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

critical thinking

Currently, over 50 000 000 websites promote alternative medicine, and consumers are bombarded with information not just via the Internet, but also via newspapers, magazines and other sources. This has the potential of needlessly separating them from their cash or even seriously harming their health. As there is little that protects us from greedy entrepreneurs and over-enthusiastic therapists, we should think about protecting ourselves. Here I will provide five simple tips that may fortify you against fake news in the realm of alternative medicine.

Imagine you read somewhere that the condition you are affected by is curable (or at least improvable) by THERAPY XY. It is only natural that you are exited by this news. Before you now rush to the next health shop or alternative medicine centre, it is worth asking yourself the following questions:

  • Is the claim plausible? As a rule of thumb, it is fair to say that, if it sounds too good to be true, it probably is too good to be true. Not so long ago, UK newspapers reported that a herbal mixture called ‘CARCTOL’ had been discovered to be an efficacious and safe cancer cure (before that, it was Essiac, shark cartilage, Laetrile and many more). I only needed a minimal amount of research to find that the claim had no basis in fact. Come to think of it, it is not plausible that any alternative therapy will ever emerge as a miracle cure for any condition, particularly a serious disease like cancer. It is also not plausible that a herbal mixture would ever prove to be a cure for a wide range of different cancers. The very idea of such ‘cures’ is a contradiction in terms. If an alternative therapy ever did turn out to be efficacious, it would become mainstream even before the clinical tests to prove its efficacy are fully concluded. The notion of an alternative cure presumes that conventional scientists and clinicians reject a treatment simply because it originated from the realm of alternative medicine. There is no precedent that this has ever occurred, and I am sure it will never happen in future.
  • What is the evidence for the claim? In the case of CARCTOL, the claim was based on a UK doctor apparently observing that, in several patients, tumours had been melting like butter in the sun after they took this herbal mixture. One particularly irresponsible headline read: “I’ve seen herbal remedy make tumours disappear, says respected cancer doctor.” This, however, is no evidence but mere anecdotes, and we confuse the two at our peril. Remember: the plural of anecdote is anecdotes, not evidence. With anecdotes, we can never be sure about cause and effect. Therapeutic claims must be based on good evidence, e.g. controlled clinical trials.
  • Who is behind the claim? In the UK, the CARCTOL claim emerged around 2004 and originated mainly from Dr Rosy Daniel. In the above newspaper article, she was called ‘a respected cancer doctor’. Personally, I do NOT ‘respect’  someone who makes claims of this nature without having good evidence. And a ‘cancer doctor’ is usually understood to be an oncologist; to the best of my knowledge, Dr Daniel is NOT an oncologist. In fact, she now calls herself a ‘Lifestyle and Integrative Medicine Consultant’. Faced with an important new health claim, one should always check who is behind it. Check out whether this person is reputable and free of conflicts of interest. An affiliation to a reputable university is usually more convincing than being a director of your own private heath centre.
  • Where was the claim published? The CARCTOL story had been published in newspapers – and nowhere else! Even today, there is only one Medline-listed publication on the subject. It is my own review of the evidence which, in 2004, concluded that “The claim that Carctol is of any benefit to cancer patients is not supported by scientific evidence.”   *** If important new therapeutic claims like ‘therapy xy cures cancer’ are reported in the popular media, you should always check where they were first published (or simply dismiss it without researching it). It is unthinkable that such an important claim is not made first in a proper, peer-reviewed article in a good medical journal. Go on ‘Medline’, conduct a quick search and find out whether the new findings have been published. If the claim does not come from peer-reviewed journals, forget about it. If it has been published in any journal that has alternative, complementary, integrative or similar terms in its name, take it with a good pinch of salt.
  • Is there money involved? In the case of CARCTOL, the costs were high. I was called once by a woman who had read my article telling me that she was pursued by the doctor who had treated her husband. Tragically, the man had nevertheless died of his cancer, and the widow was now pursued for £8 000 which she understandably was reluctant to pay. Many new treatments are expensive. So, high costs are not necessarily suspicious. Still, I advise you to be extra cautious in situations where there is the potential for someone to make a fast buck. Financial exploitation is sadly rife in the realm of alternative medicine.

A similar checklist originates from a team of experts. Researchers from Uganda, Kenya, Rwanda, Norway, and England, worked to identify the most important ideas a person would need to grasp thinking critically about health claims. They came up with excellent points:

  1. Just because a treatment is popular or old does not mean it’s beneficial or safe.
  2. New, brand-name, or more expensive treatments may not be better than older ones.
  3. Treatments usually come with both harms and benefits.
  4. Beware of conflicts of interest — they can lead to misleading claims about treatments.
  5. Personal experiences, expert opinions, and anecdotes aren’t a reliable basis for assessing the effects of most treatments.
  6. Instead, health claims should be based on high-quality, randomized controlled trials.

Alternative medicine can easily turn into a jungle or even a nightmare. Before you fall for any dubious claim that THERAPY XY is good for you, please go through the simple sets of questions above. This might protect you from getting ripped off or – more importantly – from getting harmed.

 

*** After this article had been published, I received letters from layers threatening me with legal action unless I withdrew the paper. I decided to ignore them, and no legal action followed.

In their now famous 1998 NEJM editorial about alternative medicine, Angell and Kassirer concluded that “It is time for the scientific community to stop giving alternative medicine a free ride. There cannot be two kinds of medicine — conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted. But assertions, speculation, and testimonials do not substitute for evidence. Alternative treatments should be subjected to scientific testing no less rigorous than that required for conventional treatments.”

Then and today, I entirely agree(d) with these sentiments. Years later, the comedian Tim Minchin brought it to the point: “You know what they call alternative medicine that’s been proved to work? – Medicine.”  So, comedians have solved the terminology problem, but we, the experts, have not managed to get rid of the notion that there is another type of medicine. Almost 20 years after the above editorial, we still struggle to find the ideal name.

Despite their desperate demand ‘THERE CANNOT BE TWO KINDS OF MEDICINE’, Angell and Kassirer still used the word ALTERNATIVE MEDICINE. On this blog, I usually do the same. But there are many terms, and it is only fair to ask: which one is the most suitable?

  1. ALTERNATIVE MEDICINE is strictly speaking an umbrella term for modalities (therapy or diagnostic technique) employed as a replacement of conventional medicine; more commonly the term is used for all heterodox modalities.
  2. CHARLATANERY treatment by someone who professes to have expertise that he does not have.
  3. COMPLEMENTATY MEDICINE is an umbrella term for modalities usually employed as an adjunct to conventional healthcare.
  4. COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM) an umbrella term for both 1 and 3 often used because the same alternative modality  can be employed either as a replacement of or an add-on to conventional medicine.
  5. COMPLEMENTARY AND INTEGRATIVE MEDICINE (CIM) a nonsensical term recently created by authors of an equally nonsensical BMJ review.
  6. DISPROVEN MEDICINE is an umbrella term for treatments that have been shown not to work (as proving a negative is usually impossible, there are not many such therapies).
  7. FRINGE MEDICINE is the term formerly used for alternative medicine.
  8. HETERODOX MEDICINE is the linguistically correct term for unorthodox medicine (this could be the most correct term but has the disadvantage that consumers are not familiar with it).
  9. HOLISTIC MEDICINE is healthcare that emphasises whole patient care (as all good medicine is by definition holistic, the term seems problematic).
  10. INTEGRATED MEDICINE describes the use of treatments that allegedly incorporate ‘the best of both worlds’, i.e. the best of alternative and conventional healthcare (integrated medicine can be shown to be little more than a smokescreen for adopting bogus treatments in conventional medicine).
  11. INTEGRATIVE MEDICINE is the same as 10 (10 is more common in the UK, 11 is more common in the US).
  12. NATURAL MEDICINE is healthcare exclusively employing the means provided by nature for treating disease.
  13. QUACKERY is the deliberate misinterpretation of the ability of a treatment or diagnostic technique to treat or diagnose disease (quackery exists in all types of healthcare).
  14. TRADITIONAL MEDICINE is healthcare that has been in use before the scientific era (the assumption is that such treatments have stood the test of time).
  15. UNCONVENTIONAL MEDICINE is healthcare not normally used in conventional medicine (this would include off-label use of drugs, for instance, and therefore does not differentiate well).
  16. UNORTHODOX MEDICINE the linguistically incorrect but often used term for healthcare that is not normally used in orthodox medicine.
  17. UNPROVEN MEDICINE is healthcare that lacks scientific proof (many conventional therapies fall in this category too).

These terms and explanations (mostly my own) are meant to bring out clearly that:

  • none of them is perfect,
  • none has ever been clearly defined,
  • none describes the area completely,
  • none is without considerable overlap to other terms,
  • none is really useful.

My conclusion, after pondering about these terms for many years (it can be an intensely boring issue!), is that the best solution would be to abandon all umbrella terms (see Angell and Kassirer above). Alas, that hardly seems practical when running a blog on the subject. I think therefore that I will continue to (mostly) use the term ALTERNATIVE MEDICINE (consumers understand it best, in my experience) … unless, of course, someone has a better idea.

Since more than 20 years, I have been writing about the risks of alternative therapies. One of my first papers on this issue was published in 1995 and focussed on acupuncture. Here is its abstract:

The use of acupuncture is widespread. The procedure is often claimed to be totally, or at least reasonably, safe. The published evidence regarding its potential risks is reviewed. The repeated and/or inappropriate use of an acupuncture needle carries the risk of infections. Amongst others, AIDS and hepatitis have been transmitted. Acupuncture needles may also traumatise tissues and organs. Pneumothorax is the most frequent complication caused in this way. Finally, needles may break and fragments can be dislodged into distant organs. A serious and more general concern related to the safety of acupuncture is the competence of the therapist, whether or not medically qualified. The “philosophy” of acupuncture is not in line with orthodox diagnostic skills; therefore acupuncturists can be dangerously unconcerned with diagnostic categories. Thus indirect risks might add significantly to the direct risks of acupuncture. It is concluded that the true risk of acupuncture cannot be estimated. Whatever its extent, it could and probably should be lowered by enforcing educational and clinical standards.

My reason for banging on about the potential harms (direct and indirect risks) of alternative medicine is fairly obvious: I want to alert healthcare professionals and consumers to the fact that these treatments may not be as harmless as they are usually advertised to be. Yet, I have often be called an alarmist fear-monger. In my view, nothing could be further from the truth.

Thinking about fear-mongering, I began to ask myself whether those who regularly accuse me are the ones guilty of the deed. Are alternative practitioners fear-mongers? Surely not all of them, but some clearly are. Here are a few of the strategies they use for their fear-mongering.

NON-EXISTING DIAGNOSES

Perhaps the most obvious way to instil fear into people is to tell them that they are affected by a disease or condition they do not have. Many alternative practitioners do exactly that!

  • A chiropractor might tell you that you have a subluxation in your spine.
  • A naturopath would inform you that your body is full of toxins.
  • An acupuncturist will tell you that your life energy is blocked.
  • A homeopath might warn you that your vital force is too low.

These diagnoses have one thing in common: they do not exist. They are figments of the therapist’s imagination. And they have another thing in common: the abnormalities need to be corrected, and – surprise, surprise – the very therapy that the practitioner specialises in happens to be just the ticket for that purpose.

  • The chiropractor will tell you that a simple spinal adjustment will solve the problem.
  • The naturopath will inform you that a bit of detox will eliminate the toxins.
  • The acupuncturist will tell you that his needles will de-block your chi.
  • The homeopath will persuade you that he can find the exact remedy to revive your vital force.

And there we have the third thing these diagnoses have in common: they are all treatable, will all result in a nice bill, and will all improve the cash-flow of the therapist.

MEDICALIZING TRIVIALITIES

But often, it is not even necessary for an alternative therapist to completely invent a diagnosis. Patients usually consult an alternative practitioner with some sort of symptom – frequently with what one might call a medical triviality that does not need any treatment at all but can be dealt with differently, for instance, by issuing some life-style advice or just simple re-assurance that nothing major is amiss. But for the fear-monger, this is not enough. He feels the need to administer his therapy, and for that purpose he needs to medicalize trivialities :

  • A low mood thus becomes a clinical depression.
  • A sore back is turned into a nasty lumbago.
  • A tummy upset morphs into a dangerous gastritis.
  • Abdominal unrest is diagnosed to be a leaky gut syndrome.
  • A food aversion turns into a food intolerance, etc., etc.

The common denominator is again the fact that fear is instilled into the patient. And again, a useless therapy is administered, if at all possible in the form of a lengthy series of treatments. This, of course, generates significant benefit – not therapeutic, but financial!

DEMONIZING CONVENTIONAL MEDICINE

But there is always the risk that the patient is wiser than expected. She might be so scared learning of her condition that she decides to see her doctor. That would mean a loss of income which has to be avoided! The trick to achieve this is usually not difficult: conventional healthcare professionals must be demonized.

  • They are not treating the root cause of the problem.
  • They are in the pocket of BIG PHARMA.
  • They prescribe medicines with terrible side-effects.
  • They have no idea about holism.
  • They never have enough time to listen, etc., etc.

I know, some of these criticisms are not entirely incorrect (for instance, many conventional medicines do have serious side-effects but, as I try to point out ad nauseam, we need to consider their risk/benefit balance). But that is hardly the point here; the point is to scare the patient off conventional medicine. Only a person who is convinced that the ‘medical mafia’ is out to get her, will prove to be a loyal customer of all things alternative.

DISEASE PREVENTION

And a loyal customer is someone who comes not just once or twice but regularly, ideally from cradle to grave. The way to achieve this ultimate stimulus of the practitioners cash flow is to convince the patient that she needs regular treatments, even when she feels perfectly alright. The magic word here is PREVENTION! The masters here are the chiropractors, I guess; they promote what they call ‘maintenance care’, i.e. the regular treatment of healthy individuals to keep their spines subluxation-free. It goes without saying that maintenance care is a money-making scam.

The strategy requires two little lies, but that’s forgivable considering the good cause, boosting the income of the practitioner:

  1. Conventional doctors don’t do prevention.
  2. The alternative treatment is an effective preventative.

The first statement can be shown to be an obvious lie. All we know about effective disease prevention today comes from conventional medicine and science; nothing originates from the realm of alternative medicine. Remarkably, the most efficacious preventative measure of all times, immunisation, is frequently defamed and neglected by alternative practitioners.

The second statement is a necessary lie; how else would a patient agree to pay regularly for the practitioner’s services? I am not aware of any alternative therapy that can effectively prevent any disease.

CONCLUSIONS

  • Some alternative practitioners regularly instil fear into consumers.
  • Several strategies are being used for this purpose.
  • They have the aim of maximising the therapists’ income.
  • Fear-mongering is unethical and despicable.
  • Pointing out that a certain therapy might fail to generate more good than harm is not fear-mongering.

Before starting to treat a patient, all health care professionals – including of course alternative practitioners – have to obtain informed consent. This is not optional but an ethical and legal imperative. Informed consent must usually include full information on:

  • the diagnosis
  • its natural history
  • the most effective treatment options available
  • the proposed therapy
  • its effectiveness
  • its risks
  • its cost
  • a rough treatment plan

Only when this information has been transmitted to and understood by the patient can informed consent be considered complete.

One could easily argue that, in alternative medicine, informed consent is a practical impossibility.

To explain why, let us consider two scenarios.

SCENARIO 1

A patient with fatigue and headaches consults a Reiki healer. The practitioner asks a few questions and proceeds to apply Reiki. The therapist has no means to obtain informed consent because:

  • he is not qualified to make diagnoses
  • he knows little about the natural condition of the patient
  • he is ignorant of the most effective treatment options
  • he is convinced that Reiki works but is unaware of the evidence

SCENARIO 2

A patient with fatigue and headaches consults a chiropractor. The chiropractor takes a history, conducts a physical examination, tells the patient that her headaches are due to spinal misalignments which he suggests to treat with spinal manipulations, and proceeds to apply his treatments. The chiropractor has no means to obtain informed consent because:

  • he has insufficient knowledge of other therapeutic options
  • he is biased as to the effectiveness of spinal manipulations
  • he believes that they are risk-free
  • he has an overt conflict of interest (he earns his money by applying his treatments)

In some respects, these might be extreme scenarios. They were chosen to explain why informed consent is rarely possible in the realm of alternative medicine. Put simply, informed consent requires knowledge that alternative practitioners almost never possess. I know this will sound chauvinistic, but it requires knowledge that normally only doctors have – I mean doctors who have been through medical school. Moreover, it requires a lack of financial interest such that the clinician is not in danger of loosing out on some income, if he advises his patient not to receive treatment from him. Finally, informed consent requires information about the treatment. Arguably, this should include explanations how it works. For many alternative therapies, this information is not available. If it is unavailable, informed consent is impossible.

If I am correct – and I am fully aware that many will think I am not – what implications would this have? If informed consent is usually not provided or even impossible, one cannot help but conclude that alternative medicine, as it is practised in most places today, is not ethical.

In my previous post, I mentioned the current volume of the ‘Allgemeinen Homöopathischen Zeitung’ which contains the abstracts of the ‘Homeopathic World Congress 2017’ (btw: the remarkable opening speech for the WORLD CONFERENCE ON HOMEOPATHY 1937, in Berlin might also be of interest; excerpts from it can be found here). Amongst these abstracts, the collector can find many true gems. Today I have for you a few more abstracts that I found remarkable; they are from what I call pre-clinical (or non-clinical) research.

Homeopathy has a polarized image. Many people experience homeopathic cure, but critics say this is only a placebo-effect. However, there, are 3800 studies and evidence is steadily growing. All comprehensive investigations prove that homeopathy is more efficient than placebo. What are the reasons for this controversy? How do we improve the image of homeopathy? Methods Data collection regarding effectiveness, benefits and mechanisms over 30 years. Order development to archive all data according to their scientific content. Systematic analysis of criticisms towards homeopathy over the last 12 years. Discussions with sceptics to understand their rejections. Findings Main reasons for controversy are: ▪ Since homeopathy does not meet the contemporary scientific concepts, people believe that homeopathy is implausible. ▪ Different homeopathic methods appear contradictory. ▪ Conventional medicine rejects homeopathy.  Missing overview regarding scientific principles. ▪ Modern studies are no more understandable. Due to our fast-moving times, people quickly form opinion with their own personal logic, influenced by media information. This causes a systematic interpretation bias. Results The knowledge of homeopathy and potentized remedies will be publicly illustrated: ▪ Information about different methods. ▪ Basics of holistic thinking and limitations of science in medicine. ▪ State of the art regarding effectiveness and benefits. ▪ Scientific principles and body of evidence. ▪ Correcting wrong media information. A special didactic structure was developed to provide this information at the portal: “Homeopathy & potentized medicines” (www.dellmour.org, available autumn 2016). Physicians and patients will find comprehensible information to aquire a plausible picture of homeopathy.

The use of agrochemicals has been associated with environmental and ecological damages. Excessive use of fertilizers, for example, can lead to the groundwater contamination with nitrate, rendering it unfit for consumption by humans or livestock. Water containing large concentrations of nitrate can poison animals by partial immobilization of the hemoglobin in blood, reducing the ability to transport oxygen. These and other environmental effects in the use of agrochemicals are unfortunate consequences in the application of these chemical tools. Researchers are constantly searching for non-chemical solutions in dealing with many of these agricultural needs. Much attention is being paid, for example, to developing “organic” methods of enhancing soil fertility and dealing with pests. The application of homeopathy in agriculture (agrohomeopathy) is an alternative that can help solve the problems caused by agrochemicals. Several countries have begun to implement this new option to solve the problems that have been caused by agrochemicals. The use of agrohomeopathy allows a control of diseases in plants, caused by bacteria, fungi, viruses and pests, it also helps to improve and promote seed germination, as well as by enhancing the growth of plants. Moreover, with the application of agrohomeopathy it is possible to decontaminate soils that have been exposed to agrochemical treatments. The goal of this study is to analyze the major results obtained in agrohomeopathy. Also we demonstrate the importance of botanical models to find out or clarify the mechanism of homeopathy in living organisms.

Dr. Hahnemann improvised homeopathy to such an extent, that his discovery of potentization of homeopathic medicines questioned the fundamental belief systems of the basic sciences. This resulted in a constant disapproval of homeopathic system by the main stream science and was accused as a placebo therapy, yet the clinical efficacy of homeopathy remained unquestionable. Objectives The present study was done to analyze the presence/absence of particles in aurum metallicum 6C to CM and carbo vegetabilis 6C to CM potencies. This is a part of the 31 homeopathic drugs studied by using HRTEM&EDS and FESEM&EDS in Centesimal scale 6C, 30, 200, 1M, 10M, 50M and CM and LM scale in LM1, LM6, LM12, LM18, LM24 and LM30 potencies. Method HRTEM (High Resolution Transmission Electron Microscope), FESEM (Field Emission Scanning Electron Microscope) and EDS (Energy dispersive Spectroscopy) were used for the analysis of samples. Results Plenty of particles in nanometer and Quantum Dots (QD – less than 10nm) scale were seen in aur. with presence of gold in all the potencies of aur. Enormous particles were identified in all the potencies of carb-v. in nanometer scale composed of carbon and oxygen. Conclusion The presence of NPs & QDs in all potencies must be the reason for the cure in diseases and also produce signs and symptoms in Hahnemannian drug proving. This discovery of NPS in all the drug potencies is an important evidence which substantiate the individualized drug selection and place homeopathy an established “individualized nanomedicine” with 200 years of collective clinical experience.

In March 2015, the Australian National Health and Medical Research Council (NHMRC) published an Information Paper on homeopathy. This document, designed for the general public, provides a summary of the findings of a review of systematic reviews, carried out by NHMRC to assess the evidence base for effectiveness of homeopathy in humans. ’The Australian report’, concludes that ”there are no health conditions for which there is reliable evidence that homeopathy is effective … no goodquality, well-designed studies with enough participants for a meaningful result reported either that homeopathy caused greater health improvements than placebo, or caused health improvements equal to those of another treatment”. Such overly-definitive negative conclusions are immediately surprising, being inconsistent with the majority of comprehensive systematic reviews on homeopathy. In-depth analysis has revealed the report’s multiple methodological flaws, which explain this inconsistency. Most crucially, NHMRC’s findings hinge primarily on their definition of reliable evidence: for a trial to be deemed ’reliable’ it had to have at least 150 participants and a quality score of 5/5 on the Jadad scale (or equivalent on other scales). Trials that failed to meet either of these criteria were dismissed as being of ’insufficient quality and/or size to warrant further consideration of their findings’. Setting such a high quality threshold is highly unusual, but the n=150 minimum sample size criterion is arbitrary, without scientific justification, and unprecedented in evidence reviews. Out of 176 trials NHMRC included in the homeopathy review, only 5 trials met their definition of ’reliable’, none of which, according to their analysis, demonstrated effectiveness of homeopathy. This explains why NHMRC concluded there is ’no reliable evidence’ that homeopathy is effective. A distillation of other detailed findings, presented at conference, reveals further significant flaws in this highly influential report, providing critical awareness of its misrepresentation of the homeopathy evidence base.

An extensive review of the literature dealing on the results obtained by homeopathy during epidemics has revealed important findings about the efficacy of homeopathic treatment. The main findings of this research are: ▪ With more than 25,000 volumes, the homeopathic literature is vast and rich in reports about results obtained by homeopathy during epidemics. The speaker has uncovered over 7,000 references addressing this subject. ▪ Results obtained by homeopathy during epidemics reveal a very important and clear constancy: a very low mortality rate. This constancy remains, regardless of the physician, time, place or type of epidemical disease, including diseases carrying a very high mortality rate, such as cholera, smallpox, diphtheria, typhoid fever, yellow fever and pneumonia. ▪ Interestingly, this low mortality rate is always superior to the results obtained not only by allopathy practiced at that particular time but, as a rule, by allopathy of today, despite benefiting from modern nursing and hygienic care. ▪ Even the lesser-trained homeopaths obtained, as a rule, better results than the highest authorities of the allopathic school. However, the most consistent, predictable and impressive results were obtained by the ones who practiced genuine homeopathy whom are known as Hahnemannians. ▪ Homeopathic remedies have been successfully used to protect large segments of the population from upcoming infectious diseases. Homeopathic prophylaxis is safe and effective combining inexpensive costs. ▪ The results obtained by homeopathy during epidemics cannot be explained by the placebo effect.

It is often considered that a physico-chemical explanation of homeopathy would require a major rewriting of much of physics, chemistry and biochemistry. Yet, despite the fact that the bio-activity of homeopathic dilutions appears to fly in the face of modern science, such an upheaval might not actually be necessary. The aim of this presentation is to demonstrate that we can indeed formulate a plausible and testable theory of homeopathy based on current physics and chemistry. We will start by going over the requirements made of an explanation of homeopathy, such as: memory of the starting substance, compatibility with the dilution/succussion process and finally bio-activity. We will then formulate a minimal set of physical assumptions able to explain the experimental results found in homeopathy. We will show how these assumptions are validated both from the theoretical physics and experimental physico-chemistry side. On the one hand we have, the theoretical predictions of Preparata and DelGuidice of the existence in water structures. These predict the formation of distinct water domains through the stabilising effect of electromagnetic oscillations. On the other hand, we will present a set of experiments from within and outside the field of homeopathy (Demangeat, Elia, Pollack and others). These experiments support the idea that water does form relatively stable structures under certain conditions and that these structures have electromagnetic properties, which could be at the root of the specific biological effects seen in clinical and animal studies. Thus we will show that it is possible to formulate a plausible physico-chemical explanation of homeopathy based on current physic and chemistry. Crucially this formulation is testable, providing important parameters and suggestions for the design of future experiments.

Hilarious, isn’t it? There are many sentences that are memorable treasures in these abstracts. One is almost tempted to book a ticket to Leipzig and listen to the presentations. I particularly love the following statements:

  • All comprehensive investigations prove that homeopathy is more efficient than placebo…
  • …the clinical efficacy of homeopathy remained unquestionable…
  • …overly-definitive negative conclusions are immediately surprising…
  • Homeopathic prophylaxis is safe and effective…
  • …we can indeed formulate a plausible and testable theory of homeopathy based on current physics and chemistry…

The naivety, ignorance and chutzpa that we observed in the abstracts of clinical studies is mirrored here very clearly.  I am therefore inclined to repeat the questions I asked in part 1 of this post: How can a scientific committee reviewing these abstracts let them pass and allow the material to be presented at the ‘World Congress’? How can a Health Secretary accept the patronage of such a farce?

The current volume of the ‘Allgemeinen Homöopathischen Zeitung’ contains all the abstracts of the ‘Homeopathic World Congress 2017’ which will be hosted in Leipzig, 14-17 July this year by the ‘Deutschen Zentralvereins Homöopathischer Ärzte’ under the patronage of the German Health Secretary, Annette Widmann-Mauz. As not many readers of this blog are likely to be regular readers of this important journal, I have copied six of the more amusing abstracts below:

A male patient with bilateral solid renal mass was investigated and given an individualized homeopathic remedy. Antimonium crudum in 50000 potency was selected after proper case taking and evaluation. Investigations were done before and after treatment. Follow ups took place monthly. Results The patient had symptomatic relief from pain in flanks, acute retention and hematuria. The ultrasonography suggests a reduction in size of both lesions over a period of two years. A small number of lymph nodes of the para-aortic group are still visible. There is a normal level of urea and creatinine, no anemia or hypertention. The patient is surviving since 2014. Conclusion In the present day when malignancies are treated with surgeries, chemo and radiotherapies, homeopathy has a significant role to play as seen in the above case. This case with bilateral solid renal mass, probably a renal cell carcinoma, received an individualized homeopathic remedy-treatment compliant with the totality of symptoms, and permitted the patient to live longer without anemia, hypertension, anorexia or weight loss. The quality of life was maintained without the side effects of surgery, radiotherapy and chemotherapy. Acute retentions, which he used to suffer also remained absent, thereafter. The result of this case suggests to take up further studies on individualized homeopathic treatment in malignant diseases.

Urinary tract infections (UTI) are often a complaint in the homeopathic practice, mainly as uncomplicated infections in the form of a one time event. Some patients, however, have a tendency to develop recurrent or complicated urinary tract infections. Methods It is shown on the basis of case documentation that UTI should be treated homeopathic, variably. The issue of prophylaxis will be discussed. Results If there is a tendency to complicated UTI, chronic treatment after case taking of the symptom-totality of the affected must take place during a free interval. In contrast, the chronically recurring and flaming up of UTI, as well as the uniquely occurring of uncomplicated UTI, are handled as an acute illness. The treatment is based on the striking, characteristic symptoms of the infected. Conclusion The homeopathic treatment of UTI in the acute case of uncomplicated forms is usually very successful, The chronic treatment of complicated UTI shows certain difficulties. A safe homeopathic prophylaxis, in terms of conventional medicine, is problematical.

The homeopathic clinic of the Municipal Public Servant Hospital of São Paulo (HSPM – Brazil) has among patient records some cases of thyroid gland diseases (hypothyroidism or hyperthyroidism), which were treated whith the systemic homeopathic method of Carillo. This study evaluates patients with diseases of thyroid gland, analyzing improvements using a Iodium-like equalizer, adjacent to the systemic medication. The reviewed 21 cases using Iodium equalizer for the disease, adjacent to the systemic medication, in the homeopathic clinic of the HSPM, from 2000 to 2013. In four cases, it was possible to reduce the dose of allopathic medicine and finally terminate it due to normalization of the thyroid gland function. There was one case of hyperthyroidism and it was possible to terminate the use of methimazole. There were four cases, in which the function of the thyroid gland was normalized without the associated use of hormone. In three cases it was possible to reduce the dose of hormone. There were nine cases, in which it was not possible to reduce the dose of the hormone. In cases where there was an improvement applying homeopathic treatment, TSH and free T4 returned to the normal reference value. In cases that were not effective, TSH and free T4 had not normalized. Therefore, the effectiveness of Iodium depends on the ability and stability of the gland thyroid to increase or decrease hormone production, in addition to the treatment of a chronic disease, that affects the thyroid gland.

Cystitis composes infections in the urinary system, especially bladder and urethra. It has multiple causes, but the most common is infection due to microorganisms such as E. coli, streptococcus, staphylococcus etc. If the system is attacked by pathogenetic agents, the defense must include more powerful noxious agents which can fight and destroy the attacking organisms, here is the role of nosodes. Nosodes are the potentised remedies made up from dangerous noxious materials. The use of nosodes in cystitis is based on the aphorism 26– Therapeutic Law of Nature: A weaker one is always distinguished by the stronger one! Colibacillinum, streptococcinum, staphylococcinum, lyssinum, medorrhinum, psorinum and tuberculinum are useful in handling cystitis relating to the organism involved [as found in urine test] and symptom similarity. Method An observational prospective study on a group of 30 people proves the immediate, stronger defensive action of nosodes. Result Amazing! Nosodes given in low potency provided instant relief to patients. Repetition of the same, over several months offered immunity for further attacks of cystitis, as Hering had already testified nosodes have prophylactic action. Conclusion According to law of similia – as per the pathology, as per the defense! By inducing a strong artificial disease, homeopathy can eliminate the natural disease from the body. Usually nosodes are used as intercurrent drugs which play the role of catalysts, on the journey to recovery, but they are also very effective in cystitis as an acute remedy. Acute cystitis is a very troublesome state for the patients, to cure it homeopathy has an arsenal of nosodes.

In 1991, no antiretroviral therapy (ART) treatment was available. The Central Council for Research in Homeopathy had established a clinical research unit at Mumbai for undertaking investigations in HIV/AIDS. So far 2502 cases have been enrolled for homeopathic treatment and three studies have been published since then. In this paper we will highlight the impact of long term homeopathic management of cases, which have been followed up for more than 15 years. Method The HIV positive cases enrolled in different studies are continuously being managed in this unit and even after study conclusion. All the cases are being treated solely with individualised homeopathy. The cases are assessed clinically (body weight, opportunistic infections, etc.) as well as in respect to CD4 counts and CD4/CD8 ratio. Results The CD4 count was maintained in all patients, except in one case. Three patients had the CD4 level in the range of 500–1200, four in the range of 300–500, one had a 272 CD4 count. There has been a decline of CD4/ CD8 ratio since baseline, but the patients have maintained their body weights and remained free from major HIV related illnesses and opportunistic infections. The frequently indicated remedies were pulsatilla pratensis, lycopodium clavatum, nux vomica,tuberculinum bovinum, natrum muriaticum, rhus toxicodendron, medorrhinum, arsenicum album, mercurius solubilis, thuja occidentalis, nitic acid, sulphur, bryonia alba and hepar sulph. Conclusion In the emergent scenario of drug resistance and adverse reactions of ART in HIV infections, there may be a possibility of employing homeopathy as an adjuvant therapy to existing standard ART treatment. Further studies are desirable.

In the last 20 years we have treated in the Clinica St. Croce many patients with cancer. We often deal with palliative states and we aim at pain relief and improvement of life-quality, and if possible a prolongation of life. Is this possible by prescribing a homeopathic therapy? Methodology The exact application and the knowledge of the responses to the Q-potencies often give indications for the correct choice of remedy. Acute conditions of pain often need a more frequent repetition of the C-potencies needed for pain relief. Results Even with severe pain or in so-called final stages homeopathy can offer great assistance. On the basis of case reports from Clinica St. Croce, the procedure for the homeopathic treatment of cancer, and the treatment of pain and final states will be illustrated and clarified. In addition, some clinically proven homeopathic remedies will be presented for the optimal palliation in the treatment of end-states and accompanying the dying. Conclusions With the precise application and knowledge of the responses to the Q- and C-potencies, the homeopathic doctor is given a wonderful helper to treat even the most serious palliative states and can accomplish, sometimes, a miraculous healing.

MY BRIEF COMMENT

These abstracts are truly hilarious and show how totally unaware some homeopaths are of the scientific method. I say ‘some’, but perhaps it is most or even all? How can a scientific committee reviewing these abstracts let them pass and allow the material to be presented at the ‘World Congress’? How can a Health Secretary accept the patronage of such a farce?

These abstracts are therefore not just hilarious but also truly depressing. If we had needed proof that homeopathy has no place in real healthcare of today, these abstracts would go a long way in providing it. To realise that politicians, physicians, patients, consumers, journalists etc. take such infantile nonsense seriously is not just depressing but at the same time worrying, I find.

The fact that some alternative medicine (the authors use the abbreviation ‘CAM’) practitioners recommend against vaccination is well-known and often-documented. Specifically implicated are:

As a result, children consulting homeopaths, naturopaths or chiropractors are less likely to receive vaccines and more likely to get vaccine-preventable diseases. These effects have been noted for several childhood infections but little is known about how child CAM-usage affects influenza vaccination.

A new nationally representative study fills this gap; it analysed ∼9000 children from the Child Complementary and Alternative Medicine File of the 2012 National Health Interview Survey. Adjusting for health services use factors, it examined influenza vaccination odds by ever using major CAM domains: (1) alternative medical systems (AMS; eg, acupuncture); (2) biologically-based therapies, excluding multivitamins/multi-minerals (eg, herbal supplements); (3) multi-vitamins/multi-minerals; (4) manipulative and body-based therapies (MBBT; eg, chiropractic manipulation); and (5) mind-body therapies (eg, yoga).

Influenza vaccination uptake was lower among children ever (versus never) using AMS (33% vs 43%; P = .008) or MBBT (35% vs 43%; P = .002) but higher by using multivitamins/multiminerals (45% vs 39%; P < .001). In multivariate analyses, multivitamin/multimineral use lost significance, but children ever (versus never) using any AMS or MBBT had lower uptake (respective odds ratios: 0.61 [95% confidence interval: 0.44-0.85]; and 0.74 [0.58-0.94]).

The authors concluded that children who have ever used certain CAM domains that may require contact with vaccine-hesitant CAM practitioners are vulnerable to lower annual uptake of influenza vaccination. Opportunity exists for US public health, policy, and medical professionals to improve child health by better engaging parents of children using particular domains of CAM and CAM practitioners advising them.

There is hardly any need to point out that CAM-use is associated with low vaccination-uptake. We have discussed this on my blog ad nauseam – see for instance here, here, here and here. Too many CAM practitioners have an irrational view of vaccinations and advise against their patients against them. Anyone who needs more information might find it right here by searching this blog. Anyone claiming that this is all my exaggeration might look at these papers, for instance, which have nothing to do with me (there are plenty more for those who are willing to conduct a Medline search):

  • Lehrke P, Nuebling M, Hofmann F, Stoessel U. Attitudes of homeopathic physicians towards vaccination. Vaccine. 2001;19:4859–4864. doi: 10.1016/S0264-410X(01)00180-3. [PubMed]
  • Halper J, Berger LR. Naturopaths and childhood immunizations: Heterodoxy among the unorthodox. Pediatrics. 1981;68:407–410. [PubMed]
  • Colley F, Haas M. Attitudes on immunization: A survey of American chiropractors. Journal of Manipulative and Physiological Therapeutics. 1994;17:584–590. [PubMed]

One could, of course, argue about the value of influenza vaccination for kids, but the more important point is that CAM practitioners tend to be against ANY immunisation. And the even bigger point is that many of them issue advice that is against conventional treatments of proven efficacy.

In a previous post I asked the question ‘Alternative medicine for kids: when is it child-abuse?’ I think that evidence like the one reported here renders this question all the more acute.

A recent post discussed a ‘STATE OF THE ART REVIEW’ from the BMJ. When I wrote it, I did not know that there was more to come. It seems that the BMJ is planning an entire series on the state of the art of BS! The new paper certainly looks like it:

Headaches, including primary headaches such as migraine and tension-type headache, are a common clinical problem. Complementary and integrative medicine (CIM), formerly known as complementary and alternative medicine (CAM), uses evidence informed modalities to assist in the health and healing of patients. CIM commonly includes the use of nutrition, movement practices, manual therapy, traditional Chinese medicine, and mind-body strategies. This review summarizes the literature on the use of CIM for primary headache and is based on five meta-analyses, seven systematic reviews, and 34 randomized controlled trials (RCTs). The overall quality of the evidence for CIM in headache management is generally low and occasionally moderate. Available evidence suggests that traditional Chinese medicine including acupuncture, massage, yoga, biofeedback, and meditation have a positive effect on migraine and tension headaches. Spinal manipulation, chiropractic care, some supplements and botanicals, diet alteration, and hydrotherapy may also be beneficial in migraine headache. CIM has not been studied or it is not effective for cluster headache. Further research is needed to determine the most effective role for CIM in patients with headache.

My BS-detector struggled with the following statements:

  • integrative medicine (CIM), formerly known as complementary and alternative medicine (CAM) – the fact that CIM is a nonsensical new term has been already mentioned in the previous post;
  • evidence informed modalities – another new term! evidence-BASED would be too much? because it would require using standards that do not apply to CIM? double standards promoted by the BMJ, what next?
  • CIM commonly includes the use of nutrition – yes, so does any healthcare or indeed life!
  • the overall quality of the evidence for CIM in headache management is generally low and occasionally moderate – in this case, no conclusions should be drawn from it (see below);
  • evidence suggests that traditional Chinese medicine including acupuncture, massage, yoga, biofeedback, and meditation have a positive effect on migraine and tension headaches – no, it doesn’t (see above)!
  • further research is needed to determine the most effective role for CIM in patients with headache – this sentence does not even make the slightest sense to me; have the reviewers of this article been asleep?

And this is just the abstract!

The full text provides enough BS to fertilise many acres of farmland!

Moreover, the article is badly researched, cherry-picked, poorly constructed, devoid of critical input, and poorly written. Is there anything good about it? You tell me – I did not find much!

My BS-detector finally broke when we came to the conclusions:

The use of CIM therapies has the potential to empower patients and help them take an active role in their care. Many CIM modalities, including mind-body therapies, are both self selected and self administered after an education period. This, coupled with patients’ increased desire to incorporate integrative medicine, should prompt healthcare providers to consider and discuss its inclusion in the overall management strategy. Low to moderate quality evidence exists for the effectiveness of some CIM therapies in the management of primary headache. The evidence for and use of CIM is continuously changing so healthcare professionals should direct their patients to reliable and updated resources, such as NCCIH.

WHAT IS HAPPENING TO THE BMJ?

IT USED TO BE A GOOD JOURNAL!

The website of BMJ Clinical Evidence seems to be popular with fans of alternative medicine (FAMs). That sounds like good news: it’s an excellent source, and one can learn a lot about EBM when studying it. But there is a problem: FAMs don’t seem to really study it (alternatively they do not have the power of comprehension to understand the data); they merely pounce on this figure and cite it endlessly:

They interpret it to mean that only 11% of what conventional clinicians do is based on sound evidence. This is water on their mills, because now they feel able to claim:

THE MAJORITY OF WHAT CONVENTIONAL CLINICIANS DO IS NOT EVIDENCE-BASED. SO, WHY DO SO-CALLED RATIONAL THINKERS EXPECT ALTERNATIVE THERAPIES TO BE EVIDENCE-BASED? IF WE NEEDED PROOF THAT THEY ARE HYPOCRITES, HERE IT IS!!!

The question is: are these FAMs correct?

The answer is: no!

They are merely using a logical fallacy (tu quoque); what is worse, they use it based on misunderstanding the actual data summarised in the above figure.

Let’s look at this in a little more detail.

The first thing we need to understand the methodologies used by ‘Clinical Evidence’ and what the different categories in the graph mean. Here is the explanation:


So, arguably the top three categories amounting to 42% signify some evidential support (if we decided to be more rigorous and merely included the two top categories, we would still arrive at 35%). This is not great, but we must remember two things here:

  • EBM is fairly new;
  • lots of people are working hard to improve the evidence base of medicine so that, in future, these figures will be better (by contrast, in alternative medicine, no similar progress is noticeable).

The second thing that strikes me is that, in alternative medicine, these figures would surely be much, much worse. I am not aware of reliable estimates, but I guess that the percentages might be one dimension smaller.

The third thing to mention is that the figures do not cover the entire spectrum of treatments available today but are based on ~ 3000 selected therapies. It is unclear how they were chosen, presumably the choice is pragmatic and based on the information available. If an up-to date systematic review has been published and provided the necessary information, the therapy was included. This means that the figures include not just mainstream but also plenty of alternative treatments (to the best of my knowledge ‘Clinical Evidence’ makes no distinction between the two). It is thus nonsensical to claim that the data highlight the weakness of the evidence in conventional medicine. It is even possible that the figures would be better, if alternative treatments had been excluded (I estimate that around 2 000 systematic reviews of alternative therapies have been published [I am the author of ~400 of them!]).

The fourth and possibly the most important thing to mention is that the percentage figures in the graph are certainly NOT a reflection of what percentage of treatments used in routine care are based on good evidence. In conventional practice, clinicians would, of course, select where possible those treatments with the best evidence base, while leaving the less well documented ones aside. In other words, they will use the ones in the two top categories much more frequently than those from the other categories.

At this stage, I hear some FAMs say: how does he know that?

Because several studies have been published that investigated this issue in some detail. They have monitored what percentage of interventions used by conventional clinicians in their daily practice are based on good evidence. In 2004, I reviewed these studies; here is the crucial passage from my paper:

“The most conclusive answer comes from a UK survey by Gill et al who retrospectively reviewed 122 consecutive general practice consultations. They found that 81% of the prescribed treatments were based on evidence and 30% were based on randomised controlled trials (RCTs). A similar study conducted in a UK university hospital outpatient department of general medicine arrived at comparable figures; 82% of the interventions were based on evidence, 53% on RCTs. Other relevant data originate from abroad. In Sweden, 84% of internal medicine interventions were based on evidence and 50% on RCTs. In Spain these percentages were 55 and 38%, respectively. Imrie and Ramey pooled a total of 15 studies across all medical disciplines, and found that, on average, 76% of medical treatments are supported by some form of compelling evidence — the lowest was that mentioned above (55%),6 and the highest (97%) was achieved in anaesthesia in Britain. Collectively these data suggest that, in terms of evidence-base, general practice is much better than its reputation.”

My conclusions from all this:

FAMs should study the BMJ Clinical Evidence more thoroughly. If they did, they might comprehend that the claims they tend to make about the data shown there are, in fact, bogus. In addition, they might even learn a thing or two about EBM which might eventually improve the quality of the debate.

The new guidelines by the American College of Physicians entitled ‘Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians’ have already been the subject of the previous post. Today, I want to have a closer look at a small section of these guidelines which, I think, is crucial. It is entitled ‘HARMS OF NONPHARMACOLOGIC THERAPIES’. I have taken the liberty of copying it below:

“Evidence on adverse events from the included RCTs and systematic reviews was limited, and the quality of evidence for all available harms data is low. Harms were poorly reported (if they were reported at all) for most of the interventions.

Low-quality evidence showed no reported harms or serious adverse events associated with tai chi, psychological interventions, multidisciplinary rehabilitation, ultrasound, acupuncture, lumbar support, or traction (9,95,150,170–174). Low-quality evidence showed that when harms were reported for exercise, they were often related to muscle soreness and increased pain, and no serious harms were reported. All reported harms associated with yoga were mild to moderate (119). Low-quality evidence showed that none of the RCTs reported any serious adverse events with massage, although 2 RCTs reported soreness during or after massage therapy (175,176). Adverse events associated with spinal manipulation included muscle soreness or transient increases in pain (134). There were few adverse events reported and no clear differences between MCE and controls. Transcutaneous electrical nerve stimulation was associated with an increased risk for skin site reaction but not serious adverse events (177). Two RCTs (178,179) showed an increased risk for skin flushing with heat compared with no heat or placebo, and no serious adverse events were reported. There were no data on cold therapy. Evidence was insufficient to determine harms of electrical muscle stimulation, LLLT, percutaneous electrical nerve stimulation, interferential therapy, short-wave diathermy, and taping.”

The first thing that strikes me is the brevity of the section. Surely, guidelines of this nature must include a full discussion of the risks of the treatments in question!

The second thing that is noteworthy is the fact that the authors confirm the fact I have been banging on about for years: clinical trials of alternative therapies far too often fail to mention adverse effects.  I have often pointed out that the failure to report adverse effects in clinical trials is an unacceptable violation of medical ethics. By contrast, the guideline authors seem not to feel strongly about this omission.

The third thing that is noteworthy is that the guidelines evaluate the harms of the treatments purely on the basis of the adverse effects reported in the clinical trials and systematic reviews included in their efficacy assessments. This is nonsensical for at least two reasons:

  1. The guideline authors themselves are aware that the trials very often fail to mention adverse effects.
  2. For any assessment of harm, one has to go far beyond the evidence of clinical trials, because trials tend to be too small to pick up rare adverse effects, and because they are always conducted under optimally controlled conditions where adverse effects are less likely to occur than in real life.

Together, these features of the assessment of harms explain why the guideline authors arrive at conclusions which are oddly misguided; I would even feel that they resemble a white-wash. Here are two of the most overt misjudgements:

  • no harms associated with acupuncture,
  • only trivial harm associated with spinal manipulations.

The best evidence we have today shows that acupuncture leads to mild adverse effects in about 10% of all cases and is also associated with very severe complications (e.g. pneumothorax, cardiac tamponade, infections, deaths) in an unknown number of patients. More details can be found for instance here, here, here and here.

And the best evidence available shows that spinal manipulation leads to moderately severe adverse effects in ~50% of all cases. In addition, we know of hundreds of cases of very severe complications resulting in stroke, permanent neurological deficits or deaths. More details can be found for instance here, here, here and here.

In the introduction, I stated that this small section of the guidelines is crucial.

Why?

The reason is simple: any responsible therapeutic decision has to be based not just on the efficacy of the treatment in question but on its risk/benefit balance. The evidence shows that the risks of some alternative therapies can be considerable, a fact that is almost totally neglected in the guidelines. Therefore, the recommendations of the new guidelines by the American College of Physicians entitled ‘Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians’ are in several aspects not entirely correct and need to be reconsidered.

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