For ‘my’ journal FACT, I review all the new articles that have emerged on the subject of alternative medicine on a monthly basis. Here are a few impressions and concerns that this activity have generated:
- The number of papers on alternative medicine has increased beyond belief: between the year 2000 and 2010, there was a slow, linear increase from 335 to 610 Medline-listed articles; thereafter, the numbers exploded to 1189 (2011), 1674 (2012) and 2236 (2013).
- This fast growing and highly lucrative ‘market’ has been cornered mainly by one journal: ‘EVIDENCE BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE’ (EBCAM), a journal that I mentioned several times before (see here, for instance). In 2010, EBCAM published 76 papers, while these figures increased to 546, 880 and 1327 during the following three years.
- Undeniably, this is big business, as authors have to pay tidy sums each time they get published in EBCAM.
- The peer-review system of EBCAM is farcical: potential authors who send their submissions to EBCAM are invited to suggest their preferred reviewers who subsequently are almost invariably appointed to do the job. It goes without saying that such a system is prone to all sorts of serious failures; in fact, this is not peer-review at all, in my opinion, it is an unethical sham.
- As a result, most (I estimate around 80%) of the articles that currently get published on alternative medicine are useless rubbish. They tend to be either pre-clinical investigations which never get followed up and are thus meaningless, or surveys of no relevance whatsoever, or pilot studies that never are succeeded by more definitive trials, or non-systematic reviews that are wide open to bias and can only mislead the reader.
- Nowadays, very few articles on alternative medicine are good enough to get published in mainstream journals of high standing.
The consequences of these fairly recent developments are serious:
- Conventional scientists and clinicians must get the impression that there is little research activity in alternative medicine (while, in fact, there is lots) and that the little research that does emerge is of poor quality.
- Consequently alternative medicine will be deemed by those who are not directly involved in it as trivial, and the alternative medicine journals will be ignored or even become their laughing stock.
- At the same time, the field of alternative medicine and its proponents (the only ones who might actually be reading the plethora of rubbish published in alternative medicine journals) will get more and more convinced that their field is supported by an ever- abundance of peer-reviewed, robust science.
- Gradually, they will become less and less aware of the standards and requirements that need to be met for evidence to be called reliable (provided they ever had such knowledge in the first place).
- They might thus get increasingly frustrated by the lack of acceptance of their ‘advances’ by proper scientists – an attitude which, from their perspective, must seem unfair, biased and hostile.
- In the end, conventional and alternative medicine, rather than learning from each other, will move further and further apart.
- Substantial amounts of money will continue to be wasted for research into alternative medicine that, whenever assessed critically, turns out to be too poor to advance healthcare in any meaningful way.
- The ones who medicine should be all about, namely the patients who need our help and rely on the progress of research, are not well served by these developments.
In essence this suggests, I think, that alternative medicine is ill-advised and short-sighted to settle for standards that are so clearly below those generally deemed acceptable in medicine. Similarly, conventional medicine does a serious disfavour to progress and to us all, if it ignores or tolerates this process.
I am not at all sure how to reverse this trend. In the long-term, it would require a change of attitude that obviously is far from easy to bring about. In the short-term, it might help, I think, to de-list journals from Medline that are in such obvious conflict with publication ethics.
In the realm of alternative medicine, we encounter many therapeutic claims that beggar belief. This is true for most modalities but perhaps for none more than chiropractic. Many chiropractors still adhere to Palmer’s gospel of the ‘inate’, ‘subluxation’ etc. and thus they believe that their ‘adjustments’ are a cure all. Readers of this blog will know all that, of course, but even they might be surprised by the notion that a chiropractic adjustment improves the voice of a choir singer.
This, however, is precisely the ‘hypothesis’ that was recently submitted to an RCT. To be precise, the study investigated the effect of spinal manipulative therapy (SMT) on the singing voice of male individuals.
Twenty-nine subjects were selected among male members of a local choir. Participants were randomly assigned to two groups: (A) a single session of chiropractic SMT and (B) a single session of non-therapeutic transcutaneous electrical nerve stimulation (TENS). Recordings of the singing voice of each participant were taken immediately before and after the procedures. After a 14-day wash-out period, procedures were switched between groups: participants who underwent SMT on the first occasion were now subjected to TENS and vice versa. Recordings were assessed via perceptual audio and acoustic evaluations. The same recording segment of each participant was selected. Perceptual audio evaluation was performed by a specialist panel (SP). Recordings of each participant were randomly presented thus making the SP blind to intervention type and recording session (before/after intervention). Recordings compiled in a randomized order were also subjected to acoustic evaluation.
No differences in the quality of the singing on perceptual audio evaluation were observed between TENS and SMT.
The authors concluded that no differences in the quality of the singing voice of asymptomatic male singers were observed on perceptual audio evaluation or acoustic evaluation after a single spinal manipulative intervention of the thoracic and cervical spine.
There is nevertheless an important point to be made here, I feel: some claims are just too silly to waste resources on. Or, to put it in more scientific terms, hypotheses require much more than a vague notion or hunch.
To set up, conduct and eventually publish an RCT as above requires expertise, commitment, time and money. All of this is entirely wasted, if the prior probability of a relevant result approaches zero. In the realm of alternative medicine, this is depressingly often the case. In the final analysis, this suggests that all too often research in this area achieves nothing other than giving science a bad name.
NATURAL NEWS announced the death of Nicholas Gonzalez with the following words:
It is with great sadness that we report the death of health freedom advocate and individualized nutrition specialist Dr. Nick Gonzalez, who on the eve of July 21 died from an alleged heart attack. Dr. Gonzalez’ contributions to anticancer nutrition protocols and an array of other nutritional therapies have been invaluable, and we would like to honor this pioneering natural healer by recognizing his benevolent legacy…
In contrast to the conventional cancer treatment model, Dr. Gonzalez’s approach was always about helping individuals heal through individualized care. Along with fellow colleague Dr. Linda Isaacs, Dr. Gonzalez helped build a repository of dietary protocols to help patients overcome their specific conditions through advanced nutritional therapies. His methodology centered around detoxification, supplementation with healing foods and nutrients, and specialized enzyme therapy…
Dr. Gonzalez was always a strong adherent to sound science, and he was never in it for the money. His humble, cogent approach to helping people heal naturally without drugs or surgery is a legacy worth remembering and passing on, and we’re thankful to have gotten to know this honorable man during his time on this earth…
This sounds as though Gonzalez was some kind of medical genius and scientific pioneer. Most cancer experts would disagree very sharply with this. Here is what Louise Lubetkin wrote on this blog about him, and I very much encourage you to read her whole post.
Those who recognize and appreciate a fine example of pseudoscientific baloney when they see one know that there is no richer seam, no more inexhaustible source, than the bustling, huckster-infested street carnival that is alternative medicine. There one can find intellectual swindlers in abundance, all offering outrageously implausible claims with the utmost earnestness and sincerity. But the supreme prize, the Fabergé egg found buried among the bric-a-brac, surely belongs to that most convincing of illusionists, the physician reborn as an ardent advocate of alternative medicine…
So what are we to make of Gonzalez? Is he a cynical fraud or does he genuinely believe that coffee enemas, skin brushing and massive doses of supplements are capable of holding back the tsunami of cancer?
At the end of the day it hardly matters: either way, he’s a dangerous man.
Personally, I believe much more in the text of Louise Lubetkin. How about you?
The press officers of journals like to send out press-releases of articles which are deemed to be particularly good and important. Sadly, it is not often that articles on alternative medicine fulfil these criteria. I was therefore excited to receive this press-release which seemed encouraging, to say the least:
Medical evidence supports the potential for acupuncture to be significantly more effective in the treatment of dermatologic conditions such as dermatitis, pruritus, and urticaria than alternative treatment options, “placebo acupuncture,” or no treatment, according to a review of the medical literature published in The Journal of Alternative and Complementary Medicine, a peer-reviewed publication from Mary Ann Liebert, Inc., publishers…
The abstract was equally promising:
Objectives: Acupuncture is a form of Traditional Chinese Medicine that has been used to treat a broad range of medical conditions, including dermatologic disorders. This systematic review aims to synthesize the evidence on the use of acupuncture as a primary treatment modality for dermatologic conditions.
Methods: A systematic search of MEDLINE, EMBASE, and the Cochrane Central Register was performed. Studies were limited to clinical trials, controlled studies, case reports, comparative studies, and systematic reviews published in the English language. Studies involving moxibustion, electroacupuncture, or blood-letting were excluded.
Results: Twenty-four studies met inclusion criteria. Among these, 16 were randomized controlled trials, 6 were prospective observational studies, and 2 were case reports. Acupuncture was used to treat atopic dermatitis, urticaria, pruritus, acne, chloasma, neurodermatitis, dermatitis herpetiformis, hyperhidrosis, human papillomavirus wart, breast inflammation, and facial elasticity. In 17 of 24 studies, acupuncture showed statistically significant improvements in outcome measurements compared with placebo acupuncture, alternative treatment options, and no intervention.
Conclusions: Acupuncture improves outcome measures in the treatment of dermatitis, chloasma, pruritus, urticaria, hyperhidrosis, and facial elasticity. Future studies should ideally be double-blinded and standardize the control intervention.
One has to read the actual full text article to understand that the evidence presented here is dodgy to the extreme. In fact, one has to go into the tedious details of the methods section to find the reasons why: All searches were limited to clinical trials, controlled studies, case reports, comparative studies, and systematic reviews published in the English language.
There are many more weaknesses of this review, but the inclusion of uncontrolled studies and even anecdotes is, in my view, a virtual death sentence to its credibility. It means that no general conclusions about the effectiveness of acupuncture, such as the authors have decided to make, are possible.
Such overt exaggerations are sadly no rarities in the realm of alternative medicine. I think, this begs a number of serious questions:
- Does this cross the line between flawed research and scientific misconduct?
- Why did the reviewers not pick up these flaws?
- Why did the editor pass this article for publication?
- How can the publisher tolerate such dubious behaviour?
- Should this journal (which I have commented on before here and which is one with the highest impact factor of all the alt med journals) be de-listed from Medline?
I don’t think that we will get answers from the people responsible for this disgrace, but I would like to learn my readers’ opinions.
The BMJ is my favourite medical journal by far; I think it is full of good science as well as entertaining to read, and I look forward to finding it in my letter box every Friday. It is thus hard for me to criticise the BMJ, and this is not made easier by the fact that I am the author of one of the two pieces in question. However, the current ‘HEAD TO HEAD’ entitled ‘SHOULD DOCTORS RECOMMEND HOMEOPATHY’ does, in my view, not mark the finest hour of this journal. Let me explain why.
The first question that arises is whether homeopathy is a good subject for such a debate. As several commentators have pointed out, it is not – the debate has long been closed; to serious scientists and many doctors, homeopathy tends to be a subject that is nothing more than an odd, obsolete triviality that does not even deserve a mention in the BMJ or any other serious publication. In a way, this notion has almost been proven wrong by the high level of interest the subject quickly generated. So, I will not dwell on this point any longer.
The second issue that arises just from nothing more than merely reading the title of the debate is that the question posed is imprecise. ‘Homeopathy’ is too broad a term for a focussed discussion; it includes amongst other phenomena empathetic encounters, remedies with material doses of highly active ingredients (e.g. Arsenic D1) and remedies that contain absolutely nothing at all (any ‘potency’ beyond C12). In my piece, I tried to make it clear that I speak mostly about ultra-molecular dilutions. This is less obvious in Peter Fisher’s article, and there is doubtlessly a lot of confusion in the debate as well as the comments that follow.
The two articles had to be written without either author knowing the text of the other. Consequently the issues raised by one author were not necessarily addressed by the other. This is somewhat frustrating, as it fails to clarify issues that could easily have been dealt with. In a previous post, I have already explained that the peer-review process of the two articles was seriously flawed. It failed to correct the many misleading statements in Fisher’s piece, as Alan Henness has pointed out in his response both in the BMJ and on this blog. In fact, reading Fisher’s article, I fail to find a single passage that is not factually wrong or highly misleading (the accompanying podcast is even worse, in my view). To me it is obvious that the debate about homeopathy cannot advance, if one side continues to behave in this fashion.
Homeopaths are very adept at recruiting ‘grass roots’ for public relation activities. We know this from various previous experiences. It was therefore predictable that this would swiftly get organised also in this instance. I happen to know from more than one source that there was a highly active campaign by homeopaths trying to persuade their supporters to post responses on the BMJ site and to vote on the BMJ straw poll (scientists, by contrast, know that such polls are silly gadgets and tend to view homeopathy as a triviality that is not worth the effort). In this way, they try to generate the impression that the majority of the public stands firmly behind homeopathy and want doctors to recommend it. It does not need too much to realise that popularity is not a measure of efficacy. Homeopaths, however, tend to relish logical fallacies and therefore will rejoice at such nonsense and celebrate it as their very own victory.
So, was this ‘HEAD TO HEAD’ a mistake? Should I have refused to participate? With hindsight, perhaps. My main reason for accepting was that, had I declined the offer, someone else would have written the piece (there are plenty of excellent scientists who could do an excellent job at this). As sure as hell, that person would subsequently gotten attacked for not ever having researched and/or practiced homeopathy (in the podcast, Fisher even tried to undermine my authority by pointing out that 1) I have not worked as a clinician for decades and 2) I have no NHS contract). I think I may be one of the few critics of homeopathy who cannot possibly be accused of not knowing enough about homeopathy to discuss the subject.
My hope is that, because the BMJ is such an excellent journal, the two articles will survive the current hoo-hah and some people will read them carefully, look up and study the references, analyse all this critically and weigh the arguments responsibly. Then they must be able to discern the fiction from the facts. And in this case, perhaps it was worth it after all.
The ‘Homeopathy Action Trust’ (HAT) is a charity that claims to encourage and support public understanding of homeopathy. They believe that homeopathy is invaluable to many people and plays an important role in maintaining their health and wellbeing. The HAT advocates that patients have a right to choose homeopathic treatments and access to it on the NHS or privately. Many of HAT’s projects are about promoting to use of homeopathy in Africa, for instance, where they advocate homeopathy as a treatment for all sorts of serious diseases.
Recently HAT embarked on another project: a campaign against the current Wiki-page on homeopathy which HAT believes to be biased against homeopathy. Thus they issued a ‘position statement’ on their website. Here is a short paragraph from that statement which I find worthy of a comment (the numbers were inserted by me and refer to my comments below; otherwise the text in bold is by HAT):
We acknowledge that the scientific evidence in support of Homeopathy remains inconclusive (1), but it is by no means definitively negative (2) and there is in fact an active and growing field of research worldwide (3). We acknowledge that the mechanism of action of homeopathic remedies is unknown (4) – as it is for some conventional medicines – but this does not preclude their usage in clinical situations (5). We welcome honest and open-minded debate (6) about Homeopathy and fully support the call for high quality (7), appropriately designed research studies (8) into the effectiveness of homeopathy as it is practised by both medical and professional homeopaths (9).
- The evidence is not ‘inconclusive’ but the most reliable evidence fails to convincingly show efficacy (see here, for instance).
- In healthcare, we do not focus on the question whether the evidence for anything is ‘definitely negative’, but we base our decisions on the question whether or not the evidence is positive. In other words, we use those treatments that are backed up with positive evidence and not those where this is in serious doubt.
- The research activity in homeopathy has been in decline for some time; this can easily be verified by searching Medline.
- No, we know that there cannot be a mechanism of action that is in line with the laws of nature.
- If such therapies are used in conventional healthcare, it is because they are (contrary to homeopathy) supported by sufficiently strong clinical evidence.
- So far, this ‘position statement’ is neither honest nor open-minded, in my view.
- More research seems unnecessary, perhaps even unethical, and most research in this area is not of high quality.
- ‘Appropriately designed’ sounds frightfully suspicious to me, because homeopaths tend to see any trial that fails to confirm their bizarre notions as ‘not appropriately designed’.
- ‘Professional homeopath’ is a term designed to mislead the public; lay homeopaths would be more to the point, I think.
The last time I had contact with Dr Fisher was when he fired me from the editorial board of his journal ‘Homeopathy’. He did that by sending me the following letter:
Dear Professor Ernst,
This is to inform you that you have been removed from the Editorial Board of Homeopathy. The reason for this is the statement you published on your blog on Holocaust Memorial Day 2013 in which you smeared homeopathy and other forms of complementary medicine with a ‘guilt by association’ argument, associating them with the Nazis.
I should declare a personal interest….[Fisher goes on to tell a story which is personal and which I therefore omit]… I mention this only because it highlights the absurdity of guilt by association arguments.
Peter Fisher Editor-in-Chief, Homeopathy
I did not expect to have any more dealings with him after this rather unpleasant encounter. But, as it turns out, I recently did have a further encounter.
When the BMJ invited me to write a debate article about the question whether homeopathy should continue to be available on the NHS, I accepted (with some reservations, I hasten to add). At the time, I did not know who would do the ‘other side’ of this debate. It turned out to be Peter Fisher, and our two articles have just been published.
As one would expect from a good journal, the articles were both peer reviewed. One of the peer-reviewers of my piece was most scathing of it essentially claiming that it was entirely worthless. Feeling that this was a bit harsh and very impolite, I was keen to see who this reviewer had been; it was none other than Andrew Vickers. This is remarkable because Vickers had not only published several homeopathic papers with Fisher, but also had been in the employment of the ‘Royal London Homeopathic Hospital’ under Fisher. To the best of my knowledge, his conflicts of interested had not been disclosed. I did point that out to the BMJ, but they seemed to think nothing of it.
Anyway, I was pleased to eventually (the whole procedure took many months) see the articles published, but at the same time somewhat irritated by Fisher’s piece. It contained plenty of misleading information that the peer-reviewers obviously had failed to correct. Here is a small sample from Fishers piece:
… recent overviews have had more favourable conclusions, including a health technology assessment commissioned by the Swiss federal government that concluded that homeopathy is “probably” effective for upper respiratory tract infections and allergies.
Readers interested in the clinical evidence can access the CORE-HOM database of clinical research in homeopathy free of charge (www.carstens-stiftung.de/core-hom). It includes 1117 clinical trials of homeopathy, of which about 300 are randomised controlled trials.
In the podcast that accompanies the articles Fisher insists that, on this database, there are well over 300 RCT, and I had to admit that this was new to me. Keen to learn more, I registered with the database and had a look. What I found startled me. True, the database does claim that almost 500 RCTs are available, but just a very superficial scrutiny of these studies reveals that
- some are not truly randomised,
- some are not even clinical trials,
- the list includes dual publications, re-analyses of already published studies as well as aborted trials,
- many have never been peer-reviewed,
- many are not double-blind,
- many are not placebo controlled,
- the majority are of poor methodological quality.
As to the other thing mentioned in the above excerpt from Fisher’s article, the famous ‘health technology assessment commissioned by the Swiss federal government’, I can refer my readers to a blog post by J W Nienhuys which probably says it all, if not, there is plenty more criticism of this report available on the Internet.
My conclusion from all this?
THE QUEEN’S HOMEOPATH USES ARGUMENTS THAT SEEM JUST AS BOGUS AS HOMEOPATHY ITSELF.
Many chiropractors try to tell us that vaccinations are not necessary, if we receive regular spinal adjustments. This claim is based on the assumption that spinal manipulations stimulate the immune system. Take the text published on this website, for instance:
The nervous system and immune system are hardwired and work together to create optimal responses for the body to adapt and heal appropriately. Neural dysfunctions due to spinal misalignments are stressful to the body and cause abnormal changes that lead to a poorly coordinated immune response. Chiropractic adjustments have been shown to boost the coordinated responses of the nervous system and immune system…
Subluxation is the term for misalignments of the spine that cause compression and irritation of nerve pathways affecting organ systems of the body. Subluxations are an example of physical nerve stress that affects neuronal control. According to researchers, such stressful conditions lead to altered measures of immune function & increased susceptibility to a variety of diseases.
Inflammatory based disease is influenced by both the nervous, endocrine, and immune systems. Nerve stimulation directly affects the growth and function of inflammatory cells. Researchers found that dysfunction in this pathway results in the development of various inflammatory syndromes such as rheumatoid arthritis and behavioral syndromes such as depression. Additionally, this dysfunctional neuro-endo-immune response plays a significant role in immune-compromised conditions such as chronic infections and cancer.
Wellness based chiropractors analyze the spine for subluxations and give corrective adjustments to reduce the stress on the nervous system. A 1992 research group found that when a thoracic adjustment was applied to a subluxated area the white blood cell (neutrophil) count collected rose significantly.
Other websites go even further:
The best way to prevent meningitis, and other illness, is to develop a robust immune system. The most important element in developing a robust immune system is optimum communication between all systems of the body. Chiropractic does this. The goal of chiropractic is to remove interference in the nervous system, the system that controls and coordinates all other parts of the body. Interference is caused by subluxations or misalignments in the spine. When subluxations are corrected, the body’s nervous system functions optimally and boosts the immune functioning. In fact, individuals who receive chiropractic care have 200% greater immune competence than individuals who don’t. This is why it is vital to receive regular chiropractic adjustments…
If we look at the actual research that might support such strange claims, we find that that it is scarce, flimsy and unconvincing. To the best of my knowledge, nobody has yet shown that people who receive regular chiropractic care are protected from conditions mediated via the immune system. Unless such a phenomenon can be demonstrated beyond reasonable doubt, we should be highly sceptical of the claim that chiropractic care stimulates the immune system and thus generates better health. In my view, regular chiropractic adjustments stimulate only one thing: the cash flow of the therapist.
My conclusion: The claim that chiropractic adjustments have such profound effects on human health is highly irresponsible.
A paper entitled ‘Real world research: a complementary method to establish the effectiveness of acupuncture’ caught my attention recently. I find it quite remarkable and think it might stimulate some discussion on this blog. Here is its abstract:
Acupuncture has been widely used in the management of a variety of diseases for thousands of years, and many relevant randomized controlled trials have been published. In recent years, many randomized controlled trials have provided controversial or less-than-convincing evidence that supports the efficacy of acupuncture. The clinical effectiveness of acupuncture in Western countries remains controversial.
Acupuncture is a complex intervention involving needling components, specific non-needling components, and generic components. Common problems that have contributed to the equivocal findings in acupuncture randomized controlled trials were imperfections regarding acupuncture treatment and inappropriate placebo/sham controls. In addition, some inherent limitations were also present in the design and implementation of current acupuncture randomized controlled trials such as weak external validity. The current designs of randomized controlled trials of acupuncture need to be further developed. In contrast to examining efficacy and adverse reaction in a “sterilized” environment in a narrowly defined population, real world research assesses the effectiveness and safety of an intervention in a much wider population in real world practice. For this reason, real world research might be a feasible and meaningful method for acupuncture assessment. Randomized controlled trials are important in verifying the efficacy of acupuncture treatment, but the authors believe that real world research, if designed and conducted appropriately, can complement randomized controlled trials to establish the effectiveness of acupuncture. Furthermore, the integrative model that can incorporate randomized controlled trial and real world research which can complement each other and potentially provide more objective and persuasive evidence.
In the article itself, the authors list seven criteria for what they consider good research into acupuncture:
- Acupuncture should be regarded as complex and individualized treatment;
- The study aim (whether to assess the efficacy of acupuncture needling or the effectiveness of acupuncture treatment) should be clearly defined and differentiated;
- Pattern identification should be clearly specified, and non-needling components should also be considered;
- The treatment protocol should have some degree of flexibility to allow for individualization;
- The placebo or sham acupuncture should be appropriate: knowing “what to avoid” and “what to mimic” in placebos/shams;
- In addition to “hard evidence”, one should consider patient-reported outcomes, economic evaluations, patient preferences and the effect of expectancy;
- The use of qualitative research (e.g., interview) to explore some missing areas (e.g., experience of practitioners and patient-practitioner relationship) in acupuncture research.
Furthermore, the authors list the advantages of their RWR-concept:
- In RWR, interventions are tailored to the patients’ specific conditions, in contrast to standardized treatment. As a result, conclusions based on RWR consider all aspects of acupuncture that affect the effectiveness.
- At an operational level, patients’ choice of the treatment(s) decreases the difficulties in recruiting and retaining patients during the data collection period.
- The study sample in RWR is much more representative of the real world situation (similar to the section of the population that receives the treatment). The study, therefore, has higher external validity.
- RWR tends to have a larger sample size and longer follow-up period than RCT, and thus is more appropriate for assessing the safety of acupuncture.
The authors make much of their notion that acupuncture is a COMPLEX INTERVENTION; specifically they claim the following: Acupuncture treatment includes three aspects: needling, specific non-needling components drove by acupuncture theory, and generic components not unique to acupuncture treatment. In addition, acupuncture treatment should be performed on the basis of the patient condition and traditional Chinese medicine (TCM) theory.
There is so much BS here that it is hard to decide where to begin refuting. As the assumption of acupuncture or other alternative therapies being COMPLEX INTERVENTIONS (and therefore exempt from rigorous tests) is highly prevalent in this field, let me try to just briefly tackle this one.
The last time I saw a patient and prescribed a drug treatment I did all of the following:
- I greeted her, asked her to sit down and tried to make her feel relaxed.
- I first had a quick chat about something trivial.
- I then asked why she had come to see me.
- I started to take notes.
- I inquired about the exact nature and the history of her problem.
- I then asked her about her general medical history, family history and her life-style.
- I also asked about any psychological problems that might relate to her symptoms.
- I then conducted a physical examination.
- Subsequently we discussed what her diagnosis might be.
- I told her what my working diagnosis was.
- I ordered a few tests to either confirm or refute it and explained them to her.
- We decided that she should come back and see me in a few days when her tests had come back.
- In order to ease her symptoms in the meanwhile, I gave her a prescription for a drug.
- We discussed this treatment, how and when she should take it, adverse effects etc.
- We also discussed other therapeutic options, in case the prescribed treatment was in any way unsatisfactory.
- I reassured her by telling her that her condition did not seem to be serious and stressed that I was confident to be able to help her.
- She left my office.
The point I am trying to make is: prescribing an entirely straight forward drug treatment is also a COMPLEX INTERVENTION. In fact, I know of no treatment that is NOT complex.
Does that mean that drugs and all other interventions are exempt from being tested in rigorous RCTs? Should we allow drug companies to adopt the RWR too? Any old placebo would pass that test and could be made to look effective using RWR. In the example above, my compassion, care and reassurance would alleviate my patient’s symptoms, even if the prescription I gave her was complete rubbish.
So why should acupuncture (or any other alternative therapy) not be tested in proper RCTs? I fear, the reason is that RCTs might show that it is not as effective as its proponents had hoped. The conclusion about the RWR is thus embarrassingly simple: proponents of alternative medicine want double standards because single standards would risk to disclose the truth.
I have always wondered how pharmacists might justify using or recommending or selling homeopathic remedies. So far, I have not come across a pharmacist who would want to stick his/her neck out for homeopathy. Many pharmacists earn money by selling homeopathic preparations – but most seem to be embarrassed by this fact and don’t want to defend it.
Therefore, I was pleased when I found this interview with the pharmacist Christophe Merville. He got introduced to homeopathy as a 11 year old boy suffering from hay fewer; after using homeopathy, “the crises became less severe and less frequent”. Later, he studied to become a pharmacist in France and, in 1990, he joined Boiron, the world’s largest manufacturer of homeopathic remedies. The following is an extensive excerpt (I did not want to cite him ‘out of context’) from his interview about his views on homeopathy.
I remember attending the delivery of a woman and the contractions were very strong, and painful. She had some homeopathic medicine to take just at that time to make those contractions more regular and useful: less intense but longer and less brusque. I saw that happening within minutes, and I was thinking, “That’s very impressive.” That’s probably the time when I concluded that there is something to it.
I witnessed the action of homeopathic medicines on pets also, on young children. I had enough personal anecdotes that I could say there is something more than just suggestion, or placebo, or just the simple act of being cared for. My attitude is to say, “There are enough signs to say that it’s really worth exploring more why it works, how it works, when does it work.” We are past the stage where we can say, “No, there is nothing.” It has been around for a long time and if was just mere placebo effect, it would have gone away, as so many different techniques did.
If you look at the history of science, you find many instances where people first said, for example, “The theory of gravity explains everything.” And when some things are discovered that show it didn’t work in certain very narrow cases, there’s an understanding that we have to adjust. But every time you have to make that adjustment, there is a great body of people who say, “No, it cannot be.”
The main argument against homeopathy is that a remedy is very, very diluted, so it cannot work. My reaction to that is to examine what happens when you dilute something. The act of dilution is not very simple. Those molecules are interacting together, they are interacting with the walls of the container, they are interacting with the solvent, and this interaction does not adhere to a precise mathematical law. The skeptics say, “You divide the number of molecules by 100 each time, so after awhile, there is less than one chance to find one single molecule.” They have their math right, but they have their physics wrong.
Chemists try to use very pure substances. When you buy your reagent, you buy it at 99.999 percent pure. But you don’t have anything that’s 100 percent pure. It would take an infinite amount of energy to get rid of the last impurity. What I think we should explore is the fact that after a certain number of dilutions, the process is not very efficient at removing the last molecules. So there is always something that stays. That’s one thing.
The second thing is in pharmacology for years, we were interested in the ability of large quantities of substances. But what about small ones? I always use the example of butterflies that can sense pheromones at great distances, salmon finding their way back to their native creek from far away, to sharks being able to detect blood in a huge amount of water. Biology uses very small quantities. In cells, you have communication between cells using a few molecules of a certain substance—and it works.
I don’t pretend that I’ve put A and B and C together, and I’m able to provide you with a complete explanation. But I would say those are things to explore. Already the research that exists points to possible action of homeopathic dilution on activation or deactivation of genes. I won’t go into details, but I welcome the skepticism, I think it’s very constructive. But what I don’t really like is people whose mind is set on their misconception of what exactly a dilution is. Of course homeopathy doesn’t violate the laws of physics and chemistry, because that’s absurd.
My first role is pharmacy development. I look at what are the tools that allow pharmacists to know what homeopathy is and for a certain number of them, how to use homeopathy. I consider how to train them, how to have them integrate homeopathy in their practice, because the goal isn’t about replacing other medicines with homeopathy. My first role is to say to pharmacists, “You have to know what it is because these are drugs. If you don’t believe in them, you don’t have to use them, but at least you need to be able to answer customers, your patients.”
And the second thing is that for those who are interested in knowing more, I translate books from France, I design trainings, activities, interactions, so they are placed in a situation of recommending and deciding if it is appropriate to recommend homeopathy, and what treatment is adapted to that particular person.
“Before coming to the conference, I researched what homeopathy is, and you will have a hard time telling me that it can work.” I talk with them to explore a little bit more what it is. We speak the language of pharmacology together, and what strikes me is that very soon, they are into it. They say, “Okay, we see the logic of it.” They realize that they have a tool where they can relieve without doing any harm, without interactions, so their interest is piqued. And they recognize that the mode of action of conventional medicines is not as clear as we thought.
Pharmacists are very pragmatic people—you cannot tell them fairy tales. When they see it, explore it, and use it, then when I meet them later, they tell me, “That stuff works.” And I ask, “Yeah, but do you know how it works?” They don’t, but they see the patient coming back happy.
Of course, they are interested in the research and knowing how it works, but I just give them what we know in clinical research and we discuss it. They see that there is ongoing research and one day we’ll find more. But meanwhile, they are using the product.
You have two approaches. What I call “the user approach” is when people may not really completely understand how a medicine works, but they’re interested in taking it for stress or for allergies, whatever it might be, to see if it works for them. They’re interested in how this medicine will affect them, how should they take it. If it works for them, then great.
Then you have what I call the “intellectual approach”—which is concerned about more cultural, philosophical, and social questions: what is the place of homeopathic medicine in today’s medicine, what are its principles, its history, its perspective. Is it a philosophy, is it a cult, what is it? My role is to try to give context for what homeopathy is. It’s a simple tool in the toolbox—we don’t exactly know all the details of how it works. And this is what we know, and this is what we don’t know, and this is what we speculate might be the way it works. People educate themselves.
Every day, I say, homeopathy doesn’t vaccinate, homeopathy doesn’t cure cancer, homeopathy doesn’t cure diabetes. It can relieve some of the symptoms or side effects of the treatments, but it has limits like every therapy. I fight against those outrageous claims and sometimes people that are really fanatical advocates for homeopathy do much worse for the cause. And I have to tell them: You cannot say that. It is untrue and it is dangerous. This is why I think pharmacists listen to me, because I’m not telling them to change their practice and their ethics. I’m telling them, this is another tool and this is how to use it properly. But there are fundamentals that are still there and will be there for a long time. You cannot replace vaccination by any other techniques—it’s unethical, it’s dangerous, it’s deadly. So we don’t do that. I’m completely against these kinds of claims.
Let’s explore that: a patient suffering with AIDS, advanced infection with HIV, with immunity that decreases. Or a patient treated with antiretroviral therapy, they still have sometimes diarrhea, because their immune system is not able to fight everything. They still have side effects or anxiety. We want their treatment to be as comfortable as possible, because we want them to keep using the treatment. The same thing with cancer. The patient says, “I don’t want to have chemotherapy because it’s hurting me, it’s very difficult and uncomfortable.” We have with homeopathy ways to reduce nausea, for instance, then we increase the comfort of the patient, and the outcome is always better. That’s the framework. Someone who would say, “Oh, you have AIDS, throw away your antiretrovirals, I’m going to treat you with homeopathy”—that person would be a murderer.
We develop tools to help people self-medicate. We say, “Okay, you’re stressed out, you need to sleep a little bit, you’re lacking sleep. Take this for a certain period of time—if it works for you, fine. If it doesn’t, doesn’t, stop it.” For people with what we call “self-limiting conditions”— a cold or a cough—we have good tools with warnings and precautions and things like that for them to self-medicate. And in the warnings, we tell them, “If you experience that kind of fever, if you have that symptom, see a doctor.” We don’t say see a homeopath, we say see a doctor. And among these doctors, there are doctors who have added in different techniques and some of them are using homeopathy when appropriate. For me, what is most important, is that a patient sees someone who is medically qualified.
For people who want to further explore the possibilities that homeopathy offers, I recommend that they see a physician who is skilled in homeopathy but will not use homeopathy for everything. And is able to diagnose. A physician will tell you, “In this case, I can do something with homeopathy, or, in that case, I cannot use homeopathy.”
As I have once worked as a junior doctor in a homeopathic hospital (the full story is here), I knew of course all these arguments and fallacies. Nevertheless, I still ask myself: HOW CAN PHARMACISTS GET CONVINCED IN THIS WAY? ARE THEY REALLY CONVINCED? OR DO THEY JUST DO IT FOR THE MONEY?
I do not feel like prejudging these questions just now. But I do hope to hear from my readers, particularly from the pharmacists amongst them, what they think.