conflict of interest
The UK Royal Pharmaceutical Society have published a quick reference guide on homeopathy. In it, they make the following 5 ‘key points’:
- The Royal Pharmaceutical Society (RPS) does not endorse homeopathy as a form of treatment because there is no scientific basis for homeopathy nor any evidence to support the clinical efficacy of homeopathic products beyond a placebo effect.
- The RPS does not support the prescribing of homeopathic products on the NHS.
- Pharmacists should ensure, wherever possible, that patients do not stop taking their prescribed conventional medication, if they are taking or are considering taking a homeopathic product.
- Pharmacists must be aware that patients requesting homeopathic products may have serious underlying undiagnosed medical conditions which may require referral to another healthcare professional.
- Pharmacists must advise patients considering a homeopathic product about their lack of efficacy beyond that of a placebo.
This publication is a few months old, but I only saw it recently. It could not be clearer and it is much more to the point than the General Pharmaceutical Council’s ‘Standards for Pharmacy Professionals‘ which state:
People receive safe and effective care when pharmacy professionals reflect on the application of their knowledge and skills and keep them up-to-date, including using evidence in their decision making. A pharmacy professional’s knowledge and skills must develop over the course of their career to reflect the changing nature of healthcare, the population they provide care to and the roles they carry out. There are a number of ways to meet this standard and below are examples of the attitudes and behaviours expected.
People receive safe and effective care when pharmacy professionals:
- recognise and work within the limits of their knowledge and skills, and refer to others when needed
- use their skills and knowledge, including up-to-date evidence, to deliver care and improve the quality of care they provide
- carry out a range of continuing professional development (CPD) activities relevant to their practice
- record their development activities to demonstrate that their knowledge and skills are up to date
- use a variety of methods to regularly monitor and reflect on their practice, skills and knowledge
The two statements together should suffice to finally get some sense into UK pharmacies when it comes to the sale of homeopathic remedies. What is needed now, I think, is an (under-cover?) investigation to see how many UK community pharmacists abide by this guidance.
If anyone has the means to conduct it, I would be delighted to advise them on the best methodology.
I remember reading this paper entitled ‘Comparison of acupuncture and other drugs for chronic constipation: A network meta-analysis’ when it first came out. I considered discussing it on my blog, but then decided against it for a range of reasons which I shall explain below. The abstract of the original meta-analysis is copied below:
The objective of this study was to compare the efficacy and side effects of acupuncture, sham acupuncture and drugs in the treatment of chronic constipation. Randomized controlled trials (RCTs) assessing the effects of acupuncture and drugs for chronic constipation were comprehensively retrieved from electronic databases (such as PubMed, Cochrane Library, Embase, CNKI, Wanfang Database, VIP Database and CBM) up to December 2017. Additional references were obtained from review articles. With quality evaluations and data extraction, a network meta-analysis (NMA) was performed using a random-effects model under a frequentist framework. A total of 40 studies (n = 11032) were included: 39 were high-quality studies and 1 was a low-quality study. NMA showed that (1) acupuncture improved the symptoms of chronic constipation more effectively than drugs; (2) the ranking of treatments in terms of efficacy in diarrhoea-predominant irritable bowel syndrome was acupuncture, polyethylene glycol, lactulose, linaclotide, lubiprostone, bisacodyl, prucalopride, sham acupuncture, tegaserod, and placebo; (3) the ranking of side effects were as follows: lactulose, lubiprostone, bisacodyl, polyethylene glycol, prucalopride, linaclotide, placebo and tegaserod; and (4) the most commonly used acupuncture point for chronic constipation was ST25. Acupuncture is more effective than drugs in improving chronic constipation and has the least side effects. In the future, large-scale randomized controlled trials are needed to prove this. Sham acupuncture may have curative effects that are greater than the placebo effect. In the future, it is necessary to perform high-quality studies to support this finding. Polyethylene glycol also has acceptable curative effects with fewer side effects than other drugs.
END OF 1st QUOTE
This meta-analysis has now been retracted. Here is what the journal editors have to say about the retraction:
After publication of this article , concerns were raised about the scientific validity of the meta-analysis and whether it provided a rigorous and accurate assessment of published clinical studies on the efficacy of acupuncture or drug-based interventions for improving chronic constipation. The PLOS ONE Editors re-assessed the article in collaboration with a member of our Editorial Board and noted several concerns including the following:
- Acupuncture and related terms are not mentioned in the literature search terms, there are no listed inclusion or exclusion criteria related to acupuncture, and the outcome measures were not clearly defined in terms of reproducible clinical measures.
- The study included acupuncture and electroacupuncture studies, though this was not clearly discussed or reported in the Title, Methods, or Results.
- In the “Routine paired meta-analysis” section, both acupuncture and sham acupuncture groups were reported as showing improvement in symptoms compared with placebo. This finding and its implications for the conclusions of the article were not discussed clearly.
- Several included studies did not meet the reported inclusion criteria requiring that studies use adult participants and assess treatments of >2 weeks in duration.
- Data extraction errors were identified by comparing the dataset used in the meta-analysis (S1 Table) with details reported in the original research articles. Errors included aspects of the study design such as the experimental groups included in the study, the number of study arms in the trial, number of participants, and treatment duration. There are also several errors in the Reference list.
- With regard to side effects, 22 out of 40 studies were noted as having reported side effects. It was not made clear whether side effects were assessed as outcome measures for the other 18 studies, i.e. did the authors collect data clarifying that there were no side effects or was this outcome measure not assessed or reported in the original article. Without this clarification the conclusion comparing side effect frequencies is not well supported.
- The network geometry presented in Fig 5 is not correct and misrepresents some of the study designs, for example showing two-arm studies as three-arm studies.
- The overall results of the meta-analysis are strongly reliant on the evidence comparing acupuncture versus lactulose treatment. Several of the trials that assessed this comparison were poorly reported, and the meta-analysis dataset pertaining to these trials contained data extraction errors. Furthermore, potential bias in studies assessing lactulose efficacy in acupuncture trials versus lactulose efficacy in other trials was not sufficiently addressed.
While some of the above issues could be addressed with additional clarifications and corrections to the text, the concerns about study inclusion, the accuracy with which the primary studies’ research designs and data were represented in the meta-analysis, and the reporting quality of included studies directly impact the validity and accuracy of the dataset underlying the meta-analysis. As a consequence, we consider that the overall conclusions of the study are not reliable. In light of these issues, the PLOS ONE Editors retract the article. We apologize that these issues were not adequately addressed during pre-publication peer review.
LZ disagreed with the retraction. YM and XD did not respond.
END OF 2nd QUOTE
Let me start by explaining why I initially decided not to discuss this paper on my blog. Already the first sentence of the abstract put me off, and an entire chorus of alarm-bells started ringing once I read further.
- A meta-analysis is not a ‘study’ in my book, and I am somewhat weary of researchers who employ odd or unprecise language.
- We all know (and I have discussed it repeatedly) that studies of acupuncture frequently fail to report adverse effects (in doing this, their authors violate research ethics!). So, how can it be a credible aim of a meta-analysis to compare side-effects in the absence of adequate reporting?
- The methodology of a network meta-analysis is complex and I know not a lot about it.
- Several things seemed ‘too good to be true’, for instance, the funnel-plot and the overall finding that acupuncture is the best of all therapeutic options.
- Looking at the references, I quickly confirmed my suspicion that most of the primary studies were in Chinese.
In retrospect, I am glad I did not tackle the task of criticising this paper; I would probably have made not nearly such a good job of it as PLOS ONE eventually did. But it was only after someone raised concerns that the paper was re-reviewed and all the defects outlined above came to light.
While some of my concerns listed above may have been trivial, my last point is the one that troubles me a lot. As it also related to dozens of Cochrane reviews which currently come out of China, it is worth our attention, I think. The problem, as I see it, is as follows:
- Chinese (acupuncture, TCM and perhaps also other) trials are almost invariably reporting positive findings, as we have discussed ad nauseam on this blog.
- Data fabrication seems to be rife in China.
- This means that there is good reason to be suspicious of such trials.
- Many of the reviews that currently flood the literature are based predominantly on primary studies published in Chinese.
- Unless one is able to read Chinese, there is no way of evaluating these papers.
- Therefore reviewers of journal submissions tend to rely on what the Chinese review authors write about the primary studies.
- As data fabrication seems to be rife in China, this trust might often not be justified.
- At the same time, Chinese researchers are VERY keen to publish in top Western journals (this is considered a great boost to their career).
- The consequence of all this is that reviews of this nature might be misleading, even if they are published in top journals.
I have been struggling with this problem for many years and have tried my best to alert people to it. However, it does not seem that my efforts had even the slightest success. The stream of such reviews has only increased and is now a true worry (at least for me). My suspicion – and I stress that it is merely that – is that, if one would rigorously re-evaluate these reviews, their majority would need to be retracted just as the above paper. That would mean that hundreds of papers would disappear because they are misleading, a thought that should give everyone interested in reliable evidence sleepless nights!
So, what can be done?
Personally, I now distrust all of these papers, but I admit, that is not a good, constructive solution. It would be better if Journal editors (including, of course, those at the Cochrane Collaboration) would allocate such submissions to reviewers who:
- are demonstrably able to conduct a CRITICAL analysis of the paper in question,
- can read Chinese,
- have no conflicts of interest.
In the case of an acupuncture review, this would narrow it down to perhaps just a handful of experts worldwide. This probably means that my suggestion is simply not feasible.
But what other choice do we have?
One could oblige the authors of all submissions to include full and authorised English translations of non-English articles. I think this might work, but it is, of course, tedious and expensive. In view of the size of the problem (I estimate that there must be around 1 000 reviews out there to which the problem applies), I do not see a better solution.
(I would truly be thankful, if someone had a better one and would tell us)
Some homeopaths claim that there is anecdotal support for the use of the homeopathic medicine Arsenicum album in preventing post-vaccination fever. As far as I know, the claim has not been tested in clinical trials. This study was aimed at evaluating the efficacy of this approach in preventing febrile episodes following vaccination.
In the community medicine out-patient of Mahesh Bhattacharyya Homoeopathic Medical College and Hospital, West Bengal, a double-blind, randomized, placebo-controlled trial was conducted on 120 children. All of them presented for the 2nd and 3rd dose of DPT-HepB-Polio vaccination and reported febrile episodes following the 1st dose. They were treated with Arsenicum album 30cH 6 doses or placebo (indistinguishable from verum), thrice daily for two subsequent days. Parents were advised to report any event of febrile attacks within 48h of vaccination.
The groups were comparable at baseline. Children reporting fever after the 2nd dose was 29.8% and 30.4% respectively for the homeopathy group and control group respectively [Relative Risk (RR)=1.008] with no significant difference (P=0.951) between groups. After the 3rd dose, children reporting fever were 31.5% and 28.3% respectively for the homeopathy group and control group respectively (RR=0.956) with no significant difference (P=0.719) between groups.
The authors concluded that empirically selected Arsenicum album 30cH could not produce differentiable effect from placebo in preventing febrile episodes following DPT-HepB-Polio vaccination.
I can hear it now, the chorus of homeopaths:
- this is part of a conspiracy against homeopathy,
- the authors of this study display an anti-homeopathy bias,
- this study did not closely follow the principles of homeopathy,
- it lacked the input by experience homeopaths,
- no homeopath worth his money would use Arsenicum album 30cH for this purpose,
- no homeopath in his right mind would employ 6 doses thrice daily for two subsequent days,
- etc., etc.
Well guys, I have to disappoint you: the authors of this paper have the following affiliations:
- Dept. of Pathology and Microbiology, Mahesh Bhattacharyya Homoeopathic Medical College and Hospital, Govt. of West Bengal
- Dept. of Community Medicine, Mahesh Bhattacharyya Homoeopathic Medical College and Hospital, Govt. of West Bengal
- Mahesh Bhattacharyya Homoeopathic Medical College and Hospital, Govt. of West Bengal
- National Institute of Homoeopathy, Ministry of AYUSH, Govt. of India
- Central Council of Homoeopathy, Vill, Champsara
So, perhaps it’s true: highly diluted homeopathic remedies are pure placebos.
- Despite calling themselves ‘doctors’, they are nothing of the sort.
- DCs are not adequately educated or trained to treat children.
- They nevertheless often do so, presumably because this constitutes a significant part of their income.
- Even if they felt confident to be adequately trained, we need to remember that their therapeutic repertoire is wholly useless for treating sick children effectively and responsibly.
- Therefore, harm to children is almost inevitable.
- To this, we must add the risk of incompetent advice from DCs – just think of immunisations.
Now we have more data on this subject. This new study investigated the effectiveness of adding manipulative therapy to other conservative care for spinal pain in a school-based cohort of Danish children aged 9–15 years.
The design was a two-arm pragmatic randomised controlled trial, nested in a longitudinal open cohort study in Danish public schools. 238 children from 13 public schools were included. A text message system and clinical examinations were used for data collection. Interventions included either (1) advice, exercises and soft-tissue treatment or (2) advice, exercises and soft-tissue treatment plus manipulative therapy. The primary outcome was number of recurrences of spinal pain. Secondary outcomes were duration of spinal pain, change in pain intensity and Global Perceived Effect.
No significant difference was found between groups in the primary outcomes of the control group and intervention group. Children in the group receiving manipulative therapy reported a higher Global Perceived Effect. No adverse events were reported.
The authors – well-known proponents of chiropractic (who declared no conflicts of interest) – concluded that adding manipulative therapy to other conservative care in school children with spinal pain did not result in fewer recurrent episodes. The choice of treatment—if any—for spinal pain in children therefore relies on personal preferences, and could include conservative care with and without manipulative therapy. Participants in this trial may differ from a normal care-seeking population.
The study seems fine, but what a conclusion!!!
After demonstrating that chiropractic manipulation is useless, the authors state that the treatment of kids with back pain could include conservative care with and without manipulative therapy. This is more than a little odd, in my view, and seems to suggest that chiropractors live on a different planet from those of us who can think rationally.
This systematic review included 18 studies assessing homeopathy in depression. Two double-blind placebo-controlled trials of homeopathic medicinal products (HMPs) for depression were assessed. The first trial (N = 91) with high risk of bias found HMPs were non-inferior to fluoxetine at 4 (p = 0.654) and 8 weeks (p = 0.965); whereas the second trial (N = 133), with low risk of bias, found HMPs was comparable to fluoxetine (p = 0.082) and superior to placebo (p < 0.005) at 6 weeks.
The remaining research had unclear/high risk of bias. A non-placebo-controlled RCT found standardised treatment by homeopaths comparable to fluvoxamine; a cohort study of patients receiving treatment provided by GPs practising homeopathy reported significantly lower consumption of psychotropic drugs and improved depression; and patient-reported outcomes showed at least moderate improvement in 10 of 12 uncontrolled studies. Fourteen trials provided safety data. All adverse events were mild or moderate, and transient. No evidence suggested treatment was unsafe.
The authors concluded that limited evidence from two placebo-controlled double-blinded trials suggests HMPs might be comparable to antidepressants and superior to placebo in depression, and patients treated by homeopaths report improvement in depression. Overall, the evidence gives a potentially promising risk benefit ratio. There is a need for additional high quality studies.
It is worth having a look at these two studies, I think.
Here is its abstract:
Homeopathy is a complementary and integrative medicine used in depression, The aim of this study is to investigate the non-inferiority and tolerability of individualized homeopathic medicines [Quinquagintamillesmial (Q-potencies)] in acute depression, using fluoxetine as active control. Ninety-one outpatients with moderate to severe depression were assigned to receive an individualized homeopathic medicine or fluoxetine 20 mg day−1 (up to 40 mg day−1) in a prospective, randomized, double-blind double-dummy 8-week, single-center trial. Primary efficacy measure was the analysis of the mean change in the Montgomery & Åsberg Depression Rating Scale (MADRS) depression scores, using a non-inferiority test with margin of 1.45. Secondary efficacy outcomes were response and remission rates. Tolerability was assessed with the side effect rating scale of the Scandinavian Society of Psychopharmacology. Mean MADRS scores differences were not significant at the 4th (P = .654) and 8th weeks (P = .965) of treatment. Non-inferiority of homeopathy was indicated because the upper limit of the confidence interval (CI) for mean difference in MADRS change was less than the non-inferiority margin: mean differences (homeopathy-fluoxetine) were −3.04 (95% CI −6.95, 0.86) and −2.4 (95% CI −6.05, 0.77) at 4th and 8th week, respectively. There were no significant differences between the percentages of response or remission rates in both groups. Tolerability: there were no significant differences between the side effects rates, although a higher percentage of patients treated with fluoxetine reported troublesome side effects and there was a trend toward greater treatment interruption for adverse effects in the fluoxetine group. This study illustrates the feasibility of randomized controlled double-blind trials of homeopathy in depression and indicates the non-inferiority of individualized homeopathic Q-potencies as compared to fluoxetine in acute treatment of outpatients with moderate to severe depression.
There are many important points to make about this trial:
- Contrary to what the reviewers claim, the trial had no placebo group.
- It was a double-dummy equivalence study comparing individualised homeopathy with the antidepressant fluoxetine.
- Fluoxetine might have been under-dosed (see below).
- Equivalence studies require large sample sizes, and with just 91 patients (only 55 of whom finished the study), this trial was underpowered which means the finding of equivalence is false positive.
- The authors noted that a higher percentage of troublesome adverse effects reported by patients receiving fluoxetine. This means that the trial was not double-blind; patients were able to tell by their side-effects which group they were in.
- The authors also state that more patients randomized to homeopathy than to fluoxetine were excluded due to worsening of their depressive symptoms. I think this confirms that homeopathy was ineffective.
Here is its abstract:
Background: Perimenopausal period refers to the interval when women’s menstrual cycles become irregular and is characterized by an increased risk of depression. Use of homeopathy to treat depression is widespread but there is a lack of clinical trials about its efficacy in depression in peri- and postmenopausal women. The aim of this study was to assess efficacy and safety of individualized homeopathic treatment versus placebo and fluoxetine versus placebo in peri- and postmenopausal women with moderate to severe depression.
Methods/Design: A randomized, placebo-controlled, double-blind, double-dummy, superiority, three-arm trial with a 6 week follow-up study was conducted. The study was performed in a public research hospital in Mexico City in the outpatient service of homeopathy. One hundred thirty-three peri- and postmenopausal women diagnosed with major depression according to DSM-IV (moderate to severe intensity) were included. The outcomes were: change in the mean total score among groups on the 17-item Hamilton Rating Scale for Depression, Beck Depression Inventory and Greene Scale, after 6 weeks of treatment, response and remission rates, and safety. Efficacy data were analyzed in the intention-to-treat population (ANOVA with Bonferroni post-hoc test).
Results: After a 6-week treatment, homeopathic group was more effective than placebo by 5 points in Hamilton Scale. Response rate was 54.5% and remission rate, 15.9%. There was a significant difference among groups in response rate definition only, but not in remission rate. Fluoxetine-placebo difference was 3.2 points. No differences were observed among groups in the Beck Depression Inventory. Homeopathic group was superior to placebo in Greene Climacteric Scale (8.6 points). Fluoxetine was not different from placebo in Greene Climacteric Scale.
Conclusion: Homeopathy and fluoxetine are effective and safe antidepressants for climacteric women. Homeopathy and fluoxetine were significantly different from placebo in response definition only. Homeopathy, but not fluoxetine, improves menopausal symptoms scored by Greene Climacteric Scale.
And here are my critical remarks about this trial:
- The aim of a small study like this cannot be to assess or draw conclusions about the safety of the interventions used; for this purpose, we need sample sizes that are at least one dimension bigger.
- Fluoxetine might have been under-dosed (see below).
- The blinding of patients might have been jeopardized by patients experiencing the specific side-effects of fluoxetine. The authors reported adverse effects in all three groups. However, the characteristic and most common side-effects of fluoxetine (such as hives, itching, skin rash, restlessness, inability to sit still) were not included.
Immediate-release oral formulations:
Initial dose: 20 mg orally once a day in the morning, increased after several weeks if sufficient clinical improvement is not observed
Maintenance dose: 20 to 60 mg orally per day
Maximum dose: 80 mg orally per day
Delayed release oral capsules:
Initial dose: 90 mg orally once a week, commenced 7 days after the last daily dose of immediate-release fluoxetine 20 mg formulations.
Considering all this, I feel that the conclusions of the above review are far too optimistic and not justified. In fact, I find them misleading, dangerous, unethical and depressing.
It’s been often said that we live in the age of information. Everyone can get tons of it at the click of a button. This is undoubtedly true. Sadly, it also means that we are exposed to tons of misinformation, and sometimes it seems to me that we now live in THE AGE OF MISINFORMATION.
Here I will explain the consequences of this phenomenon on two examples that, at first glance, seem to have nothing in common at all (other than being close to my heart):
With homeopathy, the public are confronted by a steady flood of misinformation from the powerful homeopathy lobby who tell us quite incredible untruths about it:
- Homeopathy is effective
- Homeopathy is harmless
- Homeopathy is natural
- Homeopathy is holistic
- Homeopathy is supported by many of the brightest people
- Homeopathy is an important contribution to public health
- Homeopathy prevents epidemics
- Homeopathy works through quantum effects
- Homeopathy is nano-medicine
- Homeopathy is energy medicine
- Homeopathy works for infants
- Homeopathy works in animals
- Homeopathy works for plants
- Homeopathy is the victim of a propaganda campaign against it
Those who put out this multi-level misinformation pretend that they inform the public. Of course, the public must be informed – how else could they possibly make informed choices? (If this important aim requires a bit of cheating here and there, so be it!)
And the public reacts as directed: they buy homeopathic preparations in droves. The result is that the promoters of homeopathy can claim that THE PUBLIC IS VOTING WITH THEIR FEET! The people have decided, they say, homeopathy is a good thing!
With Brexit, the public is confronted by a steady flood of misinformation from the powerful Brexit lobby who tell us quite incredible untruths about it:
- Brexit is going to give us our country back
- Brexit is good for the economy
- Brexit will mean more money for the NHS
- Brexit will be easy
- Brexit will allow us to trade with the rest of the world
- Brexit will keep foreigners out
- Brexit is going to create jobs
- Brexit is good for our industry
- Brexit is good for farmers
- Brexit is good for the environment
- Brexit will free us from the shackles of the EU
- Brexit will strengthen our alliance with the US
Those who put out this multi-level misinformation pretend that they inform the public. Of course, the public must be informed – how else could they possibly make informed choices? (If this important aim requires a bit of cheating here and there, so be it!)
And the public reacts as directed: they buy into the lies of the Brexiteers in droves. The result is that the promoters of Brexit can claim that THE PUBLIC HAS VOTED WITH THEIR FEET! The people have decided, they say, Brexit is a good thing!
Yes, I know, this is a bit simplistic. But the point I am trying to make is surely valid: misinformation not only leads to wrong and often dangerous decision, it is also the way charlatans try to fool us with their circular arguments and justify their blatant lies.
This could (and perhaps should) be a very short post:
I HAVE NO QUALIFICATIONS IN HOMEOPATHY!
The reason why it is not quite as short as that lies in the the fact that homeopathy-fans regularly start foaming from the mouth when they state, and re-state, and re-state, and re-state this simple, undeniable fact.
The latest example is by our friend Barry Trestain who recently commented on this blog no less than three times about the issue:
- Falsified? You didn’t have any qualifications falsified or otherwise according to this. In quotes as well lol. Perhaps you could enlighten us all on this. Edzard Ernst, Professor of Complementary and Alternative Medicine (CAM) at Exeter University, is the most frequently cited „expert‟ by critics of homeopathy, but a recent interview has revealed the astounding fact that he “never completed any courses” and has no qualifications in homeopathy. What is more his principal experience in the field was when “After my state exam I worked under Dr Zimmermann at the Münchner Krankenhaus für Naturheilweisen” (Munich Hospital for Natural Healing Methods). Asked if it is true that he only worked there “for half a year”, he responded that “I am not sure … it is some time ago”!
- I don’t know what you got. I’m only going by your quotes above. You didn’t pass ANY exams. “Never completed any courses and has no qualifications in Homeopathy.” Those aren’t my words.
- LOL qualification for their cat? You didn’t even get a psuedo qualification and on top of that you practiced Homeopathy for 20 years eremember. With no qualifications. You are a fumbling and bumbling Proffessor of Cam? LOL. In fact I think I’ll make my cat a proffessor of Cam. Why not? He’ll be as qualified as you.
Often, these foaming (and in their apoplectic fury badly-spelling) defenders of homeopathy state or imply that I lied about all this. Yet, it is they who are lying, if they say so. I never claimed that I got any qualifications in homeopathy; I was trained in homeopathy by doctors of considerable standing in their field just like I was trained in many other clinical skills (what is more, I published a memoir where all this is explained in full detail).
In my bewilderment, I sometimes ask my accusers why they think I should have got a qualification in homeopathy. Sadly, so far, I have not received a logical answer (most of the time not even an illogical one).
So, today I ask the question again: WHY SHOULD I HAVE NEEDED ANY QUALIFICATION IN HOMEOPATHY?
My answers are here:
- I consider such qualifications as laughable. A proper qualification in nonsense is just nonsense!
- For practising homeopathy (which I did for a while), I did not need such qualifications; as a licensed physician, I was at liberty to use the treatments I felt to be adequate.
- For researching homeopathy (which I did too and published ~120 Medline-listed papers as a result of it), I do not need them either. Anyone can research homeopathy, and some of the most celebrated heroes of homeopathy research (e. g. Klaus Linde and Robert Mathie) do also have no such qualifications.
I am therefore truly puzzled and write this post to give everyone the chance to name the reasons why they feel I needed qualifications in homeopathy.
Please do tell me!
In one of his many comments, our friend Iqbal just linked to an article that unquestionably is interesting. Here is its abstract (the link also provides the full paper):
Objective: The objective was to assess the usefulness of homoeopathic genus epidemicus (Bryonia alba 30C) for the prevention of chikungunya during its epidemic outbreak in the state of Kerala, India.
Materials and Methods: A cluster- randomised, double- blind, placebo -controlled trial was conducted in Kerala for prevention of chikungunya during the epidemic outbreak in August-September 2007 in three panchayats of two districts. Bryonia alba 30C/placebo was randomly administered to 167 clusters (Bryonia alba 30C = 84 clusters; placebo = 83 clusters) out of which data of 158 clusters was analyzed (Bryonia alba 30C = 82 clusters; placebo = 76 clusters) . Healthy participants (absence of fever and arthralgia) were eligible for the study (Bryonia alba 30 C n = 19750; placebo n = 18479). Weekly follow-up was done for 35 days. Infection rate in the study groups was analysed and compared by use of cluster analysis.
Results: The findings showed that 2525 out of 19750 persons of Bryonia alba 30 C group suffered from chikungunya, compared to 2919 out of 18479 in placebo group. Cluster analysis showed significant difference between the two groups [rate ratio = 0.76 (95% CI 0.14 – 5.57), P value = 0.03]. The result reflects a 19.76% relative risk reduction by Bryonia alba 30C as compared to placebo.
Conclusion: Bryonia alba 30C as genus epidemicus was better than placebo in decreasing the incidence of chikungunya in Kerala. The efficacy of genus epidemicus needs to be replicated in different epidemic settings.
I have often said the notion that homeopathy might prevent epidemics is purely based on observational data. Here I stand corrected. This is an RCT! What is more, it suggests that homeopathy might be effective. As this is an important claim, let me quickly post just 10 comments on this study. I will try to make this short (I only looked at it briefly), hoping that others complete my criticism where I missed important issues:
- The paper was published in THE INDIAN JOURNAL OF RESEARCH IN HOMEOPATHY. This is not a publication that could be called a top journal. If this study really shows something as revolutionarily new as its conclusions imply, one must wonder why it was published in an obscure and inaccessible journal.
- Several of its authors are homeopaths who unquestionably have an axe to grind, yet they do not declare any conflicts of interest.
- The abstract states that the trial was aimed at assessing the usefulness of Bryonia C30, while the paper itself states that it assessed its efficacy. The two are not the same, I think.
- The trial was conducted in 2007 and published only 7 years later; why the delay?
- The criteria for the main outcome measure were less than clear and had plenty of room for interpretation (“Any participant who suffered from fever and arthralgia (characteristic symptoms of chikungunya) during the follow-up period was considered as a case of chikungunya”).
- I fail to follow the logic of the sample size calculation provided by the authors and therefore believe that the trial was woefully underpowered.
- As a cluster RCT, its unit of assessment is the cluster. Yet the significant results seem to have been obtained by using single patients as the unit of assessment (“At the end of follow-ups it was observed that 12.78% (2525 out of 19750) healthy individuals, administered with Bryonia alba 30 C, were presented diagnosed as probable case of chikungunya, whereas it was 15.79% (2919 out of 18749) in the placebo group”).
- The p-value was set at 0.05. As we have often explained, this is far too low considering that the verum was a C30 dilution with zero prior probability.
- Nine clusters were not included in the analysis because of ‘non-compliance’. I doubt whether this was the correct way of dealing with this issue and think that an intention to treat analysis would have been better.
- This RCT was published 4 years ago. If true, its findings are nothing short of a sensation. Therefore, one would have expected that, by now, we would see several independent replications. The fact that this is not the case might mean that such RCTs were done but failed to confirm the findings above.
As I said, I would welcome others to have a look and tell us what they think about this potentially important study.
I have often cautioned my readers about the ‘evidence’ supporting acupuncture (and other alternative therapies). Rightly so, I think. Here is yet another warning.
This systematic review assessed the clinical effectiveness of acupuncture in the treatment of postpartum depression (PPD). Nine trials involving 653 women were selected. A meta-analysis demonstrated that the acupuncture group had a significantly greater overall effective rate compared with the control group. Moreover, acupuncture significantly increased oestradiol levels compared with the control group. Regarding the HAMD and EPDS scores, no difference was found between the two groups. The Chinese authors concluded that acupuncture appears to be effective for postpartum depression with respect to certain outcomes. However, the evidence thus far is inconclusive. Further high-quality RCTs following standardised guidelines with a low risk of bias are needed to confirm the effectiveness of acupuncture for postpartum depression.
What a conclusion!
What a review!
What a journal!
Let’s start with the conclusion: if the authors feel that the evidence is ‘inconclusive’, why do they state that ‘acupuncture appears to be effective for postpartum depression‘. To me this does simply not make sense!
Such oddities are abundant in the review. The abstract does not mention the fact that all trials were from China (published in Chinese which means that people who cannot read Chinese are unable to check any of the reported findings), and their majority was of very poor quality – two good reasons to discard the lot without further ado and conclude that there is no reliable evidence at all.
The authors also tell us very little about the treatments used in the control groups. In the paper, they state that “the control group needed to have received a placebo or any type of herb, drug and psychological intervention”. But was acupuncture better than all or any of these treatments? I could not find sufficient data in the paper to answer this question.
Moreover, only three trials seem to have bothered to mention adverse effects. Thus the majority of the studies were in breach of research ethics. No mention is made of this in the discussion.
In the paper, the authors re-state that “this meta-analysis showed that the acupuncture group had a significantly greater overall effective rate compared with the control group. Moreover, acupuncture significantly increased oestradiol levels compared with the control group.” This is, I think, highly misleading (see above).
Finally, let’s have a quick look at the journal ‘Acupuncture in Medicine’ (AiM). Even though it is published by the BMJ group (the reason for this phenomenon can be found here: “AiM is owned by the British Medical Acupuncture Society and published by BMJ“; this means that all BMAS-members automatically receive the journal which thus is a resounding commercial success), it is little more than a cult-newsletter. The editorial board is full of acupuncture enthusiasts, and the journal hardly ever publishes anything that is remotely critical of the wonderous myths of acupuncture.
My conclusion considering all this is as follows: we ought to be very careful before accepting any ‘evidence’ that is currently being published about the benefits of acupuncture, even if it superficially looks ok. More often than not, it turns out to be profoundly misleading, utterly useless and potentially harmful pseudo-evidence.
Acupunct Med. 2018 Jun 15. pii: acupmed-2017-011530. doi: 10.1136/acupmed-2017-011530. [Epub ahead of print]
Li S, Zhong W, Peng W, Jiang G.
It has been shown repeatedly that a ‘conspiracy mentality’ is associated with usage of alternative medicine. But perhaps alternative medicine is itself a conspiracy theory in disguise?
One of the questions I invariably get after a public lecture is the one about alternative medicine being the victim of some sort of sinister plot. This notion can take various shapes and forms:
- The scientific establishment prevents the public from fully benefitting from the effects of alternative medicine.
- The pharmaceutical industry suppresses the good news about alternative treatments.
- The funding agencies refuse to fund research into alternative medicine.
- The media are bent on defaming alternative medicine.
- The regulators do not allow alternative medicine to thrive as much as it would deserve.
- The medical profession is afraid that the benefits of alternative medicine become better known.
I could go on, but I am sure you get the picture.
The amazing thing is that I hear such arguments not just from fanatic proponents of alternative medicine, but also from more reasonable people. These sentiments seem to be entirely common and seemingly logical arguments. Most people I meet seem to believe them at least to some degree.
Having heard them so often, I do wonder: Can one explain alternative medicine as a conspiracy theory?
A conspiracy theory is an erroneous and often difficult to falsify notion that tries to explain a set of circumstances as the result of a secret plot by usually powerful conspirators, while ignoring obvious alternative explanations. The very concept of alternative medicine assumes that there are valuable therapies that conventional healthcare does not allow in its realm.
The reasons for the secret plot that prevents them to be included in conventional healthcare are rarely named by enthusiasts of alternative medicine. So, what are they?
- Professional jealousy?
- Financial interests?
- Lack of interest?
- Lack of caring?
According to proponents of alternative medicine who I have asked, they consist of a mixture of all of these possibilities. And all of these possibilities are, in a way, consistent with alternative medicine being based on a conspiracy theory.
When I ask people why they believe in these theories, they cannot produce any solid evidence for their beliefs. This does not surprise me because, as far as I can see, there is no evidence to support them: they are erroneous. In turn, this means that one important criterium for conspiracy theory is being met.
Another characteristic of conspiracy theories is that they cannot easily been proven to be false. None of the above-listed reasons are, in fact, difficult to falsify.
A final characteristic of conspiracy theories is that its proponents are ignoring obvious alternative explanations.
WHY ARE ALTERNATIVE THERAPIES NOT ADMITTED INTO THE REALM OF CONVENTIONAL MEDICINE?
Simply because they are not supported by sufficiently strong evidence for generating more good than harm.
So, yes, to some extent alternative medicine even is a conspiracy theory in disguise.