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

evidence

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By guest blogger Ken Harvey

Loretta Marron was the catalyst. The ‘critical thinking’ bug hit her as a child, reinforced by a BSc in Physics. If something didn’t sound logical, she couldn’t let it go. She had to check. She killed many a party by disputing misinformation – with evidence.

TV advertisements for magnetic underlays got her going, then homeopathic remedies, followed by ‘natural’ cures for cancer. To investigate outlandish claims and submit complaints, she needed to consult with experts. These included Professors John Dwyer (Medicine and Immunology) and Alastair MacLennan (Obstetrics and Gynaecology). They were always willing to help.

They also had concerns about universities teaching pseudoscience, such as ‘subluxation theory’ in chiropractic and ‘meridians’ in Traditional Chinese Medicine.

In late 2011, Professor Dwyer proposed that Loretta join forces with Professors Alastair MacLennan, Marcello Costa (neuroscientist), and Rob Morrison (science communicator) to form a new organisation promoting scientific evidence in health care. Friends of Science in Medicine (FSM) was born. John Dwyer was the inaugural President and Loretta Marron Chief Executive Officer (CEO).

The aim was to emphasise the importance of basing Australian health care on scientifically sound research and established scientific knowledge published in peer-reviewed journals of accepted standing. Valuing scientific rigour is especially important in an age where unsubstantiated health claims are rampant and scientific consensus is ‘imbalanced’ by the views of extremists.

FSM’s focus is helping consumers and health professionals to make more informed choices about medical interventions, medicines, and medical devices. We do this by submitting complaints about unethical practice, analysing policy, making submissions, encouraging regulators to act, and being a credible source of expertise for the media and others. We also encourage tertiary institutions and medicine and health sciences students to critically appraise therapeutic products and services as part of the courses offered.

Currently, FSM has more than 1,200 leading scientists, clinicians, lawyers, and consumer advocates as supporters. We also work closely with organisations such as Australian Skeptics and Choice (Australian Consumers Association).

I took over as President from John Dwyer in 2019. Loretta remains FSM CEO. The founding members continue their involvement as consultants. Ten years on, it’s worth reflecting on what has been achieved and the ongoing challenges.

An appendix lists some of the areas in which FSM has been involved and the outcomes achieved (often with the help of others).

Unethical promotion of therapeutic goods and services remain an ongoing concern. The advertising of therapeutic goods is subject to provisions in the Therapeutic Goods Advertising Code, first promulgated in 1999. Until July 2018, complaints about alleged Code violations were heard by the Therapeutic Goods Advertising Complaints Resolution Panel (CRP), thereafter by the Therapeutic Goods Administration (TGA).

FSM members submitted numerous complaints to the CRP and analysed the outcome. If a complaint was upheld, the CRP could only ‘recommend’ that it be removed. If it was not, the complaint was referred to the TGA for action. We found that certain companies consistently ignored the determinations of the CRP and, when referred to the TGA, took resulting action.

In July 2018, FSM engagement with numerous consultations and reviews eventually resulted in the TGA taking over the advertising complaint system. The TGA was given stronger investigative and compliance powers and a revised, legally enforceable advertising code. However, given the TGA’s previous track record, we continued to submit complaints, including many previously upheld by the CRP, but for which promotion continued.

An analysis of the first 12 months of the new system found that the TGA had classified most complaints as ‘low priority’. These were either ignored or closed by sending the advertiser a ‘Regulatory Obligation letter’ which stated that no further action would be taken. While the letter sometimes worked, often it did not. Stronger compliance powers were rarely used. The new complaint system was also less transparent than the one it replaced. For those low priority complaints with published outcomes, no details of the product, advertiser, or alleged Code violation were published, and no follow-up was recorded. Of 121 higher priority complaints, 79% failed to meet their key performance indicator, time to closure in 60–90 days. These included complaints about dangerous sports supplements and ineffective weight loss and hangover products.

In August 2020, an independent review of the first two years of the TGA’s compliant system was published. The study noted an unexpectedly high volume of complaints since the TGA took over the advertising complaints system, producing a large and growing backlog. A government-appointed consultant (ThinkPlace Pty Ltd) stated that providing more resources would not be in the public interest. Instead, they recommended a more cost-effective and efficient approach: amalgamating all complaints into an information database from which the TGA could consider compliance priorities.

As a result, complaints were closed by sending complainants a letter stating that their complaints will be used for ‘intelligence’ to set priorities. The TGA said risk assessment informed whether a complaint was converted into a case for investigation or stored in their information database to determine future compliance priorities. Therapeutic goods associated with COVID-19 were declared ‘priority 1’, while weight loss, hangover, and four other products groups were said to be ‘priority 2’.

A focus on COVID-19 stimulated the TGA to deal with some of these complaints more effectively. However, apart from token action on individual products, no systemic action was taken on weight loss, hangover products and many other objects of our complaints.

More recently, the TGA’s complaint database for 2018 -2020 has been removed and replaced by a new database containing only a few complaints pre-2021. In addition, the fields of many ‘products’ and ‘responsible person’, are missing. The TGA say that migration of data to the new system is continuing. Meanwhile, complainants now only receive an automated acknowledgment.

Transparency remains a problem as there is no clear indication of how many complaints the TGA receives, what they are about, how many are filed for ‘intelligence’’, how many are actioned, and what outcome eventuates.

Given this lamentable state of affairs, in association with Australian Skeptics, it is proposed to publish reports on all complaints submitted to the TGA in 2022 and their outcomes. Past experience shows that documenting problems, pointing out underlying issues and putting forward solutions can produce progress. But patience and persistence are required.

FSM has grappled with unethical advertising of pseudo-medical interventions. Controls differ for practitioners regulated by the Australian Health Practitioner Regulation Agency (AHPRA) and those regulated by State and Territory Health Complaints Commissioners. The former includes medical practitioners, pharmacists, nurses, chiropractors, osteopaths, and Traditional Chinese Medicine practitioners. The latter includes naturopaths, homeopaths, and practitioners of western herbal medicine.

FSM has held regular meetings with AHPRA senior managers. We have also met several of their national boards and attended stakeholder forums. Chiropractic was an initial focus. Many practitioners advertised that chiropractic care in pregnancy could shorten labour duration and prevent caesarean delivery – despite the absence of evidence. Pregnant women were warned that labour often resulted in the newborn babe’s spinal misalignment, which could lead to numerous problems unless put right by regular chiropractic adjustments. It was also claimed that chiropractic ‘adjustments’ could improve attention deficit hyperactivity disorder, infantile colic, and ear infection.

In 2015, FSM submitted hundreds of complaints to AHPRA, alleging that chiropractic websites were in breach of both s.133 of the Health Practitioner Regulation National Law Act 2009 and the Chiropractic Board of Australia’s Guidelines for advertising regulated health services. These provisions prohibit advertising which is false, misleading, or deceptive, creates an unreasonable expectation of beneficial treatment, or can encourage the indiscriminate or unnecessary use of health services.

Five years have passed since the Chiropractic Board first asked practitioners to ensure that their websites met legal advertising requirements. Over this time, the Board’s sole approach to this problem was educational. Although chiropractors consistently had the highest advertising complaints of all practitioners (38 per 1,000 chiropractors in 2013–14), no penalties nor disciplinary action had been applied for advertising offences.

FSM argued that repeated advertising offences required appropriate penalties. We also pointed out that some practitioners now invited patients to consult them about services they were no longer permitted to advertise. We said that limitations should be placed on chiropractic practice which lacked evidence.

AHPRA responded that, although it could act on misleading advertising, it had no power to restrict the scope of practice of chiropractors (or other registered practitioners). We said that, if lack of good evidence makes it illegal to publicly advertise a treatment, then it should be equally illegal to offer it to patients privately; after all, the real harm is caused by the treatment, not the advertising.

In 2019, following damning publicity and further representations, the Victorian Health Minister eventually instructed Safer Care Victoria (SCV) to undertake an independent review of the practice of chiropractic spinal manipulation on children under 12 years. The result was a recommendation that spinal manipulation should not be provided to children under 12 years of age, for general wellness or for the management of conditions such as hyperactivity disorders, infantile colic, or ear infections.

The Chiropractic Board has also stated that chiropractors are not trained to apply any direct treatment to an unborn child and should not deliver any treatment to the unborn child. Neither should they provide materials, information or advice that is anti-vaccination in nature. After numerous complaints from FSM members, the Chiropractic Board finally referred a prominent anti-vax chiropractor, Simon Floreani, to the Victorian Civil and Administrative Tribunal (VCAT). His registration was suspended for 6 months, and conditions placed on his re-registration.

FSM has not just been concerned about chiropractors. We have complained (with varied success) about medical practitioners promoting stem cell therapy for multiple sclerosis, Traditional Chinese Medical practitioners claiming that acupuncture can treat infertility and dubious laboratory tests used in complementary and alternative medicine.

In conclusion, the peddling of unproven and sometimes dangerous remedies has existed throughout human history.

There will always be companies (and individuals) who put the pursuit of profit before ethical behaviour. There will always be advocates for de-regulation and regulators captured by industry. To protect consumers there must be opposing forces. That is the role that FSM is proud to play, along with colleagues from the sceptical community and consumer movements.

Appendix

FSM activities and outcomes (often in association with others), 2011-2021.

  1. Removal of extravagant claims for acupuncture from the World Health Organization website and instigation of a WHO evidence review.
  2. Involvement in the 2015 Review of the Australian Government Rebate on Private Health Insurance for Natural Therapies. This led to removal of cover for therapies that lacked evidence such as homeopathy, iridology, reflexology and naturopathy (currently being reviewed again to see if additional evidence exits).
  3. Removal of unproven/disproven courses or modules from Australian universities.
  4. Removal of continuing professional development (CPD) points required annually by relevant registered practitioners for a number of AltMed courses.
  5. Following complaints to the TGA, removal of some illegal medicines not on the Australian Register of Therapeutic Goods (ARTG).
  6. De-listing some complementary medicines and medical devices (such as ‘bio-resonance’ machines) lacking evidence.
  7. Getting the TGA to declare two products of self-declared ‘Foods for special medical purposes’ illegal therapeutic goods and have them removed from the market-place.
  8. Publishing academic articles, in peer-reviewed journals, documenting regulatory problems investigated and solutions suggested.
  9. Publishing articles in lay media on current problems including in The Conversation, MJA Insight and Pearls and Irritations (around 200 over the last 5 years).
  10. Responding to consultation requests from the TGA, Medical Boards, National Medicines Policy Review, and others.
  11. Achieving the suspension of anti-vax chiropractor Simon Floreani’s registration.
  12. Stimulating the Chiropractic Board to publish standards on pregnancy and paediatric care.
  13. Responsible for the setting up of AHPRA’s ‘Advertising Compliance’ section, including their pilot auditing system (yet to report).
  14. Responding to requests for information from journalists.
  15. Correction of misinformation from the Victorian government’s ‘Better Health’ Channel.
  16. Providing a complaints avenue for people who want to remain anonymous.

Dr. Mehmet Oz is one of the most influential promoters of outright quackery. I once (many years ago) met him at a meeting where we both were lecturing. My impression was that he does not believe a single word he speaks. Oz later became a TV star and had ample occasion to confirm my suspicion.

Oz’s wife, Lisa, is a Reiki master and has spoken widely of her insights into energy and health. Mehmet Oz appeared as a health expert on The Oprah Winfrey Show. In 2009, Winfrey offered to produce a syndicated series. The Dr. Oz Show debuted in September 2009 and became the most successful promotion of charlatanery in the US. During a Senate hearing on consumer protection in 2014, Senator Claire McCaskill stated that “the scientific community is almost monolithic against you” for airing segments on weight loss products that are later cited in advertisements, concluding that Oz plays a role, intentional or not, in perpetuating these scams, and that she is “concerned that you are melding medical advice, news, and entertainment in a way that harms consumers.” This judgement was supported by a 2014 analysis published in the BMJ; here is the abstract:

Objective To determine the quality of health recommendations and claims made on popular medical talk shows.

Design Prospective observational study.

Setting Mainstream television media.

Sources Internationally syndicated medical television talk shows that air daily (The Dr Oz Show and The Doctors).

Interventions Investigators randomly selected 40 episodes of each of The Dr Oz Show and The Doctors from early 2013 and identified and evaluated all recommendations made on each program. A group of experienced evidence reviewers independently searched for, and evaluated as a team, evidence to support 80 randomly selected recommendations from each show.

Main outcomes measures Percentage of recommendations that are supported by evidence as determined by a team of experienced evidence reviewers. Secondary outcomes included topics discussed, the number of recommendations made on the shows, and the types and details of recommendations that were made.

Results We could find at least a case study or better evidence to support 54% (95% confidence interval 47% to 62%) of the 160 recommendations (80 from each show). For recommendations in The Dr Oz Show, evidence supported 46%, contradicted 15%, and was not found for 39%. For recommendations in The Doctors, evidence supported 63%, contradicted 14%, and was not found for 24%. Believable or somewhat believable evidence supported 33% of the recommendations on The Dr Oz Show and 53% on The Doctors. On average, The Dr Oz Show had 12 recommendations per episode and The Doctors 11. The most common recommendation category on The Dr Oz Show was dietary advice (39%) and on The Doctors was to consult a healthcare provider (18%). A specific benefit was described for 43% and 41% of the recommendations made on the shows respectively. The magnitude of benefit was described for 17% of the recommendations on The Dr Oz Show and 11% on The Doctors. Disclosure of potential conflicts of interest accompanied 0.4% of recommendations.

Conclusions Recommendations made on medical talk shows often lack adequate information on specific benefits or the magnitude of the effects of these benefits. Approximately half of the recommendations have either no evidence or are contradicted by the best available evidence. Potential conflicts of interest are rarely addressed. The public should be skeptical about recommendations made on medical talk shows.

During the presidential campaign in 2016, Oz supported Trump and hosted him on his TV show. In 2018, Donald Trump appointed him to the President’s Council on Sports, Fitness, and Nutrition, Oz was criticized as an example of choosing “pundits over experts”. Recently, Oz announced he intends to run for the U.S. Senate as a Republican.

A fellow physician commented that he has the same amount of enthusiasm for Oz’s candidacy as he would with a case of dysentery, the intestinal infection that causes bloody diarrhea. Dr. Daniel Summers, MD, begged Pennsylvania not to elect Oz. “It’s been obvious for years that Oz is more than happy to leverage his reputation as a cardiothoracic surgeon and medical scientist in service to his own celebrity and advancement, and isn’t one to let quaint little things like facts stand in his way,” he wrote. “Stroll down a checkout aisle in your local grocery store, and chances are strong you’ll see his smiling face on the cover of a magazine touting some wildly unhealthy weight-loss claim. He’s been promoting pseudoscience on his show for years, from obesity ‘remedies’ like green coffee and garcinia cambogia to hawking ‘homeopathy starter kits,’ so this is nothing new.” Oz faced criticism for hosting a show in which he debated the utility of “reparative therapy” and “forms of therapy that are designed to turn a gay person straight,” even though they’ve been banned by many states at the urging of the American Psychological Association.

In April 2020, Oz also spurred controversy because he said that children should be sent back into schools despite the fact that the novel coronavirus pandemic had only just begun and there were no vaccines or therapeutics yet available. “I tell you, schools are a very appetizing opportunity,” he said, claiming that resuming classes “may only cost us 2 to 3 percent in terms of total mortality,” according to his “reading” of medical journals. The mistake was so substantial that Oz later provided a kind of half-apology, saying that he “misspoke.”

But what Dr. Summers finds worse is that Oz eagerly pushed treatments like hydroxychloroquine for COVID patients. He even went so far as to push the drug on Fox & Friends. It prompted Dr. Anthony Fauci, a virologist, to explain that the data simply wasn’t clear at the time. “Although there is some suggestion [of effectiveness] with the study that was just mentioned by Dr. Oz . . . I think we’ve got to be careful that we don’t make that majestic leap to assume that this is a knockout drug,” Fauci said at the time. “We still need to do the kinds of studies that definitively prove whether any intervention, not just this one . . . is truly safe and effective.”

“Medical misinformation is literally killing people, and it is unconscionable that anyone who should know better would contribute to it. And Oz most certainly should and does know better,” said Dr. Summers. “It is telling that Oz would see a space for himself in the Republican primary field. The GOP is riddled with prominent figures who undermine the seriousness of the pandemic, refute the importance of getting vaccinated, and denigrate the public health officials tasked with keeping the American people as safe and healthy as possible. Voters for those people are the ones Oz sees himself capable of wooing. That is the base he will need to capture to make his candidacy a success.”

Open-label placebos (OLPs) are placebos without deception in the sense that patients know that they are receiving an inert sugar pill with no activity of its own. Intuitively, we think that such treatments must be ineffective. Yet, there have been several studies that seemed to show otherwise.

The objective of this paper was to systematically review and analyze the effect of OLPs in comparison to no treatment in clinical trials. A systematic literature search was carried out in February 2020. Randomized controlled trials of any medical condition or mental disorder comparing OLPs to no treatment were included. Data extraction and risk of bias rating were independently assessed. 1246 records were screened and 13 studies were included in the systematic review. Eleven trials were eligible for meta-analysis.

These trials assessed the effects of OLPs on

  • back pain,
  • cancer-related fatigue,
  • attention deficit hyperactivity disorder,
  • allergic rhinitis,
  • major depression,
  • irritable bowel syndrome,
  • menopausal hot flushes.

The risk of bias was moderate among all studies.

Click to enlarge.

A significant overall effect (standardized mean difference = 0.72, 95% Cl 0.39–1.05, p < 0.0001, I2 = 76%) of OLP. Thus, OLPs appear to be a promising treatment in different conditions. Yet, the researchers spotted several caveats and discuss them in some detail.

First, we detected hints of a publication bias in the study sample, but the respective test was not significant. The quantitative basis of the meta-analysis is based on a small number of studies, reflecting the early state of research in this field. Moreover, the set of studies showed some heterogeneity. Finally, four studies were rated to have a high risk of bias, and nine to have some concerns.

In order to assess the impact of these high-risk studies we performed an exploratory best-evidence synthesis. We excluded the four studies with a high risk of bias. In this analysis, the heterogeneity could be reduced to a non-critical value and almost all variance in the set of studies could be explained by a sampling error (I2 = 4%). With the exclusion of these four studies the mean effect size was reduced to a more conservative SMD = 0.49.

Regardless of this reduction of the overall effect, the same conclusions about the treatment-effect of OLPs can be drawn, although the lack of robustness means that interpretations require some caution. The decrease of heterogeneity shows that methodological impairments might be responsible for the considerable unexplained variance in our results. We abstained from carrying out a further sensitivity analysis for explaining heterogeneity because of the small number of studies.

This is certainly an interesting subject. And the above findings are certainly counter-intuitive.

My impression is that the effect of OLPs is small and of doubtful value in clinical practice. My prediction is that, as more and better research emerges, it will diminish further, if not vanish totally. I think that there are several reasons for this:

  • The number of trials is still quite small.
  • The studies obviously lack patient blinding.
  • Positive messages can be included alongside open-label placebos.
  • The “time lag bias” is high.

This type of bias means that, due to initial enthusiasm in a new subject, negative results are published with some delay. I have observed this bias repeatedly in the past. A new treatment initially tends to generate nothing but positive results, and only after a while, when the researchers’ euphoria has subsided, more realistic findings emerge.

Conspiracy beliefs are associated with detrimental health attitudes during the coronavirus pandemic. Prior research on these issues was mostly cross-sectional, however, and restricted to attitudes or behavioral intentions. This investigation was designed to examine to what extent conspiracy beliefs predict health behavior and well-being over a longer period of time.

In this multi-wave study on a large (N = 5745) Dutch research panel (weighted to provide nationally representative population estimates), the researchers examined if conspiracy beliefs early in the pandemic (April 2020) would predict a range of concrete health and well-being outcomes eight months later (December 2020).

The results revealed that Covid-19 conspiracy beliefs prospectively predicted a decreased likelihood of getting tested for corona; if tested, an increased likelihood of the test coming out positive; and, an increased likelihood of having violated corona regulations, deteriorated economic outcomes (job loss; reduced income), experiences of social rejection, and decreased overall well-being. Most of these effects generalized to a broader susceptibility to conspiracy theories (i.e. conspiracy mentality).

The authors concluded that conspiracy beliefs are associated with a myriad of negative life outcomes in the long run. Conspiracy beliefs predict how well people have coped with the pandemic over a period of eight months, as reflected in their health behavior, and their economic and social well-being.

These findings tie in with another recent study that investigated whether individual beliefs and personal characteristics differences affect people’s likelihood of contracting COVID-19. In the early months of the pandemic, U.S. participants responded to a variety of individual difference measures as well as questions specific to the pandemic itself. Four months later, 2120 of these participants were asked whether they had contracted COVID-19. Nearly all of the included individual difference measures significantly predicted whether a person reported testing positive for the virus in this four-month period. Additional analyses revealed that all of these relationships were primarily mediated by whether participants held accurate knowledge about COVID-19.

I find it hard not to despair vis a vis such results. Not that they were not to be expected – if you ignore the existence of risk factors exist for heart attacks, it seems plausible that your likelihood of dying of myocardial infarction is increased. What is particularly desolating are two facts:

  • This pandemic seems to have rendered the voices of stupidity and ignorance loud and popular, even fashionable.
  • Those lunatics who adhere to conspiracy beliefs harm not merely themselves but endanger all of us.

I ask myself how we will ever get past this new age of unreason.

This review summarized the available evidence on so-called alternative medicine (SCAM) used with radiotherapy. Systematic literature searches identified studies on the use of SCAM during radiotherapy. Inclusion required the following criteria: the study was interventional, SCAM was for human patients with cancer, and SCAM was administered concurrently with radiotherapy. Data points of interest were collected from included studies. A subset was identified as high-quality using the Jadad scale. Fisher’s exact test was used to assess the association between study results, outcome measured, and type of SCAM.

Overall, 163 articles met inclusion. Of these, 68 (41.7%) were considered high-quality trials. Articles published per year increased over time. Frequently identified therapies were biologically based therapies (47.9%), mind-body therapies (23.3%), and alternative medical systems (13.5%). Within the subset of high-quality trials, 60.0% of studies reported a favorable change with SCAM while 40.0% reported no change. No studies reported an unfavorable change. Commonly assessed outcome types were patient-reported (41.1%) and provider-reported (21.5%). The rate of favorable change did not differ based on the type of SCAM or outcome measured.

The authors concluded that concurrent SCAM may reduce radiotherapy-induced toxicities and improve quality of life, suggesting that physicians should discuss SCAM with patients receiving radiotherapy. This review provides a broad overview of investigations on SCAM use during radiotherapy and can inform how radiation oncologists advise their patients about SCAM.

In my recent book, I have reviewed the somewhat broader issue of SCAM for palliative and supportive care. My conclusions are broadly in agreement with the above review:

… some forms of SCAM—by no means all— benefit cancer patients in multiple ways… four important points:
• The volume of the evidence for SCAM in palliative and supportive cancer care is currently by no means large.
• The primary studies are often methodologically weak and their findings are contradictory.
• Several forms of SCAM have the potential to be useful in palliative and supportive cancer care.
• Therefore, generalisations are problematic, and it is wise to go by the current best evidence …

One particular finding of the new review struck me as intriguing: The rate of favorable change did not differ based on the type of SCAM. Combined with the fact that most studies are less than rigorous and fail to control for non-specific effects, this indicates to me that, in cancer palliation (and perhaps in other areas as well), SCAM works mostly via non-specific effects. In other words, patients feel better not because the treatment per se was effective but because they needed the extra care, attention, and empathy.

If this is true, it carries an important reminder for oncology: cancer patients are very vulnerable and need all the empathy and compassion they can get. Seen from this perspective, the popularity of SCAM would be a criticism of conventional medicine for not providing enough of it.

The complex links between so-called alternative medicine (SCAM) and the pandemic have been a regular subject on this blog. Here is more:

This study investigated if people’s response to the official recommendations during the COVID-19 pandemic is associated with conspiracy beliefs related to COVID-19, a distrust in the sources providing information on COVID-19, and an endorsement of SCAM.

The sample consisted of 1325 Finnish adults who filled out an online survey advertised on Facebook. Structural regression analysis was used to investigate whether:

1) conspiracy beliefs, a distrust in information sources, and endorsement of SCAM predict people’s response to the non-pharmaceutical interventions (NPIs) implemented by the government during the COVID-19 pandemic,

2) conspiracy beliefs, a distrust in information sources, and endorsement of CAM are related to people’s willingness to take a COVID-19 vaccine.

The results indicate that individuals with more conspiracy beliefs and lower trust in information sources were less likely to have a positive response to the NPIs. Individuals with less trust in information sources and more endorsement of SCAM were more unwilling to take a COVID-19 vaccine. Distrust in information sources was the strongest and most consistent predictor in all models. In addition, the analyses revealed that some of the people who respond negatively to the NPIs also have a lower likelihood to take the vaccine. This association was partly related to lower trust in information sources.

The authors concluded that distrusting the establishment to provide accurate information, believing in conspiracy theories, and endorsing treatments and substances that are not part of conventional medicine, are all associated with a more negative response to the official guidelines during COVID-19. How people respond to the guidelines, however, is more strongly and consistently related to the degree of trust they feel in the information sources than to their tendency to hold conspiracy beliefs or endorse CAM. These findings highlight the need for governments and health authorities to create communication strategies that build public trust.

I also believe that these findings highlight the urgent need for improvements in education. In my view, it should start at school and continue into adult life. It should focus on a better understanding of science and – crucially – on the ability to differentiate facts from fiction and conspiracies.

Steiner (Waldorf) schools, like anthroposophical medicine, are the inventions of Rudolf Steiner. His followers have often been associated with rampant anti-vax sentiments. Yet, officially such beliefs are usually denied.

A few days ago, I came across this tweet:

Der Dachverband der anthroposophischen Medizin begrüßt Corona-Impfungen… & distanziert sich von Querdenken und Co. Steiner war selbst gegen Pocken geimpft und ließ impfen. 

As it is in German, allow me to translate it for you:

The umbrella organization of anthroposophical medicine welcomes corona vaccinations… & distances itself from lateral thinking and co. Steiner himself was vaccinated against smallpox and had it vaccinated.

Almost simultaneously, it was reported that, after the Corona outbreak at a Freiburg Steiner school with more than 100 people infected, it is now certain: the certificates presented to the school for exemption from wearing masks were invalid.

During circus performances at the Steiner school in Freiburg, more than 100 people had become infected with the coronavirus in October: among them pupils, teachers, and contact persons. Therefore, the school inspectorate of the Freiburg Regional Council examined the certificates that freed people from the obligation to wear masks at school for health reasons. Heike Spannagel, a spokeswoman for the Freiburg Regional Council, called the results surprising. There were 55 certificates, 52 from pupils and three from teachers – and all of them were invalid. Heike Spannagel added that the school will no longer recognize any of the certificates. Those who cannot present new certificates that are more convincing will therefore have to wear the mask, Spannagel said.

It was noticeable that many certificates came from (far remote) private clinics in Bavaria or Berlin. In addition, a Freiburg doctor had exempted pupils from the obligation to wear a mask with identical justifications. According to the regional council, however, justifications must be individually tailored. In the meantime, the public prosecutor’s office in Freiburg has requested documents from the regional council in order to initiate an investigation.

So, what has been going on?

To me, it looks like the Steiner school was tolerating or even encouraging the use of dodgy certificates. This contrasts somewhat with the tweet cited above. And, in turn, this seems to indicate that proponents of anthroposophy say one thing about COVID and then do something entirely different. This suspicion was strengthened by a tweet that appeared a little while later as a response to the tweet cited above:

Alle Anhänger der Anthroposophie, die ich kenne, sind nicht geimpft. Es ist ja schön, wenn diese Verbände das öffentlich so verkünden. Die Praxis sieht leider anders aus.

Allow me to translate again:

All the followers of anthroposophy that I know are not vaccinated. It is nice when these associations proclaim this publicly. Unfortunately, the practice looks different.

Long-COVID syndrome is a condition that will affect a large proportion of those who survived a COVID-19 infection. According to a recent meta-analysis, it is associated predominantly with poor quality of life, persistent symptoms including fatigue, dyspnea, anosmia, sleep disturbances, and mental health problems.

At present, we are still struggling to understand the exact causes and mechanisms of this condition. Therefore, its optimal treatment is as yet uncertain. Governments around the world have therefore made sizable research funds available to make progress in this area, and research in this area is frantically active.

Regardless of the evidence, practitioners and entrepreneurs of so-called alternative medicine (SCAM) are gearing up to jump on this bandwagon by declaring that their offerings are a solution to this growing problem. Indeed, many of them have already done so. Here are just three sites that I found today which are promoting homeopathy for long COVID:

One hardly needs to mention that homeopathy is not supported by sound evidence in the management of long-Covid (or any other condition for that matter). Neither does one need to stress that homeopaths are just one example, and virtually all other SCAM providers are promoting their services in the absence of evidence.

A recent review of the literature stated this:

Patients with long COVID commonly refer to taking ‘the stack’ or ‘the supplement stack’, which includes high-dose vitamin C and D, niacin (nicotinic acid), quercetin, zinc, selenium, and sometimes also magnesium. Further research is needed to confirm or refute the impact of supplements in long COVID. Examples of noteworthy interactions with supplements include: niacin causing an increased risk of bleeding events when combined with selective serotonin reuptake inhibitors or non-steroidal anti-inflammatory drugs, increased risk of rhabdomyolysis together with statins, and quercetin causing inhibition and induction of various human cytochrome P450 enzymes.

Why then are SCAM providers promoting SCAM for long-COVID?

This is a daft question if there ever was one.

It seems obvious they do it because:

  • they are believers who don’t care about evidence,
  • they are in it for the money,
  • or both.

Some time ago, this homeopath already indicated, that SCAM providers should see COVID as an opportunity: For homeopathy, shunned during its 200 years of existence by conventional medicine, this outbreak is a key opportunity to show potentially the contribution it can make in treating COVID-19 patients. We should perhaps not hold our breath to see the emergence of convincing evidence, but we should be prepared to warn the public of getting exploited by charlatans who disregard both ethics and evidence.

Equine-assisted therapies (EAT) are sometimes used for improving the physical function and the quality of life (QoL) of people (often children) with disabilities through the practice of hippotherapy or therapeutic riding (TR). Yet, the effectiveness for or against these approaches has so far not been well documented.

This review aimed to systematically evaluate and meta-analyze the available data on the potential health benefits of EAT in patients with multiple sclerosis (PwMS).

Four electronic databases (MEDLINE/PubMed, Web of Science, SPORTDiscus, and Scopus) were searched systematically from their inception until June 2021 for randomized controlled trials (RCTs) and comparative studies that provided information regarding the effects of EAT on PwMS. The studies’ methodological quality assessment was performed using the PEDro and the MINORS scales. For the meta-analysis, heterogeneity across studies was quantified using the I2 statistic. Fixed-effect or random-effects models were applied to obtain the pooled results in the case of low (I2 < 30%) or high (I2 > 30%) heterogeneity values, respectively. Standardized mean differences (SMD) and 95% confidence intervals (CIs) were calculated to assess the change in each outcome.

After removing duplicated studies, 234 results were retrieved by the literature search and 11 were eligible for full text search. Finally, 9 studies with a methodological quality ranging from good to low quality met the inclusion criteria. Six of them focused on hippotherapy and 4 of them were included in the quantitative analysis.

In them, a total of 225 PwMS patients were evaluated. Findings from the meta-analysis indicated that this therapy improved static (SMD = 0.42; 95% CI: 0.05, 0.78) but not dynamic balance (SMD = 0.51; 95% CI: -0.04, 1.06), while significant benefits were observed on the patients’ QoL (SMD = 0.37; 95% CI: 0.00, 0.73). Hippotherapy showed effectiveness for reducing self-perceived fatigue (SMD = 0.70; 95% CI: 0.33, 1.07), while TR showed mixed effects on balance and QoL.

The authors concluded that the actual evidence on the effectiveness of EAT in PwMS is mainly limited to hippotherapy. This rehabilitation approach seems to have beneficial effects on static balance, QoL and fatigue, but not directly on gait and dynamic balance. Altogether, the findings suggest that hippotherapy could be incorporated as a complementary therapy when developing comprehensive care plans for PwMS.

These results are further supported by a new study concluding that Hippotherapy improved postural balance, functional mobility, fatigue, and quality of life in people with relapsing-remitting MS. This suggests that hippotherapy may be a useful approach for complementary treatment among people with MS.

EAT is, of course, one of those modalities which are difficult to research. What, for instance, is a good control intervention? And how can one blind the patient? Moreover, EAT is expensive and required lots of resources that are rarely available. Considering these issues, one should perhaps ask whether EAT is sufficiently better than other therapeutic options to justify the cost.

Guest post by Richard Rasker

Last summer, I strolled through my garden, enjoying the abundance of flowers and insects. At the far end, the garden gave way to shrubs and reedy grass and a tiny pond that, contrary to past years, hadn’t dried out completely yet.

And right there, at the water’s edge, is where I stumbled upon IT.

At first I thought the small white object was a twig or something similar, but upon closer inspection it turned out to be a small bone – looking remarkably like a human femur, albeit a bit eroded. So I looked around in the vicinity, to see if I could find any more bones. This was not the case, but what I DID find was even more breathtaking: a slender, 2-inch long gauze-like wing.

Immediately a mind-blowing realization dawned: there are fairies in the back of my garden!

Of course I had to be careful not to get carried away based on this single observation, so I spent the following months painstakingly searching for more corroborating evidence. And what I found was astounding: at least a dozen similar bones and wings, and even a very small tuft of brownish hair. And the bogs and marshes a few miles from my home proved an even richer treasure trove. Of course I also identified remains of numerous dead animals, mostly mice and other small rodents, but the femur-like bones I found were definitely too long for mice.

So I can now safely reveal my findings: fairies do exist after all! This is truly world-shattering!

Now what does this have to do with homeopathy, one may ask? The answer is simple: the gathering of evidence for the viability of homeopathy (and many other alternative modalities) is fully analogous to the way that I found scientific evidence for the existence of fairies:

  • People (scientists or homeopaths) believe that they stumbled upon something special.
  • They almost immediately consider their finding as either a type of revelation, or as something that lends strong support to their prior belief.
  • They then set out to gather more evidence in support of the phenomenon they found, thus affirming their belief.
  • And after a lot of painstaking work, the conclusion is reached that the observed phenomenon indeed exists!

Recently, a commenter on this blog tried to bolster the validity of homeopathy by naming a couple of scientists who did exactly this: they started believing in homeopathy, not because of proper clinical trials with homeopathic medicines, but because of revelation-type experiences, or because of hypotheses and/or observations that appeared to explain and support one important prerequisite of homeopathy, the so-called ‘water memory’.

These scientists come up with all sorts of hypothetical mechanisms how this water memory is supposed to work. Usually, quantum physics is invoked – even though real quantum physicists are unanimous in condemning this as nonsense, because quantum physics doesn’t work the way that homeopaths say it does. Nevertheless, these believers in homeopathy come up with ‘explanations’ that involve entanglement, or ‘coherence domains’, or stable nanostructures in water. And there are still lots of other mechanisms dreamed up by believers in homeopathy that aim to explain the all-important water memory.

First of all, most of these hypotheses are completely bonkers, without any real-world evidence to back up the suggestions and claims made – and none of these scientists have so far succeeded in distinguishing an arbitrary homeopathic dilution from plain water, even though some claim that they can find minute differences for a few very specific substances. Just too bad that these results have not been replicated by other scientists, and that they have not been published in any peer-reviewed scientific journal. And even if these results are legitimate, the effect found is absolutely tiny – just like all other homeopathic research with positive results.

But for the sake of the argument, let’s assume that these findings with regard to water memory are real (although no two researchers agree on even the basics of the purported mechanisms). Does this provide enough evidence to make us accept that homeopathy is a viable system of medicine?

No, of course it doesn’t!

Even if water would retain certain ‘nanostructures’ or ‘coherence domains’ or ‘quantum-entangled particles’, this means just that: that an almost undetectable ‘something’ apparently persists in water. It says NOTHING about how this tiny something can have a huge range of highly specific therapeutic effects, necessitating a hugely intricate structure (of which not a trace has ever been found). It says nothing about how this something finds its way from the water to the specific parts of the body to exert those beneficial effects, or about the way that this something interacts with the organism. It does not tell us why this something only ends up in water if it is shaken, or why this something becomes more potent with higher dilutions, or how this something can pass from homeopathic water to sugar pellets while retaining its very special water-based(!) structure – or why, in spite of this all, literally nobody can distinguish a homeopathic dilution from plain water.

Saying that the existence of water memory proves that homeopathy is real is like saying that the existence of those bones and wings I found proves that fairies exist. It is a totally unwarranted inference, and an excellent example of, in the words of Dr. Harriet Hall, Tooth Fairy science: these people spend lots of time, effort and money doing very serious research into all sorts of mechanisms and effects to explain how homeopathy works, but totally neglect to answer the primary question first: does homeopathy work at all? And even worse: these people think that the tiniest glimmer of an effect supporting their hypothesis immediately proves all of homeopathy right. Which is not so much jumping to conclusions, but making leaps of astronomical proportions that would have made even Neil Armstrong jealous. This is not how science works.

For homeopathy, I think that the primary question is answered pretty definitively: even after 227 years, homeopaths have not succeeded in coming up with even ONE ‘remedy’ that is efficacious beyond a shadow of a doubt. NOT ONE.

And to add insult to injury, nothing in science even remotely supports the very core tenets of homeopathy, the similia principle and the law of infinitesimals. ‘Like’ does NOT ‘cure like’, and higher dilutions most certainly were never found to become more potent medicines – quite the contrary, as is observed on a daily basis literally everywhere.

Most other ancient and traditional forms of medicine have come up with at least some treatments or herbs that turned out to have scientifically proven efficacy and have become part of modern medicine – but not homeopathy. Homeopathy DOES NOT WORK, PERIOD.

(Although, to be fair, homeopathy has given us one important insight with regard to medicine: that for many ailments, simply doing nothing is often the best choice. Because most conditions resolve naturally, without medical intervention.)

On a friendlier note: I do not think that those people who study water memory mechanisms and other similarly elusive effects are useless as scientists. Their painstaking research into things like nanostructures in water may one day produce interesting and useful new scientific insights. But it would benefit them greatly if they would distance themselves from homeopathy and its associated pseudoscience, because that is truly a dead-end street, bringing them nothing but scorn and derision.

And oh, about those bones and wings that I said I found? Those were of course likely from frogs and dragonflies, respectively. Or maybe I was the victim of a prank, or maybe I simply made up the whole story. Believe what you will, but you probably agree with me that almost any explanation one can think of is more likely than the fairy scenario. And this again is analogous to homeopathy: almost any explanation one can think of is more plausible than the explanation that mere shaking and diluting magically transforms water into a highly specific medicine.

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