MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

critical thinking

In part one, we have dealt with three common tricks used by quacks to convince the public to consult them and to keep coming back for more. It has been pointed out to me that some of these tricks are used not just by alternative practitioners but also by real physicians. This is, of course, absolutely true. A quack can be defined as “a person who dishonestly claims to have special knowledge and skill in some field, typically medicine.” Therefore real doctors can be real quacks, of course. I happen to have an interest mainly in alternative medicine; that’s why I write about these type of quacks (if it helps keeping you blood pressure within the limits of normal, I can tell you that I occasionally also published about quackery in mainstream medicine, for instance here).

Anyway, now it is time to continue this series of posts by discussing three further common deceptions used by quacks.

A CURE TAKES A LONG TIME

Imagine a scenario where, even after, several therapy sessions, a patient’s condition has not improved. Let’s assume the problem is back pain, and that it has not improved a  bit despite the treatments and the money spent on it. Surely, many patients in such a situation are sooner or later going to give up. They will have had enough! And this is, of course, a serious threat to the practitioner’s cash flow.

Luckily, there is a popular ploy to minimize the risk: the practitioner merely has to explain that the patient’s condition has been going on for a very long time (if, in the above scenario, this were not the case, the practitioner would explain that the pain might be relatively recent but the underlying condition is chronic). This means that a cure will also have to take a very long time – after all, Rome was not built in one day!

This plea to carry on with the ineffective treatments despite any improvement of symptoms is usually not justifiable on medical grounds. It is, however, entirely justifiable on the basis of financial considerations of the practitioners. They rely on their patients’ regular payments and will therefore think of all sorts of means to achieve this aim.

Take my advice and see a clinician who can help you within a reasonable and predictable amount of time.

IT’S DUE TO THE POISONS YOUR DOCTOR GAVE YOU

In the pursuit of a healthy cash-flow, almost all means seem to be allowed – even the fabrication of the bogus notion that the reasons for the patient’s problem were the poisonous drugs prescribed by her doctor who, of course, is in cahoots with BIG PHARMA. Alternative medicine thrives on conspiracy theories, and the one of the evil ‘medical mafia’ is one of the all-time favourites. It enables scrupulous practitioners to instil a good dose of fear into the minds of their patients, a fear that minimises the risk of them returning to real medicine.

My advice is that alternative practitioners who habitually use this or any other conspiracy theory should be avoided at all costs.

THINK HOLISTICALLY

The notion that alternative medicine takes care of the whole person is a most attractive and powerful ploy. Never mind that nothing could be further from being holistic than, for instance, diagnosing conditions by looking at a patient’s iris (iridology), or focussing on her spine (chiropractic, osteopathy), or massaging the soles of her feet (reflexology). And never mind that any type of good conventional medicine is by definition holistic. What counts is the label, and ‘holistic’ is a most desirable one, indeed. Nothing sells quackery better than holism.

Most alternative practitioners call themselves holistic and they rub the holism into the minds of their patients whenever and however they can. This insistence on holism has the added advantage that they have seemingly plausible excuses for their therapeutic failures.

Imagine a patient consulting a practitioner with depression and, even after prolonged treatment, her condition is unchanged. Even in such a situation, the holistic practitioner does not need to despair: he will point out that he never treats diagnostic labels but always the whole person. Therefore, the patient’s depression might not have changed, but surely other issues have improved… and, if the patient introspects a little, she might find that her appetite has improved, that her indigestion is better, or that her tennis elbow is less painful (some things always change given enough time). The holism of quacks may be a false pretence, but its benefits for the practitioner are obvious.

My advice: take holism from quacks with a pinch of salt.

“When orthodox medicine has nothing more to offer” is the title of an article by Dr Elizabeth Thompson, a UK medical homeopath. The article was written years ago, but it is still an excellent example for disclosing the dangerously false and deeply unethical reasoning used by many alternative practitioners. The notion that all sorts of disproven treatments like homeopathy are justified when orthodox medicine has nothing more to offer is so very prevalent that I decided to do this post analysing it.

In the following, you see the most relevant sections of Dr Thompson’s original article (in normal print) and my brief comments (in brackets and in bold):

…Some people come when conventional treatments can no longer offer them anything to save their lives. This is a frightening time for them and although the homeopathic approach may not offer a cure at this late stage of their illness (Is she implying that, in some cases, homeopathy can cure cancer?), it can often offer hope of a different kind. (Surely, one does not need homeopathy for giving patients hope). Sometimes it helps people to outlive the prognosis given to them by months or even years. (A prognosis is not a precise time of death; it is based on statistics and therefore depicts a likelihood, not a certainty. Thus patients outlive their prognosis all the time regardless of treatments.) Sometimes it helps them need less (less than what? there is no control group and therefore the statement seems nonsensical) in the way of conventional medicine including pain killers and offers them continuing support despite progressive disease (is she trying to say that in conventional medicine patients with progressive disease do not get continuing support?).

As a doctor working in both conventional and complementary cancer care I have learned the importance of integrating these two perspectives (the integration of unproven therapies into EBM can only render the latter less effective). Ideally the doctor practising homeopathy would work as an integral part of a much wider team which would include family members, nurses, general practitioners, oncologists, surgeons, palliative physicians and other complementary therapists (the concept of a multi-disciplinary team for cancer is one from conventional medicine where it has long been routine). It is disappointing sometimes to see that other healthcare professionals can be unsupportive of a person’s desire to use complementary therapies and for some people the knowledge that the team is not working together can cause doubt and insecurity (for the majority of patients, however, it might be reassuring to know that their oncology-team is evidence-based).

Some patients come at the beginning of their diagnosis wanting to support their bodies with gentler (homeopathic remedies are not gentler, they are ineffective) approaches and help themselves recover from some difficult and powerful treatments such as chemotherapy and radiotherapy (Why are they being told that alternative therapies are effective in achieving these aims when there is no good evidence to show that this is true? Isn’t that unethical?). As well as using homeopathic medicines (no good evidence of effectiveness!!!), the GHH also has experience in using Mistletoe which is given by injection and has been shown to stimulate the group of white cells whose numbers can be depleted during chemotherapy and radiotherapy (also no good evidence that it works clinically!!!).

Other patients come when they have finished most of their treatments but may still not be feeling well despite being given the all clear by their doctors (same again: no good evidence!!!)…

One wonderful aspect of the homeopathic approach is that it can be a very important opportunity to help someone re-evaluate their life and their health (We don’t need to prescribe placebos for that, this aim is better reached by employing a clinical psychologist).

Sometimes hurts in the past have never been healed and sitting with someone as they describe difficult experiences can be itself therapeutic. Combining this therapeutic listening time with substances from nature that gently stimulate the body’s own healing potential (where is the evidence for that claim?) can be an approach that through patient demand and research (what research?) we can demonstrate is really worth offering to many more people…

END OF QUOTE

 

This text shows in an exemplary fashion how desperate patients can be convinced to make dramatically wrong choices. If you read Dr Thompson’s text without my comments, it probably sounds fairly reasonable to many people. I can understand why patients and carers end up thinking that homeopathy or other disproven therapies are reasonable options WHEN ORTHODOX MEDICINE HAS NOTHING MORE TO OFFER.

But the claim of homeopaths and others that mainstream medicine has, in certain cases, nothing more to offer is demonstrably wrong. Supportive and palliative care are established and important parts of conventional medicine. To deny this fact amounts to a lie! The implied scenario where a patient is told by her oncology team: “sorry but we cannot do anything else for you”, does quite simply not exist. The argument is nothing else but a straw-man – and a vicious one at that.

Moreover, the subsequent argument of homeopaths, “as ‘they’ have given you up, we now offer you our effective homeopathic remedies”, is not supported by good evidence. In other words, one lie is added to another. To call this unethical, would be the understatement of the year, I think.

Homeopathy must be effective! It is used extensively throughout the world, not least India! If it were ineffective, as all these nasty sceptics insist, Indians would not use it in such large numbers.

How often have we heard this argument?

Take, for instance, statements from the ‘peer-reviewed’ literature such as this one: “At present, in India, homeopathy is the third most popular method of medical treatment after allopathy and Ayurveda. There are over 200,000 registered homeopathic doctors currently, with approximately 12,000 more being added every year.” Or take statements from UK homeopaths like this one: “It seems clear that homeopathy is there to stay in India. So next time you see or read some condescending and patronising rubbish about homeopathy in the media, know that in India, a country with a population of 1.2 billion people (that’s more than 20x the population of the UK) homeopathy is an integral part of the healthcare system and deeply respected by the people of that country.”

Yes, homeopaths have always loved to mislead the public with fallacies!

The appeal to popularity is, of course, a classic fallacy – but, in the case of homeopathy’s popularity in India, it is not just that; here is an intriguing aspect to the use of homeopathy in that country that shines a different light on the whole story.

Epidemiologists from Canada conducted semi-structured interviews of 175 Mumbai slum-based practitioners holding degrees in Ayurveda, homeopathy and Unani. Most providers gave multiple interviews. The researchers also observed 10 providers in clinical interactions, documenting clinical examinations, symptoms, history taking, prescriptions and diagnostic tests.

No practitioners exclusively used his or her system of training. The practice of biomedicine was frequent, with practitioners often using biomedical disease categories and diagnostics. The use of homeopathy was rare; only 4% of consultations with homeopaths resulted in the prescription of homeopathic remedies.

The authors concluded that important sources of health care in Mumbai’s slums, AYUSH physicians frequently use biomedical therapies and most refer patients with TB to chest physicians or the public sector. They are integral to TB care and control.

These data seem to suggest that the use of homeopathic remedies in India is far, far less than often claimed by apologists. Indian homeopaths seem to have much more sense than to use homeopathy for serious conditions. This is good news for Indian public health, in my view.

The story also shows how the ‘appeal to popularity’ is being misused for the promotion of homeopathy: not only is it based on poor logic but often also on false information.

John Garrow died yesterday at home.

John had suffered a stroke about 6 weeks ago but had previously been in good health.

His professional achievements were too many to list here in full. He had been Professor of Human Nutrition, University of London, Honorary consultant physician St Bartholomew’s Hospital, St Mark’s Hospital, Royal London Hospital and Northwick Park Hospital. He also was head of Nutrition Research Unit at the MRC Clinical Research Centre, Harrow, and member of Department of Health Committee on Medical Aspects of Food Policy; Chair of the Joint Advisory Committee on Nutrition Education and the Chair of Association for the Study of Obesity. For many years, he also acted as editor in chief of the European Journal of Clinical Nutrition, and as the chairman of HealthWatch.

John was a clinician and an active researcher with a focus on nutrition and, occasionally, alternative medicine. He has published many ground-breaking articles on these and other subjects. I had the pleasure to plan, conduct and publish a study with John; it was an investigation into an area which, at the time, was entirely novel. I think it might have been the first RCT into the peer-review system ever conceived. Here is the full abstract:

A study was designed to test the hypothesis that experts who review papers for publication are prejudiced against an unconventional form of therapy. Two versions were produced (A and B) of a ‘short report’ that related to treatments of obesity, identical except for the nature of the intervention. Version A related to an orthodox treatment, version B to an unconventional treatment. 398 reviewers were randomized to receive one or the other version for peer review. The primary outcomes were the reviewers’ rating of ‘importance’ on a scale of 1-5 and their verdict regarding rejection or acceptance of the paper. Reviewers were unaware that they were taking part in a study. The overall response rate was 41.7%, and 141 assessment forms were suitable for statistical evaluation. After dichotomization of the rating scale, a significant difference in favour of the orthodox version with an odds ratio of 3.01 (95% confidence interval, 1.03 to 8.25), was found. This observation mirrored that of the visual analogue scale for which the respective medians and interquartile ranges were 67% (51% to 78.5%) for version A and 57% (29.7% to 72.6%) for version B. Reviewers showed a wide range of responses to both versions of the paper, with a significant bias in favour of the orthodox version. Authors of technically good unconventional papers may therefore be at a disadvantage in the peer review process. Yet the effect is probably too small to preclude publication of their work in peer-reviewed orthodox journals.

Years later, John also contributed a chapter entitled ‘CAM IN COURT’ to a book that I had edited. I remember very well what a pleasure it was to co-operate with John. He was quick to conceive new ideas and had an intellectual rigor and honesty that I have not often encountered elsewhere.

But it is not his professional achievements which impressed me most about John. What I found even more remarkable was his ability to understand, his kindness and warmth. He had the gift not just to grasp the issues but also to empathize with the people behind them. I am proud to have known John, worked with him, and been inspired by him.

I will sorely miss my friend.

Turmeric (Curcuma longa) is a truly fascinating plant with plenty of therapeutic potential. It belongs to the ginger family, Zingiberaceae and is native to southern Asia. Its main active ingredients are curcumin (diferuloylmethane) and the related compounds, demethoxycurcumin and bis-demethoxycurcumin (curcuminoids) which are secondary metabolites. Turmeric  has been used extensively in Ayurvedic medicine and has a variety of pharmacologic properties including antioxidant, analgesic, anti-inflammatory, and antiseptic activities.

In the often weird world of alternative medicine, turmeric is currently being heavily hyped as the new panacea. Take this website, for instance; it promotes turmeric for just about any ailment known to mankind. Here is a short excerpt to give you a flavour (pun intended, turmeric is, of course, a main ingredient in many curries):

It comes at a surprise to a lot of people that herbs can be highly effective, if not more effective, than conventional medications …

To date, turmeric is one of the top researched plants. It was involved in more than 5,600 peer-reviewed and published biomedical studies. In one research project that extended over a five year period, it was found that turmeric could potentially be used in preventive and therapeutic applications. It was also noted that it has 175 beneficial effects for psychological health…

The 14 Medications it Mimics

Or should we say the 14 medications that mimic turmeric, since turmeric has been around much longer than any chemical prescription drug. Here’s a quick look at some of them:

  • Lipitor: This is a cholesterol drug that is used to reduce inflammation and oxidative stress inside of patients suffering from type 2 diabetes. When the curcuminoid component inside of turmeric is properly prepared, it can offer the same effects (according to a study published in 2008).
  • Prozac: This is an antidepressant that has been overused throughout the past decade. In a study published back in 2011, turmeric was shown to offer beneficial effects that helped to reduce depressive behaviors (using animal models).
  • Aspirin: This is a blood thinner and pain relief drug. In a study done in 1986, it was found that turmeric has similar affects, which makes it a candidate for patients that are susceptible to vascular thrombosis and arthritis.
  • Metformin: This is a drug that treats diabetes. It is used to activate AMPK (to increase uptake of glucose) and helps to suppress the liver’s production of glucose. In a study published in 2009, it was found that curcumin was 500 to 100,000 times more effective at activating AMPK ad ACC.
  • Anti-Inflammatory Drugs: This includes medications like ibuprofen, aspirin and dexamethasone, which are designed to reduce inflammation. Again, in 2004, it was proven that curcumin was an effective alternative option to these chemical drugs.
  • Oxaliplatin: This is a chemotherapy drug. A study done in 2007 showed that curcumin is very similar to the drug, acting as an antiproliferative agent in colorectal cell lines.
  • Corticosteroids: This is a steroid medication, which is used to treat inflammatory eye diseases. In 1999, it was found that curcumin was effective at managing this chronic condition. Then in 2008, curcumin was used in an animal model that proved it could also aid in therapy used to protect patients from lung transplantation-associated injuries by “deactivating” inflammatory genes.

Turmeric Fights Drug-Resistant Cancers… it’s been shown that curcumin can battle against cancers that are resistant to chemotherapy and radiation…

END OF QUOTE

As I said, turmeric is fascinating and promising, but such hype is clearly counter-productive and dangerous. As so often, the reality is much more sobering than the fantasy of uncritical quacks. Research is currently very active and has produced a host of interesting findings. Here are the conclusions (+links) of a few, recent reviews:

Overall, there is early evidence that turmeric/curcumin products and supplements, both oral and topical, may provide therapeutic benefits for skin health. However, currently published studies are limited and further studies will be essential to better evaluate efficacy and the mechanisms involved.

This meta-analysis of RCTs suggested a significant effect of curcumin in lowering circulating TNF-α concentration.

While statistical significant differences in outcomes were reported in a majority of studies, the small magnitude of effect and presence of major study limitations hinder application of these results.

Overall, scientific literature shows that curcumin possesses anti-diabetic effects and mitigates diabetes complications.

The highlighted studies in the review provide evidence of the ability of curcumin to reduce the body’s natural response to cutaneous wounds such as inflammation and oxidation. The recent literature on the wound healing properties of curcumin also provides evidence for its ability to enhance granulation tissue formation, collagen deposition, tissue remodeling and wound contraction. It has become evident that optimizing the topical application of curcumin through altering its formulation is essential to ensure the maximum therapeutical effects of curcumin on skin wounds.

What emerges from a critical reading of the evidence is that turmeric has potential in several different areas. Generally speaking, clinical trials are still thin on the ground, not of sufficient rigor and therefore not conclusive. In other words, it is far too early to state or imply that we all should rush to the next health food store and buy the supplements.

On the contrary, at this stage, I would even warn people not to be seduced by the unprofessional hype and wait until we know more – much more. There might be risks associated with ingesting turmeric at high doses over long periods of time. And there are fundamental open questions about oral intake. One recent review cautioned: …its extremely low oral bioavailability hampers its application as therapeutic agent.

WATCH THIS SPACE!

Homeopaths assume lots of things; one of their main claims is, for instance, that the process of repeatedly diluting a remedy and vigorously shaking it at each step – they call this potentisation – renders it more potent. This is the famous MEMORY OF WATER’ theory of homeopathy. In Hahnemann’s own words: ‘…the power of a medicine in solution is much increased by intimate mixture with a large volume of fluid…’ And elsewhere he stated that ‘as the smallest quantity of medicine naturally disturbs the organism least, we should choose the very smallest doses, provided always that they are a match for the disease… hardly any dose of the homeopathically selected remedy can be so small as not to be stronger than the natural disease…’

Hahnemann’s explanation for this extraordinary assumption (which he claimed to have observed empirically) was that his remedies do not work through any material effects but via spirit-like energies. As this sounds a little silly in the light of modern science, homeopaths have been keen to find more rational support for their theories. Thus they have developed several ‘sciency’ concepts to explain the mode of action of their highly diluted homeopathic remedies. For instance that postulated that water can form secondary structures that hold some information of the original substance (stock), even if it has long been diluted out of the remedy. Alternatively, they claimed that the shaking of the remedy generates nano-particles or silicone-particles which, in turn, are the cause of the clinical effects.

Today, I want to assume for a minute, that one of these theories is correct – they cannot all be right, of course. Homeopaths regularly show us investigations that seem to support them, even though it only needs a real expert in the particular field of science to cast serious doubt on them. I will nevertheless assume that, after potentisation, the diluent retains information via nano-particles or some other phenomenon. For the purpose of this mind-experiment, I grant homeopaths that, in this respect, they are correct. In other words, let’s for a moment assume that the ‘memory of water’ theory is correct.

As I have been more than generous, I want homeopaths to return the favour and consider what this would really mean: information has been transferred from the stock to the diluent. Does that prove anything? Does it show that homeopathy is valid?

Could the homeopaths who make this assumption be equally generous and answer the following questions, please?

  1. How does a nano-particle of coffee, for instance, affect the sleep centre in the brain to make the patient sleep? Or how does a nano-particle of the Berlin Wall or a duck liver affect anything at all in the human body? The claim that information has been retained by the diluent is no where near to an explanation of a rational mode of action, isn’t it?
  2. Most homeopathic remedies are consumed not as liquids but as ‘globuli’, i. e.  tiny little pills made of lactose. They are prepared by dropping the liquid remedy on to them. The liquid subsequently evaporates. How is it that the information retained in the liquid does not evaporate with the diluent?
  3. The diluent usually is a water-alcohol mixture which inevitably contains impurities. In fact, a liquid C12 remedy most certainly contains dimensions more impurities than stock. These impurities have, of course, also been vigorously shaken, i. e. potentised. How can we explain that their ‘potency’ has not been beefed up at each dilution step? Would this not necessitate a process where only some molecules in the diluent are agitated, while all the rest remain absolutely still? How can we explain this fantastic concept?
  4. Some stock used in homeopathy is insoluble (for instance Berlin Wall). Such stock is not diluted but its concentration in the remedy is initially lowered by a process called ‘trituration’, a process which consists in grinding the source material in another solid material, usually lactose. I have granted you that potentisation works in the way you think. But how is information transferred from one solid material to another?
  5. Everything we drink is based on water containing molecules that have been inadvertently potentised in nature a million times and therefore should have hugely powerful effects on our bodies. How is it that we experience none of these effects each time we drink?

Now, homeopaths, let me propose a deal.

If you can answer these questions satisfactorily, I will no longer doubt your memory of water theory. If you cannot do this, I think you ought to admit that all your ‘sciency’ theories about the mode of action of highly diluted homeopathic remedies are really quite silly – more silly even than Hahnemann’s idea of a ‘spirit-like’ effect.

 

The ACUPUNCTURE NOW FOUNDATION (ANF) have recently published a document that is worth drawing your attention to. But first I should perhaps explain who the ANF are. They state that “The Acupuncture Now Foundation (ANF) was founded in 2014 by a diverse group of people from around the world who were concerned about common misunderstandings regarding acupuncture and wanted to help acupuncture reach its full potential. Our goal is to become recognized as a leader in the collection and dissemination of unbiased and authoritative information about all aspects of the practice of acupuncture.”

This, I have to admit, sounds like music to my ears! So, I studied the document in some detail – and the music quickly turned into musac.

The document which they call a ‘white paper’ promises ‘a review of the research’. Reading even just the very first sentence, my initial enthusiasm turned into bewilderment: “It is now widely accepted across health care disciplines throughout the world that acupuncture can be effective in treating such painful conditions as migraine headaches, and low back, neck and knee pain, as well as a range of painful musculoskeletal conditions.” Any review of research that starts with such a deeply uncritical and overtly promotional statement, must be peculiar (quite apart from the fact that the ANF do not seem to appreciate that back and neck pain are musculoskeletal by nature).

As I read on, my amazement grew into bewilderment. Allow me to present a few further statements from this review (together with a link to the article provided by the ANF in support and a very brief comment by myself) which I found more than a little over-optimistic, far-fetched or plainly wrong:

Male fertility, especially sperm production and motility, has also been shown to improve with acupuncture. In a recent animal study, electro-acupuncture was found to enhance germ cell proliferation. This action is believed to facilitate the recovery of sperm production (spermatogenesis) and may restore normal semen parameters in subfertile patients.

The article supplied as evidence for this statement refers to an animal experiment using a model where sperm are exposed to heat. This has almost no bearing on the clinical situation in humans and does not lend itself to any clinical conclusions regarding the treatment of sub-fertile men.

In a recent meta-analysis, researchers concluded that the efficacy of acupuncture as a stand-alone therapy was comparable to antidepressants in improving clinical response and alleviating symptom severity of major depressive disorder (MDD). Also, acupuncture was superior to antidepressants and waitlist controls in improving both response and symptom severity of post-traumatic stress disorder (PTSD). The incidence of adverse events with acupuncture was significantly lower than antidepressants.

The review provided as evidence is wide open to bias; it was criticised thus: “the authors’ findings did not reflect the evidence presented and limitations in study numbers, sample sizes and study pooling, particularly in some subgroup analyses, suggested that the conclusions are not reliable”. Moreover, we need to know that by no means all reviews of the subject confirm this positive conclusion, for instance, thisthis, or this one; all of the latter reviews are more up-to-date than the one provided by ANF. Crucially, a Cochrane review concluded that “the evidence is inconclusive to allow us to make any recommendations for depression-specific acupuncture”.

“A randomized controlled trial of acupuncture and counseling for patients presenting with depression, after having consulted their general practitioner in primary care, showed that both interventions were associated with significantly reduced depression at three months when compared to usual care alone.”

We have discussed the trial in question on this blog. It follows the infamous ‘A+B versus B’ design which cannot possibly produce a negative result.

Now, please re-read the first paragraph of this post; but be careful not to fall off your chair laughing.

There would be more (much more) to criticise in the ANF report but, I think, these examples are ENOUGH!

Let me finish by quoting from the ANF’s view on the future as cited in their new ‘white paper’: “Looking ahead, it is clear that acupuncture is poised to make significant inroads into conventional medicine. It has the potential to become a part of every hospital’s standard of care and, in fact, this is already starting to take place not only in the U.S., but internationally. The treatment is a cost-effective and safe method of relieving pain in emergency rooms, during in-patient stays and after surgery. It can lessen post-operative nausea, constipation and urinary difficulties, and have a positive impact on conditions like hypertension, anxiety and insomnia…

Driven by popular demand and a growing body of scientific evidence, acupuncture is beginning to be taken seriously by mainstream conventional medicine, which is incorporating it into holistic health programs for the good of patients and the future of health care. In order for this transition to take place most effectively, misunderstandings about acupuncture need to be addressed. We hope this white paper has helped to clarify some of those misunderstandings and encourage anyone with questions to contact the Acupuncture Now Foundation.”

My question is short and simple: IGNORANCE OR FRAUD?

 

Seasonal allergic rhinitis (hay fever) is a common condition which can considerably reduce the quality of life of sufferers. Homeopathy is often advocated – but does it work?

A new study was meant to be an “assessment of the clinical effectiveness of homeopathic remedies in the alleviation of hay fever symptoms in a typical clinical setting.”

The investigator performed a ‘clinical observational study’ of eight patients from his private practice using Measure Yourself Medical Outcome Profile (MYMOP) self-evaluation questionnaires at baseline and again after two weeks and 4 weeks of individualized homeopathic treatment which was given as an add-on to conventional treatments.

The average MYMOP scores for the eyes, nose, activity and wellbeing had improved significantly after two and 4 weeks of homeopathic treatment. The overall average MYMOP profile score at baseline was 3.83 (standard deviation, SD, 0.78). After 14 and 28 days of treatment the average score had fallen to 1.14 (SD, 0.36; P<0.001) and 1.06 (SD, 0.25; P<0.001) respectively.

The author concluded as follows: Individualized homeopathic treatment was associated with significant alleviation of hay fever symptoms, enabling the reduction in use of conventional treatment. The results presented in this study can be considered as a step towards a pilot pragmatic study that would use more robust outcome measures and include a larger number of patients prescribed a single or a multiple homeopathic prescription on an individualized basis.

It is hard to name the things that are most offensively wrong here; the choice is too large. Let me just list three points:

  • The study design is not matched to the research question.
  • The implication that homeopathy had anything to do with the observed outcome is unwarranted.
  • The conclusion that the results might lend themselves to develop a pilot study is meaningless.

The question whether homeopathy is an effective therapy for hay fever has been tested before, even in RCTs. It seems therefore mysterious why one needs to revert to tiny observational studies in order to plan a pilot, and even less for an assessment of effectiveness.

There are few conditions which are more time-dependent than hay fever. Any attempt of testing the effectiveness of medical interventions without a control group seems therefore not just questionable but wasteful. Clinical studies absorb resources; even if the author was happy to waste his time, he should not assume that he can freely waste the time, effort and availability of his patients.

Two final points, if I may:

  • An observational study of homeopathy for hay-fever without a control group might be utterly useless but it is still an investigation that requires certain things. As far as I can see, this study did not even have ethics approval nor is there a mention of informed consent. Strictly speaking, this makes it an unethical study.
  • If we allow research of this nature to take place and be published, we give clinical research a bad name and undermine the confidence of the public in science.

I am puzzled how such a paper could pass peer review and how an Elsevier journal could even consider publishing it.

I have previously reported about the issue of homeopathy on the NHS in Liverpool here. Since then, the NHS Liverpool Clinical Commissioning Group (CCG) has conducted a consultation on whether to continue funding. Personally, I think such polls are a daft waste of resources.

Why?

I will explain in a moment; first read the (slightly shortened) summary:

In November 2015, NHS Liverpool CCG Governing Body stated a preference to decommission the homeopathy service and commenced the consultation exercise with the intent to ascertain how the public felt about it. This report was written by the Centre for Public Health, Liverpool John Moores University, and includes independent analysis of the consultation activities.

The consultation ran from 13th November – 22nd December 2015. The two main methods used were 1) a survey available online and in paper format. It was completed by 743 individual respondents and, of those who provided a valid postcode, 68% (323 individuals) lived within the Liverpool CCG area, 2) a small consultation event held on 4th December 2015 facilitated by Liverpool John Moores University. The event was attended by 29 individuals, the majority of whom were patients and staff from the Liverpool Medical Homeopathic Service. Eighteen of the participants at this event resided in Liverpool.

Two thirds of survey respondents (66%; 380 respondents) said they would never use homeopathy services in the future. The reasons for this included the lack of evidence and scientific basis of homeopathy; negative personal experiences of homeopathy; and believing it was an inappropriate use of NHS funding. Those who would be likely to use it in the future (28%) felt they wanted to be able to choose an alternative to conventional medicine; felt it was value for money for the NHS; appreciated the time, care and holistic consultation; and discussed their own positive experiences. Sixty six per cent of survey respondents (111) who had used homeopathy in the past reported an excellent or good experience. Those who reported a positive experience (66%) felt that homeopathy had improved their health where conventional medicine had not, and participants valued that the homeopathic practitioner had treated their emotional as well as their physical needs. Those who reported a below average or poor experience (31%) felt homeopathy had not improved their medical condition and some felt they had been misled and had not been told the remedy contained no active ingredients.

At the consultation event, the majority of the 29 participants were homeopathy service users and they described a positive experience of homeopathy and the ability to choose ‘holistic’ and non-pharmaceutical treatment. Participants also questioned what services they could use if they were unable to access homeopathy on the NHS and were concerned and angry about the service potentially being decommissioned. A small number of participants at this event agreed with the view that there is a lack of evidence regarding efficacy and felt it was an inappropriate use of NHS funds that would be better spent on other, more effective services.

Of the survey respondents, 73% (541 individuals) chose the option to stop funding all homeopathy services; when including only Liverpool residents in the analysis this decreased to 64%.  Twenty three per cent of survey respondents (170 individuals) wanted to continue to fund homeopathy services in Liverpool (either at current levels or to increase the budget); when only including Liverpool residents this proportion increased slightly to 30%. At the end of the consultation event the participants in the room (29 individuals) were asked to vote on their preferred funding option; twenty two participants (76%) wanted to continue the service and increase the maximum funding limit; three participants (14%) wanted to stay with the current situation and three participants (10%) wanted to stop funding the service.

There was some tension in what those in the consultation saw as acceptable and appropriate evidence about the effectiveness of homeopathy. Many participants in the survey and at the event reported their positive experience or anecdotal evidence as “proof” that homeopathy is effective.  There was a low understanding about how scientific research is conducted or evaluated. The NHS try to base funding decisions on rigorous, high-quality, unbiased, peer-reviewed research, however, the CCG is required to account of all evidence, including patient experience, when funding or discontinuing services.

Across the survey and the consultation event there was some confusion about what types of treatment come under the heading of “homeopathy”, with participants making reference to a range of herbal remedies and supplements. Iscador (a mistletoe extract) may be, in some cases, provided as a complementary treatment for patients with cancer, however, this is not a homeopathic remedy. There was also discussion (in the event and in the survey responses) about other herbal remedies and supplements.

END OF SUMMARY

So, why do I not think highly about exercises of this kind?

In general, surveys are tricky and often very dodgy research tools. Particularly in alternative medicine, they are as popular as they are useless. The potential problems arise from the way the methodology is often applied. For instance, sampling is crucial. If, like in the present case, no rigorous sampling techniques are applied, the results will inevitably be unreliable in reflecting the views of a population.

The findings of the survey above could easily be little more than a reflection of which camp had a better PR. Homeopaths usually are very good on such occasions at persuading others for homeopathy. In this case, the results show that, despite their best efforts, the overall vote was not positive for homeopathy. What we don’t know is whether this is a reflection on the ‘will of the people’. It could be that the public is much more against funding nonsense than this poll suggests.

I would also argue that letting people vote about the availability of medical interventions is nonsensical. The value of healthcare technologies is not determined by such ‘beauty contests’; the value depends on the scientific evidence, and that is not readily evaluated by non-experts. Imagine: next we might vote for or against bone-marrow transplants; who has the expertise to cast such a vote?

Oh yes, and the ‘small consultation’ – what was that supposed to be. Probably just an exercise in political correctness. Nobody in their right mind can have expected any meaningful insight coming from it.

Finally, I dispute that ‘patients’ experience’ is the same as ‘evidence’, as the summary above seems to claim. This is just nonsense. evidence is something entirely different from experience.

But politicians will disregard all this. They will say ‘the public has decided’ and will stop funding homeopathy on the NHS in Liverpool. More by coincidence than by design, this survey went into the right direction. Now one can only hope that the rest of the country will follow suit – on evidence, not on dodgy pseudo-evidence from surveys.

The subject of placebo is a complex but fascinating one, particularly for those interested in alternative medicine. Most sceptics believe that alternative therapies rely heavily, if not entirely, on the placebo effect. Some alternative practitioners, when unable to produce convincing evidence that their treatment is effective, seem to have now settled to admitting that their therapy works (mostly or entirely) via a placebo effect. They the hasten to add that this is perfectly fine, because it is just an explanation as to how it works – a mechanism of action, in other words. Causing benefit via a placebo effect still means, they insist, that their therapy is effective.

In a previous post, I have tried to demonstrate that this belief is erroneous and where the notion comes from. It originates, I believe, from a mistaken definition of ‘effectiveness’: for many alternative practitioners ‘effectiveness’ encompasses the specific plus the non-specific (e. g. placebo) effects of their therapy. In real medicine, ‘effectiveness’ is the degree to which a treatment works under real life conditions.

The ‘alternative’ definition is, of course, incorrect but alternative practitioners stubbornly refuse to acknowledge this fact. Here are just two reasons why it cannot be right:

  • If it were correct, it would be hardly conceivable to think of a treatment that is NOT effective. Applied with empathy and compassion, virtually all treatments – however devoid of specific effects – will produce a placebo effect. Thus they will all be effective, and the term would be superfluous because ‘treatment’ would automatically mean ‘effective’. An ineffective treatment would, in other words, be a contradiction in terms.
  • If it were correct, any pharmaceutical or devices company could legally market ineffective drugs or gadgets and rightly claim (or even prove) that they are effective. Any such therapy could very easily be shown to generate a placebo-effect under the right circumstances; and as long as this is the case, it would be certifiably effective.

I do sympathise with alt med enthusiasts who find this hard or even impossible to accept. They see almost every day how their placebo-therapy benefits their patients. (It seems worth remembering that not just the placebo phenomenon but several other factors are involved in such outcomes – take, for instance, the natural history of the disease and the regression towards the mean.) And they might think that my arguments are nothing but a devious attempt do away with the beneficial power of the placebo.

The truth, however, is that nobody wants to do anything of the sort; we all want to help patients as much as possible, and that does, of course, include the use of the placebo effect. In clinical practice, we usually want to maximise the placebo effect where possible. But for this goal, we do not require placebo therapies. If we administer a specifically effective therapy with compassion, we undoubtedly also generate a placebo response. In addition, our patients would benefit from the specific effects of the prescribed therapy. Both elements are essential for an optimal therapeutic response, and I don’t know any conventional healthcare professionals who do not aim at this optimal outcome.

Giving just placebos will not normally generate an optimal outcome, and therefore it cannot truly be in the interest of the patient. It is also ethically problematic because it usually entails a degree of deception of the patient. Moreover, placebo effects are unreliable and usually of short duration. Foremost, they do not normally cure a disease; they may alleviate symptoms but they almost never tackle their causes. These characteristics hardly make placebos an acceptable choice for routine clinical practice.

The bottom line is clear and simple: a drug that is not better than placebo can only be classified as being ineffective. The same applies to all non-drug therapies. Double standards are not acceptable in healthcare. And the demonstration of a placebo effect does not turn an ineffective therapy into an effective one.

I know that many alternative practitioners do not agree with this line of thought – so, let’s hear their counter-arguments.

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