing to properly consider the best evidence and expertise on this issue.

Supporters of homeopathy frequently cite the concept of patient choice and claim that, if patients want homeopathy, they should have it free on the NHS. The principle is obviously important, but it is crucial that this choice is an informed one. The best evidence has conclusively shown that homeopathy is not an effective treatment, and to continue to offer ineffective treatments under the guise of patient choice raises troubling questions about the important concept of informed choice, and indeed of informed consent as well as medical ethics.

The GTS were represented by Salima Budhani and Jamie Potter of Bindmans LLP. Salima said: “This case underlines the necessity of transparent and accountable decision making by the controllers of health budgets, particularly in the light of the current financial climate in the NHS. CCGs have legal obligations to properly consider relevant evidence, as well as the views of experts and residents, in deciding how precious NHS resources are to be spent. It is essential that commissioning decisions are rational and evidence-based. Liverpool CCG’s decision to reconsider its position on the funding of homeopathy in these circumstances is to be welcomed.

“Our client has also called upon the Secretary of State for Health to issue guidance on the funding of homeopathy on the NHS. Public statements by the Secretary of State indicate that he does not support ongoing funding, yet he has so far declined to ask NICE to do any work on this issue. The provision of such guidance would be of significant benefit to CCGs in justifying decisions to terminate funding.”

Commenting on their decision, a Liverpool CCG spokesperson said: “Liverpool CCG currently resources a small homeopathy contract to the value of £30,000 per year that benefits a small number of patients in the city who choose to access NHS homeopathy care and treatment services. The CCG has agreed with the Good Thinking Society to carry out further engagement with patients and the general public to inform our future commissioning intentions for this service.”

Over the last two decades, prescriptions fulfilled in community pharmacies for homeopathy on the NHS in England have fallen  by over 94% and homeopathic hospitals have seen their funding reallocated. This reduction indicates that the majority of doctors and commissioning bodies have acted responsibly by terminating funding for homeopathic treatments.

The GTS are currently fundraising in order to fund further legal challenges – donate now to support our campaign at justgiving.com/Good-Thinking-Society-Appeal/.

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