MD, PhD, FMedSci, FSB, FRCP, FRCPEd

regulation

While the previous post was about seeing a traditional herbalist (who prescribe their own herbal mixtures, tailor-made for each individual patient), this post provides essential information for those consumers who are tempted to take a commercially available herbal remedy available in pharmacies, health food shops, over the Internet etc. These remedies are usually bought by consumers and then be self-administered, or (less frequently) they might be prescribed/recommended/sold by a clinician such as a doctor, naturopath, chiropractor etc. Typically, they contain just one (or relatively few) herbal extracts and are used under similar assumptions as conventional medicines: one (hopefully well-tested) remedy is employed for treating a defined condition, diagnosed according to validated and generally accepted criteria (for instance, St John’s Wort for depression or Devil’s claw for back pain). This approach is sometimes referred to as ‘rational phytotherapy’ – it is certainly more rational than the traditional herbalism referred to in my previous post. The manufacture, promotion and sale of commercial herbal remedies (in many countries marketed as ‘dietary supplements’) has grown into a multi-billion dollar industry.

Here are a few essentials you ought to know before you decide to take such an herbal remedy:

  1. Many people claim that herbal medicine is effective because many of our modern drugs are based on plants. The latter part of this claim is true, of course, but this does not necessarily mean that herbal remedies are effective. The drugs derived from plants contain one single, well-defined, extensively researched molecule (by definition, this makes them conventional drugs and not herbal remedies), while herbal remedies are based on entire (parts of) plants; thus they contain many pharmacologically active molecules. This often means that it is difficult or impossible to tell what dose of which ingredient is being administered and what pharmacological actions can be expected.
  2. Even though national regulations differ greatly, herbal remedies generally do not have to be supported by evidence for efficacy in order to be legally available. This means that a given remedy might or might not have been tested in clinical trials to determine whether it works for the condition advertised. In fact, only very few (less than 30, I estimate) herbal remedies are supported by sound evidence for efficacy; thousands do not meet this criterion.
  3. The extremely wide-spread notion that herbal remedies are by definition natural and therefore safe is nothing but a promotional myth. Plants contain many chemicals which can have pharmacological activity. This means they might be therapeutic, but it also means that they might be toxic (traditionally the most powerful poisons originated from the plant kingdom). If anyone uses the ‘natural = safe fallacy’ remind him/her of hemlock, poison ivy etc.
  4. In addition to potential toxicity of an herbal ingredient, there are other important safety issues to be considered. Most importantly, herbal remedies can interact with prescribed medicines. For instance, St John’s Wort (one of the best-studied herbal remedies in this respect) powerfully interacts with about 50% of all prescription drugs – in fact, it lowers their level in the blood which means that a patient on anti-coagulants would lose her anti-coagulant protection and might suffer from a (potentially fatal) blood clot.
  5. In many countries, including the US, the regulation of herbal remedies is so lax, that there is no guarantee that an herbal remedy which is being legally sold is safe. The regulators are only allowed to intervene once there are reports of adverse effects. This means that the burden of proof of safety is effectively reversed which obviously exposes consumers to incalculable risks.
  6. The quality of the herbal product is equally poorly regulated in most countries. A plethora of investigations in the US, for instance, has shown that the dose of the herbal ingredient printed on the label of a commercial product can range virtually from 0 – 100%. Similarly there is little safe-guard that the ingredients listed on the label correspond to the ones in the preparation. This means that it is worth purchasing not just well-researched herbal remedies but also those marketed by high quality manufacturers via respectable outlets.
  7. Any regulation of herbal remedies, even the European one that is often praised as protecting consumers adequately, is null and void once consumers go on the Internet and purchase their herbal remedies from one of the many dubious sources found there in truly alarming profusion. Bogus claims, inferior quality and even outright dangerous products abound, and it is often impossible to tell the acceptable from the fraudulent product.

I know, I have written about this guy before – and I am likely to do so again – he is just too outstanding to pass by!

A few days ago, he was in the headlines again:  the Conservative health committee member David Tredinnick insisted that herbal medicine and even astrology should be given to patients in order to plug a growing hole in the NHS-budget: “I have referred to the fact that in some cultures astrology is part of healthcare because they need to have a voice and I’ve got up and said that,” he told Channel Four News. “But I also think we can reduce the bill by using a whole range of alternative medicine including herbal medicine, acupuncture, homeopathy…We could probably save five per cent of the [NHS] budget.”

Unbelievably, a man with such views is a member of the science and technology committee! This really does instil trust in politics!!!

His track record regarding the promotion of quackery might even dwarf that of Prince Charles; earlier this year he told MPs that astrology should be used to replace some “conventional” medicines on the NHS: “I am absolutely convinced that those who look at the map of the sky for the day that they were born and receive some professional guidance will find out a lot about themselves and it will make their lives easier,” he told the Commons. “I hope that in future we stop looking just at increasing the supply of drugs and consider the way that complementary and alternative medicine can reduce the demand for drugs, reduce pressures on the health service, increase patient satisfaction, and make everyone in this country happier.”

Speaking recently while thousands of NHS workers were on strike, he defended their pay freeze, stating that NHS’s budget was “finite”. However, asked whether he planned to take his own upcoming 9% pay rise, he refused to answer: “I’m not getting drawn on MPs pay… I’m not answering that question on this programme because we’re dealing with the health service.” Pushed further, he suggested that the rise was necessary in order to make MPs “good public servants… All members of parliament will be given a pay rise which is been set by an independent authority. Most of those members of parliament will take that pay rise because that is what is deemed necessary to have good public servants,” he insisted.

But is he really a “good public servant” ???

Addressing parliament about its ‘evidence check’ on homeopathy which came out squarely against it, Tredinnick once stated: “It is my belief that the advice the Clerks provided to the Science and Technology Committee Chairman was inadequate, in that the evidence taken by the Committee in its evidence check on homeopathy was biased, as they did not call representatives of the homeopathic profession and instead chose a professor who did not represent the alternative medicine world. They chose the one person who would give an answer that suited those who were in opposition.”  The professor he refers to is Edzard Ernst, I think! When I was invited to give evidence to the committee, Tredinnick was in the audience; I saw him as we were waiting to go in and even had a chat with him. So, he must remember that sitting next to me were several defenders of homeopathy, amongst them the Queen’s homeopath himself.

Perhaps Tredinnick just forgot!

He couldn’t be lying, could he?

No, a good public servant wouldn’t do that!

I just came across this hilarious yet revealing article by Italian authors defending homeopathy. It is far too remarkable to keep it for myself, and I therefore decided to quote its abstract here in full:

Throughout its over 200-year history, homeopathy has been proven effective in treating diseases for which conventional medicine has little to offer. However, given its low cost, homeopathy has always represented a serious challenge and a constant threat to the profits of drug companies. Moreover, since drug companies represent the most relevant source of funding for biomedical research worldwide, they are in a privileged position to finance detractive campaigns against homeopathy by manipulating the media as well as academic institutions and the medical establishment. The basic argument against homeopathy is that in some controlled clinical trials (CCTs), comparison with conventional treatments shows that its effects are not superior to those of placebo. Against this thesis we argue that a) CCT methodology cannot be applied to homeopathy, b) misconduct and fraud are common in CCTs, c) adverse drug reactions and side effects show that CCT methodology is deeply flawed, d) an accurate testing of homeopathic remedies requires more sophisticated techniques, e) the placebo effect is no more “plausible” than homeopathy, and its real nature is still unexplained, and f) the placebo effect is nevertheless a “cure” and, as such, worthy of further investigation and analysis. It is concluded that no arguments presently exist against homeopathy and that the recurrent campaigns against it represent the specific interests of the pharmaceutical industry which, in this way, strives to protect its profits from the “threat” of a safer, more effective, and much less expensive treatment modality.

Despite (or is it because?) of such nonsense, homeopathy seems to be very popular, especially in the treatment of small children, and particularly for conditions where conventional medicine has no effective treatment. Teething problems are thus an ideal target for the homeopathic industry.

A survey of British GPs found that the most frequently prescribed homeopathic remedies were for common self-limiting infantile conditions such as colic, cuts and bruises, and teething. Similarly, the Avon-study suggested that homeopathic Chamomillia is popular to alleviate the pain of teething. And prominent homeopaths recommend that “teething often responds to Chamomilla.

One website also recommends Chamomilla as well as several other homeopathic remedies leaving little doubt about their efficacy:

Chamomilla 6c: When teething is very painful and the child becomes quite cranky, satisfied with nothing and pacified only by being carried, then Chamomilla may help. Sometimes, the child seeking some relief from the discomfort will demand one thing after another, rejecting each one when it does not give relief. Children who could benefit from this remedy are very irritable, with a cry that sounds as if they are in pain. Chamomilla 6c can be taken every thirty minutes, up to six times per day, while symptoms persist.

Mercurius sol 6c: This remedy may be of help in cases where teething is accompanied by excessive salivation and drooling. In addition, the gums are likely to be red and sore, and the child may have diarrhea with a foul smell to it. Mercurius sol 6c can be taken four to six times per day for two to three days; its use should be discontinued when the symptoms diminish.

>Belladonna 30c: For children who tend to develop a fever with a flushed, red face when they are cutting teeth, Belladonna may be a good choice. Often the eyes have a glassy look due to the dilation of the pupils. The child may be irritable and crying as if angry. Belladonna 30c can be taken every thirty minutes up to four times per day, while symptoms continue.

Aconite napellus 30c: When the symptoms come on quickly and include physical and mental restlessness, this remedy may be useful. The affected gums will be hot, swollen, and inflamed and there may also be an earache with aversion to loud noises. The condition may come on following exposure to cold, dry winds. Try Aconite napellus 30c every hour for up to six times per day.

Calcarea carbonica 6c: When children are finally cutting teeth that have been late in erupting, Calcarea carbonica could be helpful. This remedy is often helpful with “late bloomers,” babies who develop a little more slowly, crawling, walking, and cutting teeth on their own schedule, weeks or months later than some other babies or toddlers. Children likely to benefit from Calcarea carbonica often have sweaty heads and feet and may have a tendency to develop cradle cap or yeast infections. With teething, they often do not show the extreme irritability that calls for Chamomilla, or the fever that indicates Belladonna, but they may have teeth that seem permanently on the verge of breaking through the surface. Calcarea carbonica 6c can be taken three times per day, for up to ten days; its use should be discontinued when symptoms improve.

Given this level of assurance, it not really surprising that manufacturers of homeopathic remedies want to profit from all this. Anxious mothers must seem like sitting ducks to the homeopathic industry.

Camilia, a homeopathic teething remedy that contains Chamomillia in the 9c potency from Boiron, the world’s largest producer of homeopathic products, will be launched shortly in the UK. The PR-agency in charge of the UK campaign to promote camilia announced that they will focus on a “national awareness drive through earned and paid-for media along with influencer engagement.” The agency is also responsible for re-building the brand’s website and implementing a strategy to drive discovery online. Amanda Meyrick of Clarion Communications, said: “Launching a product into a new market gives us the opportunity to work in partnership from the beginning to establish Camilia in the UK, and we are looking forward to seeing the results of our planning and creativity.” Remarkably, nobody seems to mention efficacy as a factor in the promotion of camilia.

However, the product is already available in the US, and from the US website we learn that this remedy “temporarily relieves symptoms of teething, including painful gums and irritability.” So, there are clear claims of efficacy after all!

Boiron is not the only firm who aim to profit from the vast market of teething problems. Nelson’s Teetha, for instance, is already available in the UK. Each 300mg sachet of TEETHA contains “the active ingredient of Chamomilla 6c.” Even Boots, the UK’s ‘trusted’ high street pharmacy, sell a product called ‘TEETHING PAIN RELIEF’ which also contains Chamomilla 6c, its only ‘active’ ingredient. Even the name of their product carries a therapeutic claim for efficacy, in my view.

But hold on! A 6c dilution equals one ml of plant extract diluted in 1 000 000 000 litres of water (add 6 zeros to that figure for the Boiron product)!!! Is that really going to alleviate teething problems?

Of course not!, you will say. Dilutions of this nature will do nothing whatsoever.

But they are not just dilutions, they are potentiations! would the homeopaths counter; they have been succussed at each dilution step, and this process transfers a vital force from the Chamomilla extract to the remedy. Yes, of course, how could I forget – it’s homeopathy where LIKE CURES LIKE and people believe in the tooth fairy.

But this does not make any sense either!

Chamomillia is nothing other than chamomile, a plant known to sooth through its anti-inflammatory actions. So, in highly diluted homeopathic products, the actions of this plant should be reversed according to the ‘like cures like’ principle. That means that these teething products, according to homeopathic ‘logic’, is not for treating inflamed gums but for treating the absence of inflammation.

My mind boggles because nothing seems to make sense any more:

  • according to real science (or just common sense), the dilutions are far to high to have any effect at all,
  • according to homeopathic ‘logic’, these products should, if anything, produce inflammation and not alleviate it,
  • according to the best clinical evidence, homeopathic remedies are not effective for teething; I am not aware of a single rigorous trial that would show its efficacy, and current reviews do not recommend homeopathy for teething problems,
  • regardless of all this and despite of regulations prohibiting it, therapeutic claims are being made for these over-priced placebos.

Puzzled?

Don’t be!

IT’S HOMEOPATHY STUPID!

Many experts have warned us that, when we opt for dietary supplements, we might get more than we bargained for. A recent article reminded us that the increased availability and use of botanical dietary supplements and herbal remedies among consumers has been accompanied by an increased frequency of adulteration of these products with synthetic pharmaceuticals. Unscrupulous producers may add drugs and analogues of various classes, such as phosphodiesterase type 5 (PDE-5) inhibitors, weight loss, hypoglycemic, antihypertensive and anti-inflammatory agents, or anabolic steroids, to develop or intensify biological effects of dietary supplements or herbal remedies. The presence of such adulterated products in the marketplace is a worldwide problem and their consumption poses health risks to consumers.

Other authors recently warned that these products are often ineffective, adulterated, mislabeled, or have unclear dosing recommendations, and consumers have suffered injury and death as a consequence. When Congress passed the Dietary Supplement Health and Education Act, it stripped the Food and Drug Administration of its premarket authority, rendering regulatory controls too weak to adequately protect consumers. State government intervention is thus warranted. This article reviews studies reporting on Americans’ use of dietary supplements marketed for weight loss or muscle building, notes the particular dangers these products pose to the youth, and suggests that states can build on their historical enactment of regulatory controls for products with potential health consequences to protect the public and especially young people from unsafe and mislabeled dietary supplements.

A new study has shown that these problems are not just theoretical but are real and common.

Twenty-four products suspected of containing anabolic steroids and sold in fitness equipment shops in the UK were analyzed for their qualitative and semi-quantitative content using full scan gas chromatography-mass spectrometry (GC-MS), accurate mass liquid chromatography-mass spectrometry (LC-MS), high pressure liquid chromatography with diode array detection (HPLC-DAD), UV-Vis, and nuclear magnetic resonance (NMR) spectroscopy. In addition, X-ray crystallography enabled the identification of one of the compounds, where reference standard was not available.

Of the 24 products tested, 23 contained steroids including known anabolic agents; 16 of these contained steroids that were different to those indicated on the packaging and one product contained no steroid at all. Overall, 13 different steroids were identified; 12 of these are controlled in the UK under the Misuse of Drugs Act 1971. Several of the products contained steroids that may be considered to have considerable pharmacological activity, based on their chemical structures and the amounts present.

The authors concluded that such adulteration could unwittingly expose users to a significant risk to their health, which is of particular concern for naïve users.

The Internet offers thousands of supplements for sale; specifically for bodybuilders there are hundreds of supplements all claiming things that are untrue or untested. The lax regulations that exist in this area seem to be often ignored completely. I think it is important to inform customers that most supplements are a waste of money and some even a waste of health.

The UK ‘Society of Homeopaths’ just proudly made this announcement: “From today, patients will be able to choose a homeopath belonging to a register vetted and approved by the Professional Standards Authority for Health and Social Care (PSA). The Society of Homeopaths’ voluntary register has been accredited under a new scheme set up by the Department of Health and administered by an independent body, accountable to Parliament.”

No, it is not April fools day, but it is clearly time to rejoice and to start believing in homeopathy. Not an easy task, you might say; perhaps this new and equally amazing article outlining 10 reasons to love homeopathy will make it a little more feasible (as it is pure comedy gold, I have only shortened it very slightly)?

1. For Love: Love your family, love thy neighbor, love your homeopath. Even if you don’t need a homeopath, your aunt, your grandmother, or grandchild might…

2. For money. Homeopathic medicines are generally less expensive than patent medicines, which have prices driven by profit, not by cost nor benefit…

3. For your bodies, minds, spirits, and communities. Homeopathy works… How is it possible that everyone can find instances where a homeopathic doctor was able to solve a problem…?

4. Because you are royalty. Kings and queens have used homeopathy – with positive effects. The Queen of England, Queen Elizabeth II has a personal physician – a homeopath. She has used homeopathic medicines for her pets as well. If it’s good enough for royalty, it’s good enough for you.

5. Because someday you might need a chiropractor, a Traditional Chinese Medicine Practitioner, Acupuncturist, an Osteopathic Doctor, an Ayurvedic practitioner, or even a midwife. …Attacking homeopathy, suggesting it be banned, is a first step in the wrong direction. Many medical disciplines are attacked independently, with a goal to remove them all from your market, your freedom to choose. If we ban homeopaths, ask yourself – who’s next?

6. For Your Freedoms: Freedom to choose Homeopathy. Freedom to choose your medicines and treatments. There are many who might prefer that you have fewer freedoms, especially those with something to sell. There are many nonsense restrictions on your freedom to choose, and freedoms avoid, specific medical treatments. It’s your body, your mind, your spirit, and your life. You have the right to choose…

7. For your symptoms. The medical model classifies all symptoms as indications of illness. It does not recognize that symptoms can be indications of healthiness, and seldom recognizes that symptoms can be indications of healing or fighting illness. Homeopathy looks at symptoms from a completely different viewpoint… 

8. For your health. Today, it’s illegal to market a product that claims to ‘improves your health’, without reference to illness. All ‘health claims’ must reference ‘a disease or health related condition’. It is illegal to sell a ‘health product’ without a reference to scientific studies of ‘illness’. Medicine, is blind to health. Homeopathy challenges many medical dogmas, opening a door open to a more comprehensive, broader, more clear view of healthiness – not just illness.

9. For your Doctor. Whether your doctor is a homeopath or not, she might need access to homeopathic ideas and medicines. Homeopathy is practiced by many doctors, dentists, naturopaths, chiropractors, acupuncturists, physician assistants, nurses, even veterinarians, and more. If homeopathy is banned, these medical professionals will be limited, or forced to hide their beliefs and activities.

10. For science. Some argue that homeopathy cannot pass the tests of science. These are people who do not understand science. Science does not find truths, it asks questions and seeks answers. The answers it finds, if they are useful, raise higher, more important questions. When science is stifled, when science becomes illegal, we all lose.

This is all so very sweet that I almost hesitate to bring you back to reality. But I have to, this is no blog for dreamers!

Here is a reminder what level-headed, independent and thorough experts have to say about homeopathy; I am sorry, if their statement comes a bit like a cold shower to the irrationalists: the evidence from research in humans does not show that homeopathy is effective for treating the range of health conditions considered.”

So, what should we make of the UK government’s decision to register homeopaths? Personally, I now look forward to the day when parliament starts discussing the new London airport for flying carpets – but, as always, I look forward to your answers.

In the US, the scope of practice of health care professionals is a matter for each state to decide. Only the one of doctors is regulated nationwide. Other health care professions’ scope of practice can vary considerably within the US. This means that a chiropractor in one state of the US might be allowed to do more (or less) than in the next state. But what exactly are US chiropractors legally allowed to do?

A recent paper was aimed at answering this very question. Its authors assessed the current status of chiropractic practice laws in the US.

A cross-sectional survey of licensure officials from the Federation of Chiropractic Licensing Boards e-mail list was conducted in 2011 requesting information about chiropractic practice laws and 97 diagnostic, evaluation, and management procedures. To evaluate content validity, the survey was distributed in draft form at the fall 2010 Federation of Chiropractic Licensing Boards regional meeting to regulatory board members and feedback was requested. Comments were reviewed and incorporated into the final survey.

Partial or complete responses were received from 96% (n = 51) of the jurisdictions. The states with the highest number of services that could be performed were Missouri (n = 92), New Mexico (n = 91), Kansas (n = 89), Utah (n = 89), Oklahoma (n = 88), Illinois (n = 87), and Alabama (n = 86). The states with the highest number of services that cannot be performed are New Hampshire (n = 49), Hawaii (n = 47), Michigan (n = 42), New Jersey (n = 39), Mississippi (n = 39), and Texas (n = 30).

The authors conclude that the scope of chiropractic practice in the United States has a high degree of variability. Scope of practice is dynamic, and gray areas are subject to interpretation by ever-changing board members. Although statutes may not address specific procedures, upon challenge, there may be a possibility of sanctions depending on interpretation.

For me, the most surprising aspect of this article was to realise how many ‘non-chiropractic’ activities chiropractors are legally permitted in some US states. Here are some of the items that amazed me most:

  • birth certificates
  • death certificates
  • premarital certificates
  • recto-vaginal exam
  • venepuncture
  • i.v. injections
  • prostatic exam
  • genital exam
  • homeopathy
  • ear irrigation
  • colonic irrigation
  • oral and i.v. chelation therapy
  • obstetrics
  • hypnotherapy
  • acupuncture
  • hyperbaric chamber

I have to admit that I did not even know what a PREMARITAL CERTIFICATE’ is; so I looked it up. The first one I found on the internet was entitled “PURITY  COVENANT” and committed the couple “to abstain from fornication and remain sincere to the Lord Jesus Christ and to each other”

I have to further admit that many other of the items on this list leave me equally speechless. For example, how can chiropractors with their training focussed on the musculoskeletal system responsibly complete a death certificate? Why are they allowed in some states to examine the genitalia of their patients?

I suspect the perceived need of chiropractors to do all these things must be closely related to their long-standing ambition to become primary care physicians. Just to be clear: a primary care physician is a physician who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis.  I have always been more than just a bit perplexed how chiropractors, who state that they are musculoskeletal specialists, might even consider being competent primary care providers.

But regardless of common sense, they do! The US ‘Council of Chiropractic Education’ accreditation process, for instance, requires schools to educate and train students to become a “competent doctor of chiropractic who will provide quality patient care and serve as a primary care physician” and the chiro-literature is awash with statements such as this one: “The primary care chiropractic physician is a viable and important part of the primary health care delivery system, with many chiropractic physicians currently prepared to participate effectively and competently in primary care.” Moreover, the phenomenon is by no means limited to the US: “chiropractors in the UK view their role as one of a primary contact healthcare practitioner and that this view is held irrespective of the country in which they were educated or the length of time in practice.”

As far as I am concerned, chiropractors might view their role as whatever they want. The fact is that, even if they add many more items to the list of their ‘services’, they are very far from being competent primary care physicians. Being able to provide the first contact as well as continuous care of medical conditions, not limited by cause, organ system, or diagnosis is not a matter of wishful thinking.

Web-sites have become a leading source of information on health matters. This is particularly true in the realm of alternative medicine. Conventional health care professionals often know too little about this subject to advise their patients, and alternative practitioners are usually too biased to be trusted. So many consumers turn to the Internet and hope that it offers information which is reliable. But is it?

American pharmacists published a study evaluating the quality of on-line information on herbal supplements. They conducted a search of 13 common herbals – including black cohosh, echinacea, garlic, ginkgo, ginseng, green tea, kava, saw palmetto, and St John’s wort – and reviewed the top 50 Web sites for each using a Google search. Subsequently, they analysed clinical claims, warnings, and other safety information.

A total of 1179 Web sites were examined in this way. Less than 8% of retail sites provided information regarding potential adverse effects, drug interactions, and other safety information; only 10.5% recommended consultation with a healthcare professional. Less than 3% cited scientific literature to support their claims.

The authors’ conclusions were worrying: Key safety information is still lacking from many online sources of herbal information. Certain nonretail site types may be more reliable, but physicians and other healthcare professionals should be aware of the variable quality of these sites to help patients make more informed decisions.

Having conducted my fair share of similar research (e.g. here or here or here or here), I can only concur with these conclusions. When it comes to health care, the Internet is a scary place! In the realm of alternative medicine, it is dominated by people who seem not to care much about anything other than their profits.

But what can be done to change this situation? How can we protect the public from Internet-charlatans? How can one control the Internet? I wish I knew! But there are nevertheless means of directing consumers to those sites which do offer reliable information. Kite-marking high quality sites might be one way of achieving this. This task would, of course, be huge and difficult, but in the interest of public safety, governments and other official institutions should consider tackling it.

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

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

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

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

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

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

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

 

Conclusion

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

 

 

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What is a competent homeopath? This intriguing question was addressed in a recent article by researchers from the Department of Public Health, School of Health and Related Research, University of Sheffield, UK, and the Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway. Non-homeopaths would probably argue that either a clinician is competent or he/she is a homeopath; being a competent homeopath seems like a contradiction in terms. So, is is interesting to see what these authors had to say on the subject.

They started by pointing out that homeopathy is unregulated in most European countries, it is therefore not clear, in their view, what it means to be a “competent homeopath”. To clarify this issue, they decided to conduct a small survey investigating homeopathy-educators’ views on what a “competent homeopath” might be and what homeopaths might require in their education. They did a qualitative study based on grounded theory methodology involving telephone interviews with 17 homeopathy-educators from different schools in 10 European countries. The main questions asked were “What do you think is necessary in order to educate and train a competent homeopath?” and “How would you define a competent homeopath?

The results indicate that the homeopathy-educators defined a “competent homeopath” as a professional who, through his/her knowledge and skills together with an awareness of his/her bounds of competence, is able to help his/her patients in the best way possible. This is achieved through the processes of study and self-development, and is supported by a set of basic resources. Becoming and being a “competent homeopath” is underpinned by a set of basic attitudes. These attitudes include course providers and teachers being student-centred, and students and homeopaths being patient-centred. Openness on the part of students is important to learn and develop themselves, on the part of homeopaths when treating patients, and for teachers when working with students. Practitioners have a responsibility towards their patients and themselves, course providers and teachers have responsibility for providing students with effective and appropriate teaching and learning opportunities, and students have responsibility for their own learning and development (in order to avoid confusion or misinterpretation, I have copied this section almost verbatim from the abstract).

The authors consider that, according to homeopathy-educators’ understanding, basic resources and processes contribute to the development of a competent homeopath, who possesses certain knowledge and skills, all underpinned by a set of basic attitudes. And they conclude that this study proposes a substantive theory to answer what homeopathy educators believe a competent homeopath is and what it takes to be educated and trained to become one. The model suggests that certain basic resources and educational and self-developmental processes contribute to developing knowledge and skills necessary to be competent homeopaths. It also pinpoints underlying attitudes needed in the education as well as the clinical practice of competent homeopaths.

I find two things particularly striking in this text which I have copied almost unchanged from the abstract of the original paper (the full text is hardly more illuminating).

Firstly, these statements tell me virtually nothing that is specific to homeopathy. In my view, they are merely a bonanza of platitudes without much real meaning. We could substitute almost any other health care profession for “homeopath”, and the text would still be applicable in a very general and politically correct sort of way. I see nothing here that is specific to homeopathy.

Secondly, according to the findings of this survey, a “competent homeopath” does not seem to have much need for evidence. With virtually every other health care profession I know, one would expect a very strong emphasis on the need for the competent clinician to abide by the rules of evidence-based medicine. Not so in homeopathy!

Why? The answer seems obvious: if a clinician practices evidence-based medicine, he/she cannot possibly practice homeopathy – the evidence shows that homeopathy is a placebo-therapy. So, here we have it: a competent homeopath has to be a contradiction in terms because either someone practices homeopathy or he/she practices evidence-based medicine. Doing both at the same time is simply not possible.

S.O. Hansson from the Royal Institute of Technology, Stockholm, Sweden recently published an interesting comment on the law regulating the labelling of homeopathic products. In it he points out that, in the European Union (EU), all pre-packaged food products must contain a list of ingredients and their quantities. The list should be “accurate, clear and easy to understand for the consumer.” Similar requirements apply to pharmaceutical drugs and products – with one notable exception: homeopathic preparations.

For such products, the ingredients need not be disclosed on the label, which should instead specify “the scientific name of the stock or stocks followed by the degree of dilution.” The degree of homeopathic dilutions is, in turn, given in an understandable jargon, such as “C60″, which actually describes a dilution of 1:10120.

The point Hansson is trying to make is that very few health care professionals and even fewer consumers would understand such abbreviations and jargon. This means that, manufacturers of homeopathic products are legally permitted to hide the fact from their customers that their remedies typically contain no active ingredient at all. Considering that homeopathic products are typically bought ‘over the counter’ (OTC), i.e. without interference from a health care professional, just like food products, the exemption seems most surprising.

The most OTC homeopathic remedies are in the “C30” potency; this signifies a dilution of 1: 1 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000. The likelihood that any potency higher than “C12” might contain a single molecule of active ingredient is very close to zero. In order to comprehend the degree of dilution in homeopathy more fully, a visual approach might be best: for it to have a reasonable chance to contain just one single molecule of active ingredient, a homeopathic pill in a “C30” potency would need to have a diameter roughly equal to the distance between the earth and the sun. Homeopathy is truly impossible to swallow.

If homeopathic manufacturers were obliged to provide a description that is “accurate, clear and easy to understand for the consumer”, it would need to state that any dilution beyond “C12” contains no active molecule. It seems clear that such accurate, clear and understandable information would discourage most consumers to spend their hard-earned money for such nonsense. It seems thus to be obvious that the EU exemption of homeopathic remedies from honest labelling protects the interests of the homeopathic industry.

But surely, this is deeply wrong. Regulations in health care are not supposed to protect commercial interests, they should protect the consumer. In my view, it is time to change such profoundly misguided EU-regulation – in the interest of honesty, single standards, transparency and foremost in the interest of the patient and the consumer.

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