MD, PhD, FMedSci, FSB, FRCP, FRCPEd

homeopathy

Recently, I have been invited by the final year pharmacy students of the ‘SWISS FEDERAL INSTITUTE OF TECHNOLOGY ZURICH‘ to discuss alternative medicine with them. The aspect I was keen to debate was the issue of retail-pharmacists selling medicines which are unproven or even disproven. Using the example of homeopathic remedies, I asked them how many might, when working as retail-pharmacists, sell such products. About half of them admitted that they would do this. In real life, this figure is probably closer to 100%, and this discrepancy may well be a reflection of the idealism of the students, still largely untouched by the realities of retail-pharmacy.

In our discussions, we also explored the reasons why retail-pharmacists might offer unproven or disproven medicines like homeopathic remedies to their customers. The ethical codes of pharmacists across the world quite clearly prohibit this – but, during the discussions, we all realised that the moral high ground is not easily defended against the necessity of making a living. So, what are the possible motivations for pharmacists to sell bogus medicines?

One reason would be that they are convinced of their efficacy. Whenever I talk to pharmacists, I do not get the impression that many of them believe in homeopathy. During their training, they are taught the facts about homeopathy which clearly do not support the notion of efficacy. If some pharmacists nevertheless were convinced of the efficacy of homeopathy, they would obviously not be well informed and thus find themselves in conflict with their duty to practice according to the current best evidence. On reflection therefore, strong positive belief can probably be discarded as a prominent reason for pharmacists selling bogus medicines like homeopathic remedies.

Another common argument is the notion that, because patients want such products, pharmacists must offer them. When considering it, the tension between the ethical duties as a health care professional and the commercial pressures of a shop-keeper becomes painfully obvious. For a shop-keeper, it may be perfectly fine to offer all products which might customers want. For a heath care professional, however, this is not necessarily true. The ethical codes of pharmacists make it perfectly clear that the sale of unproven or disproven medicines is not ethical. Therefore, this often cited notion may well be what pharmacists feel, but it does not seem to be a valid excuse for selling bogus medicines.

A variation of this theme is the argument that, if patients were unable to buy homeopathic remedies for self-limiting conditions which do not really require treatment at all, they would only obtain more harmful drugs. The notion here is that it might be better to sell harmless homeopathic placebos in order to avoid the side-effects of real but non-indicated medicines. In my view, this argument does not hold water: if no (drug) treatment is indicated, professionals have a duty to explain this to their patients. In this sector of health care, a smaller evil cannot easily be justified by avoiding a bigger one; on the contrary, we should always thrive for the optimal course of action, and if this means reassurance that no medical treatment is needed, so be it.

An all too obvious reason for selling bogus medicines is the undeniable fact that pharmacists earn money by doing so. There clearly is a conflict of interest here, whether pharmacists want to admit it or not – and mostly they fail to do so or play down this motivation in their decision to sell bogus medicines.

Often I hear from pharmacists working in large chain pharmacies like Boots that they have no influence whatsoever over the range of products on sale. This perception mat well be true. But equally true is the fact that no health care professional can be forced to do things which violate their code of ethics. If Boots insists on selling bogus medicines, it is up to individual pharmacists and their professional organisations to change this situation by protesting against such unethical malpractice. In my view, the argument is therefore not convincing and certainly does not provide an excuse in the long-term.

While discussing with the Swiss pharmacy students, I was made aware of yet another reason for selling bogus medicines in pharmacies. Some pharmacists might feel that stocking such products provides an opportunity for talking to patients and informing them about the evidence related to the remedy they were about to buy. This might dissuade them from purchasing it and could persuade them to get something that is effective instead. In this case, the pharmacist would merely offer the bogus medicine in order to advise customers against employing it. This strategy might well be an ethical way out of the dilemma; however, I doubt that this strategy is common practice with many pharmacists today.

With all this, we should keep in mind that there are many shades of grey between the black and white of the two extreme attitudes towards bogus medicines. There is clearly a difference whether pharmacists actively encourage their customers to buy bogus treatments (in the way it often happens in France, for instance), or whether they merely stock such products and, where possible, offer responsible, evidence-based advise to people who are tempted to buy them.

At the end of the lively but fruitful discussion with the Swiss students I felt optimistic: perhaps the days when pharmacists were the snake-oil salesmen of the modern era are counted?

The Australian ‘NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL’ (NHMRC) has assessed the effectiveness of homeopathy. The evaluation looks like the most comprehensive and most independent in the history of homeopathy. Its draft report has just been released and concludes that “the evidence from research in humans does not show that homeopathy is effective for treating the range of health conditions considered.”

Not for a single health conditions was there reliable evidence that homeopathy was effective. No rigorous studies reported either that homeopathy caused greater health improvements than a placebo, or that homeopathy caused health improvements equal to those of another treatment.

The overview considered a total of 57 systematic reviews that assessed the effectiveness of homeopathy for 61 different health conditions.

The draft report presents the evidence according to 4 different categories:

1)

Homeopathy was reported to be not more effective than placebo in either all the studies found, or in a large majority of the reliable studies for the treatment of the following health conditions:

  • adenoid vegetation in children
  • asthma
  • anxiety or stress-related conditions
  • diarrhoea in children
  • headache and migraine
  • muscle soreness
  • labour
  • pain due to dental work
  • pain due to orthopaedic surgery
  • postoperative ileus
  • premenstrual syndrome
  • upper respiratory tract infections
  • warts.

2)

For the following condition, although some studies reported that homeopathy was more effective than placebo, trials were not reliable and homeopathy was therefore judged to be no more effective than placebo:

  • allergic rhinitis
  • attention deficit/hyperactivity disorder
  • bruising
  • chronic fatigue syndrome
  • diarrhoea in children
  • fibromyalgia
  • hot flushes in women who have had breast cancer
  • human immunodeficiency virus infection
  • influenza-like illness
  • rheumatoid arthritis
  • sinusitis
  • sleep disturbances or circadian rhythm disturbances
  • stomatitis  due to chemotherapy
  • ulcers.

3)

For the following conditions, although some studies reported that homeopathy was as effective as or more effective than another treatment, trials were not reliable:

  • acute otitis media or otitis media with effusion
  • allergic rhinitis
  • anxiety or stress-related conditions
  • depression
  • eczema
  • non-allergic rhinitis
  • osteoarthritis
  • upper respiratory tract infection

4)

There was no reliable evidence on which to draw a conclusion about the effectiveness of homeopathy, compared with placebo, for the treatment of the following health conditions:

  • acne vulgaris
  • acute otitis media in children
  • acute ankle sprain
  • acute trauma
  • amoebiasis and giardiasis
  • ankylosing spondylitis
  • boils and pyoderma
  • Broca’s aphasia after stroke
  • bronchitis
  • cholera
  • cough
  • chronic polyarthritis
  • dystocia
  • eczema
  • heroin addiction
  • knee joint haematoma
  • lower back pain
  • nausea and vomiting associated with chemotherapy
  • oral lichen planus
  • osteoarthritis
  • proctocolitis
  • postoperative pain-agitation syndrome
  • radiodermatitis in women with breast cancer
  • seborrhoeic dermatitis
  • suppression of lactation after childbirth
  • stroke
  • traumatic brain injury
  • uraemic pruritis
  • vein problems due to cannulas in people receiving chemotherapy.

5)

There was no reliable evidence on which to draw a conclusion about the effectiveness of homeopathy compared with other therapies for the treatment of the following health conditions:

  • burns
  • fibromyalgia
  • irritable bowel syndrome
  • malaria
  • proctocolitis
  • recurrent vulvovaginal candidiasis
  • rheumatoid arthritis.

The authors of the report now invite comments from interested parties. This means that homeopaths across the world can submit evidence which they feel has been ignored. It will be fascinating to see whether this changes the conclusion of the NHMRC’s assessment.

‘Homeopathy in perspective’ is the title of a book by Anthony Campbell, the revised edition of which has recently become available. Dr Campbell has been a consultant at the Royal London Homeopathic Hospital (RLHH, as it was called then) for ~20 years and also served as the editor of the journal ‘Homeopathy‘ (as it is now called) for many years. He retired in 1998 but is still active in writing and teaching. His book is well-written, informative and far less promotional than one would expect. It summarizes the history of homeopathy in some detail and then discusses the scientific evidence – and it is, of course, this section that might be of particular interest for this blog and its readers.

I think Campbell is correct when he writes that it is wrong to say, as some critics do, that there is no objective evidence for homeopathy. There is, but most of it is of rather poor quality. Even at its best there is evidence for only a small effect, and when an effect is as small as this it may not be there at all. It is also disturbing that the better the quality of a trial the less likely it is to show a positive effect.

Amazing, coming from a retired consultant of the RLHH, isn’t it? It gets even more surprising as we read on: I conclude that there are no firm answers to questions about the efficacy of homeopathy to be found in the research that has been done up to now. Homeopathy has not been proved to work but neither has it been conclusively disproven – it is of course notoriously difficult to prove a negative.

A few paragraphs further on, Campbell provides his final conclusions on the evidence and gets even more explicit: My own assessment of homeopathy is that, while it is impossible to say categorically that all the remedies are without objective effect, any effect there may be is small and unimportant. The great majority, at least, of the improvement that patients experience is due to non-specific causes.

When I began saying and writing things like this, the world of homeopathy decided that I was a fraud and imposter who had no training in or knowledge of homeopathy; therefore, they almost unanimously agreed, my verdict was not to be trusted. I wonder how they are going to try to invalidate the words of someone who was for 20 years a consultant and director of the RLHH.

PS 

While I agree with much of what Campbell writes here, I have reservations about one particular aspect and will explain in the next post.

Indian researchers published a survey aimed at determining the practice of prescription by homeopathic undergraduate students. A cross-sectional study was carried out involving all the students from 4 government homeopathic schools of West Bengal, India. Data were collected using self-administered questionnaires.

A total of 328 forms were completed. 80.5% of all homeopathic undergraduate students admitted prescribing homeopathic medicines independently and 40.5% said that they did this 2-3 times a year. The most common reasons for this activity were ‘urgency of the problem’ (35.2%), ‘previous experience with same kind of illness’ (31.8%), and ‘the problem too trivial to go to a doctor’ (25.8%). About 63.4% of the students thought that it was alright to independently diagnose an illness, while 51.2% thought that it was alright for them to prescribe medicines to others. Common conditions encountered were fever, indigestion, and injury. Prescription by students gradually increased with academic years of homeopathic schools. Many students thought it was alright for students to diagnose and treat illnesses.

The authors conclude that prescription of medicines by homeopathic undergraduate students is quite rampant and corrective measures are warranted.

It’s hard to know whether to laugh or cry about these findings:

  • If you are a homeopath, you ought to be upset to hear that students who are obviously neither fully trained, qualified or licensed already prescribe medicines.
  • If you are aware of the fact that homeopathic remedies are pure placebos, you might laugh about all this thinking “who cares?”
  • If you are into public health, you will worry that homeopaths are obviously being taught that homeopathic remedies can treat conditions which are considered to be urgent.
  • If you are someone who believes that sick people need evidence-based treatments, you might want to change the authors’ conclusion into something like: prescription of medicines by homeopaths is quite rampant and, in the interest of patients, corrective measures are required to stop them.

Last week, it was announced that Claus Fritzsche had killed himself on 14 January 2014 at the age of 49. He was an industrious blogger and evangelic promoter of alternative medicine who seemed to spend much of his time and energy to defame those who disagreed with him. In this capacity, he certainly did tirelessly direct ‘ad hominem’ attacks in my direction. When it was revealed, about two years ago, that several German homeopathic firms paid him generously for this activity, his sponsors withdrew with plenty of egg on their faces, and subsequently Fritzsche’s insults became less frequent.

I never met Fritzsche in person but, over the years, I had many email exchanges with him. Invariably, these were unpleasant, to put it mildly. One might admire his tenacity but, from my perspective, it was hard to like Fritzsche. During the last months of his life, I refused to have contact with him, even via email – not because I failed to find our correspondence interesting or amusing, but because our exchanges always ended with some sort of escalation of aggression from his side.

Why then does his death sadden me so deeply?

Any death is a sad event but, if a death is so unnecessary and wasteful, it is particularly depressing. Fritzsche clearly had many skills and a lot of talents. He was young, intelligent and probably was a pleasant person to know personally, at least that is what some people who knew him have said. Alright, we did not agree on many things, but that does not mean that he was a bad person. He just seemed extremely irrational and tragically delivered the ultimate proof for his irrationality through his suicide.

Nobody knows what motivated Fritzsche to kill himself [when Walach speculated that his financial situation following the disclosure of the nature of his sponsorship had anything to do with it, he finds himself yet again way beyond the established facts]. Presumably, he suffered from depression, and presumably he was deeply insecure, and perhaps he was also desperately lonely.

Suspecting that this was the case, I now wish I had continued writing emails to him. Having argument after argument, even at the risk of getting yet again insulted and attacked, might have just been what was required to prevent him sliding into the abyss. I feel sorry for breaking off email contact when, in a strange sense, he might have needed me and the type of irritation people like me seemed to cause him.

The efficacy or effectiveness of medical interventions is, of course, best tested in clinical trials. The principle of a clinical trial is fairly simple: typically, a group of patients is divided (preferably at random) into two subgroups, one (the ‘verum’ group) is treated with the experimental treatment and the other (the ‘control’ group) with another option (often a placebo), and the eventual outcomes of the two groups is compared. If done well, such studies are able to exclude biases and confounding factors such that their findings allow causal inference. In other words, they can tell us whether an outcome was caused by the intervention per se or by some other factor such as the natural history of the disease, regression towards the mean etc.

A clinical trial is a research tool for testing hypotheses; strictly speaking, it tests the ‘null-hypothesis’: “the experimental treatment generates the same outcomes as the treatment of the control group”. If the trial shows no difference between the outcomes of the two groups, the null-hypothesis is confirmed. In this case, we commonly speak of a negative result. If the experimental treatment was better than the control treatment, the null-hypothesis is rejected, and we commonly speak of a positive result. In other words, clinical trials can only generate positive or negative results, because the null-hypothesis must either be confirmed or rejected – there are no grey tones between the black of a negative and the white of a positive study.

For enthusiasts of alternative medicine, this can create a dilemma, particularly if there are lots of published studies with negative results. In this case, the totality of the available trial evidence is negative which means the treatment in question cannot be characterised as effective. It goes without saying that such an overall conclusion rubs the proponents of that therapy the wrong way. Consequently, they might look for ways to avoid this scenario.

One fairly obvious way of achieving this aim is to simply re-categorise the results. What, if we invented a new category? What, if we called some of the negative studies by a different name? What about NON-CONCLUSIVE?

That would be brilliant, wouldn’t it. We might end up with a simple statistic where the majority of the evidence is, after all, positive. And this, of course, would give the impression that the ineffective treatment in question is effective!

How exactly do we do this? We continue to call positive studies POSITIVE; we then call studies where the experimental treatment generated worst results than the control treatment (usually a placebo) NEGATIVE; and finally we call those studies where the experimental treatment created outcomes which were not different from placebo NON-CONCLUSIVE.

In the realm of alternative medicine, this ‘non-conclusive result’ method has recently become incredibly popular . Take homeopathy, for instance. The Faculty of Homeopathy proudly claim the following about clinical trials of homeopathy: Up to the end of 2011, there have been 164 peer-reviewed papers reporting randomised controlled trials (RCTs) in homeopathy. This represents research in 89 different medical conditions. Of those 164 RCT papers, 71 (43%) were positive, 9 (6%) negative and 80 (49%) non-conclusive.

This misleading nonsense was, of course, warmly received by homeopaths. The British Homeopathic Association, like many other organisations and individuals with an axe to grind lapped up the message and promptly repeated it: The body of evidence that exists shows that much more investigation is required – 43% of all the randomised controlled trials carried out have been positive, 6% negative and 49% inconclusive.

Let’s be clear what has happened here: the true percentage figures seem to show that 43% of studies (mostly of poor quality) suggest a positive result for homeopathy, while 57% of them (on average the ones of better quality) were negative. In other words, the majority of this evidence is negative. If we conducted a proper systematic review of this body of evidence, we would, of course, have to account for the quality of each study, and in this case we would have to conclude that homeopathy is not supported by sound evidence of effectiveness.

The little trick of applying the ‘NON-CONCLUSIVE’ method has thus turned this overall result upside down: black has become white! No wonder that it is so popular with proponents of all sorts of bogus treatments.

There is not a discussion about homeopathy where an apologist would eventually state: HOMEOPATHY CANNOT BE A PLACEBO, BECAUSE IT WORKS IN ANIMALS!!! Those who are not well-versed in this subject tend to be impressed, and the argument has won many consumers over to the dark side, I am sure. But is it really correct?

The short answer to this question is NO.

Pavlov discovered the phenomenon of ‘conditioning’ in animals, and ‘conditioning’ is considered to be a major part of the placebo-response. So, depending on the circumstances, animals do respond to placebo (my dog, for instance, used to go into a distinct depressive mood when he saw me packing a suitcase).

Then there is the fact that the animal’s response might be less important than the owner’s reaction to homeopathic treatment. This is particularly important with pets, of course. Homeopathy-believing pet owners might over-interpret the pet’s response and report that the homeopathic remedy has worked wonders when, in fact, it has made no difference.

Finally, there may be some situations where neither of the above two phenomena can play a decisive role. Homeopaths like to cite studies where entire herds of cows were treated homeopathically to prevent mastitis, a common problem in milk-cows. It is unlikely that conditioning or wishful thinking of the owner are decisive in such a study. Let’s see whether homeopathy-promoters will also be fond of this new study of exactly this subject.

New Zealand vets compared clinical and bacteriological cure rates of clinical mastitis following treatment with either antimicrobials or homeopathic preparations. They used 7 spring-calving herds from the Waikato region of New Zealand to source cases of clinical mastitis (n=263 glands) during the first 90 days following calving. Duplicate milk samples were collected for bacteriology from each clinically infected gland at diagnosis and 25 (SD 5.3) days after the initial treatment. Affected glands were treated with either an antimicrobial formulation or a homeopathic remedy. Generalised linear models with binomial error distribution and logit link were used to analyse the proportion of cows that presented clinical treatment cures and the proportion of glands that were classified as bacteriological cures, based on initial and post-treatment milk samples.

The results show that the mean cumulative incidence of clinical mastitis was 7% (range 2-13% across herds) of cows. Streptococcus uberis was the most common pathogen isolated from culture-positive samples from affected glands (140/209; 67%). The clinical cure rate was higher for cows treated with antimicrobials (107/113; 95%) than for cows treated with homeopathic remedies (72/114; 63%) (p<0.001) based on the observance of clinical signs following initial treatment. Across all pathogen types bacteriological cure rate at gland level was higher for those cows treated with antimicrobials (75/102; 74%) than for those treated with a homeopathic preparation (39/107; 36%) (p<0.001).

The authors conclude that homeopathic remedies had significantly lower clinical and bacteriological cure rates compared with antimicrobials when used to treat post-calving clinical mastitis where S. uberis was the most common pathogen. The proportion of cows that needed retreatment was significantly higher for the homeopathic treated cows. This, combined with lower bacteriological cure rates, has implications for duration of infection, individual cow somatic cell count, costs associated with treatment and animal welfare.

Yes, I know, this is just one single study, and we need to consider the totality of the reliable evidence. Currently, there are 203 clinical trials of homeopathic treatments of animals; and they are being reviewed at the very moment (unfortunately by a team that is not known for its objective stance on homeopathy). So, we will have to wait and see. When, in 1999, A. Vickers reviewed all per-clinical studies, including those on animals, he concluded that there is a lack of independent replication of any pre-clinical research in homoeopathy. In the few instances where a research team has set out to replicate the work of another, either the results were negative or the methodology was questionable.

All this is to say that, until truly convincing evidence to the contrary is available, the homeopaths’ argument ‘HOMEOPATHY CANNOT BE A PLACEBO, BECAUSE IT WORKS IN ANIMALS!!!’ is, in my view, as weak as the dilution of their remedies.

I have written about this subject before, and I probably will do so again. The reason for my insistence is simple: some homeopathy-fans’ attitude towards and advice about immunizations is, in my view, nothing short of a scandal. Here are excerpts from two articles published in the current issue of ‘HOMEOPATHY 4 EVERYONE’ which amply explain what I mean.

The first paper is by Alan Phillips, a leading U.S. vaccine rights attorney and self-declared fan of homeopathy. It goes through the usual arguments suggesting that immunizations are not effective, outright harmful and a vicious ploy to enrich the pharmaceutical industry at the cost of public health. Subsequently, the author gives advice as to how US citizens can avoid mandatory immunizations: 

God bless homeopathy! A particularly wonderful example was in Cuba in the fall of 2008, when homeoprophylaxis was used in place of allopathic immunizations to respond to a leptospirosis outbreak. Two and a half million people were each given 2 doses of a remedy, and the results not only substantially exceeded prior experience with vaccines, it was about 1/15 the cost! And to the best of my knowledge, there are no serious adverse events with homeopathy as there are with virtually any widespread use of vaccines. The failure of our government health agencies to seize upon the Cuban and other homeoprophylaxis successes by aggressively pursuing further research in this area, and the incorporation of homeoprophylaxis into standard infectious disease control strategies, reveals a public health policy driven by something other than the best health interests of the members of our society.

With all of the problems in the allopathic world, and obvious safe and effective alternatives to immunizations that are being systematically ignored, it’s no wonder that a growing number of people are looking for ways to legally avoid immunization mandates. Ironically, vaccines are being required in greater and greater numbers for more and more people. The reason is simple: The federal government subsidizes vaccine research and development; state and federal governments mandate vaccines; state and federal governments purchase vaccines; and state and federal governments compensate those injured or killed by vaccines. So, for those who are able to throw ethics and morality out the window without a second thought, there’s a racket here offering profound profits, and a convenient vehicle for injecting who knows what into literally billions of people worldwide. The multi-billion dollar international vaccine industry is projected to grow at some 10-12% annually for the next several years…

So you’ve done your research, and you’ve decided that you’d like to postpone, or even forego some or all vaccines altogether. Can you do that? How do you do that? Well, it depends on your specific situation… 

Fortunately, everywhere vaccines are mandated in the U.S., one or more exemptions are available…

Medical exemptions can be hard to get. They usually require the support of a medical doctor, and there are usually specific, narrow criteria that must be met to qualify… So, if you’re considering a medical exemption, make sure you find out first what qualifies for the exemption in your specific situation; and if you can get a doctor to support you for a qualifying reason, then pursuing a medical exemption may be an appropriate route to take.

Religious exemptions are probably the most commonly used exemption. What qualifies is a topic too lengthy for an article, but in brief, it doesn’t require membership in an organized religion, and it doesn’t matter what religion you belong to, if you do belong to one…

Philosophical exemptions, when available, are great in that they don’t require you to justify your beliefs or to state reasons. But states have been changing laws to make them harder to get… The long-held notion of a presumed net benefit from vaccines has been slowly undermined by medical science, though the medical authorities, increasingly controlled by the pharmaceutical industry, continue to actively suppress this reality to the best of their ability… However, in those religious exemption situations where you are required to state your beliefs, and where the authorities involved have authority to scrutinize your beliefs, it is highly advisable to seek out professional help from an experienced attorney…

The second article is by Fran Sheffield, a homeopath from NSW, who began her homeopathic studies after “seeing the benefits homeopathy brought to her vaccine-injured child”, and a founding member of ‘The Do No Harm Initiative Inc.’, a lobby group misinforming communities and governments about ‘homeopathic immunisation’:

Homeoprophylaxis has a remarkable record of safety – vaccines less so. From the homeopath’s point of view they are still associated with risks: the dose is too strong, they have toxic additives, and they’re given by inappropriate pathways.

Homeoprophylaxis has avoided these problems. It’s also versatile, inexpensive, quick to produce and easy to distribute.

Keeping these points in mind, I’ll return to Von Behring who went on to say:

“I am touching here upon a subject anathematized till very recently by medical penalty: but if I am to present these problems in historical illumination, dogmatic imprecations must not deter me”…

The same sentiments are true today – dogma and penalty must not be allowed to restrict information on homeoprophylaxis or deprive others of this safe, simple option. The time has come for all of us – governments and individuals – to take a closer look at homeoprophylaxis and how it relieves the burden of disease…

Future posts show what I did with the prophylactic information, why some were offended or upset, the inevitable backlash that followed, attempts at intimidation and suppression, what happens when a matter like this goes to court, what is lost when we don’t speak out about the truth, and what we should do for the future.

I think I will abstain from any comment; if I did, I would be in danger of being libellous. However, I do hope that my readers will post their opinions freely.

 

A recent survey included a random sample of 1179 Brits who were asked about their attitude towards and usage of homeopathy as well as other forms of alternative medicine (AM). The results indicate that a slim majority had never used AM at all. The most popular treatments within the group of AM-users were herbal medicines, homeopathy and acupuncture.

Perhaps because they are more up-to-date, these findings are considerably different from our own results obtained from the Health Survey for England 2005. We used data of all 7630 respondents and showed that lifetime and 12-month prevalence of AM-use were 44.0% and 26.3% respectively; 12.1% had consulted a practitioner in the preceding 12 months. Massage, aromatherapy and acupuncture were the most commonly used therapies. Twenty-nine percent of respondents taking prescription drugs had used AM in the last 12 months. Women, university educated respondents, those suffering from anxiety or depression, people with poorer mental health and lower levels of perceived social support, people consuming ≥ 5 portions of fruit and vegetables a day were significantly more likely to use AM.

In the new survey, a quarter of those not using homeopathy said this was because they had never heard of it; a third because they had never been advised to use it and/or that they’d never had an illness that required it; and 3% said it was because homeopathic remedies were too expensive. About a quarter of non-users said that they avoided homeopathy because they didn’t believe that it worked, or that conventional medicine worked better.

Of the homeopathy-users, 49% said they were “willing to try anything and didn’t think it could do any harm”. Only 16% claimed to use it because they believed it worked better than conventional medicine. This means that only around 3% of the population have used homeopathy because of a belief that it works where conventional medicine doesn’t. The rest either have not used it, or used it for other reasons.

The researchers arrived at the following conclusions and predictions: Our research suggests that nearly half of the public don’t believe and act as if AM and conventional medicine are at odds. Coupled with the significant global industry that has grown up around AM, it is easy to see why politicians have been unwilling to respond to the clear evidence that homeopathy and AM are ineffective. In the US, it’s a $34bn industry where half of people report using them.

The competition between proponents and opponents of AM in all likelihood is set to continue. But there’s some evidence that better science education can help people to distinguish between scientific and pseudo-scientific claims, and it appears that at least some of the openness to AM might stem from concerns about how medical research is regulated. And it is these that might hold the key to who ultimately comes out of the ring in better shape.

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

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

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

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

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

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

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

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

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