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

experience

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I have to thank one of our regular commentators for inspiring me to write this post. He recently contributed this insight about homeopathic provings:

If you didn’t experience anything from a proving you didn’t perform it properly.

It is an argument that, in different forms and shapes, I have heard very often. Essentially it holds that, if an investigation or a test fails to produce the desired result, the methodology must have been faulty. Donald Trump is, I fear, about to use it in the upcoming US election: if he is voted out, he will claim that there was too much fraud going on. Therefore, he cannot accept the result as valid. Thus it is his democratic duty to remain in post, he is likely to claim.

In medicine, the argument has been popular since millennia. In our book TRICK OR TREATMENT?, we recount the story of blood letting. Based on the doctrine of the 4 humours, it was believed for centuries to be a panacea. If someone died after losing litres of blood to the believers in the doctrine, the assumption was not that he had been bled to death, but that he had sadly not received enough of the ‘cure all’. Eventually, some bright chap had the novel idea of running a rigorous test of blood-letting, and it turned out that the patients who had received the treatment had a worse chance of survival than those who had escaped it. Aaaahhh !!!, shouted the blood-letters, this shows that the concept of the scientific test is flawed.

Checking the methodological rigour of clinical studies (or homeopathic provings) can be a tricky and tedious business. It requires proper learning and experience – qualities that SCAM fanatics rarely possess. Amongst other things, one needs to know about:

  • trial design,
  • statistics,
  • sources of bias,
  • confounding,
  • and the many tricks people use to hide flaws in published studies.

This is not easy and it takes time – lots of time – to acquire the necessary skills. Having discussed such issues with enthusiasts of so-called alternative medicine (SCAM) for decades, I realise that it would be unrealistic to expect of them to spend all this time learning all these complicated things (they have to make a living, you know!). I therefore propose an entirely new and much simpler method of differentiating between valid and invalid research of SCAM. It rests on merely 2 golden rules:

  1. Any research methodology is valid, if it produces the desired result.
  2. Any research methodology is invalid, if it fails to produce the desired result.

In analogy to these two rules, one can easily extrapolate further. For instance, one can state that:

  • any person who generates or promotes the desired result is honest;
  • any person who contradicts the desired result is corrupt (bought by ‘Big Pharma’).

I am sure my readers all see the beauty of this revolutionary, new system: it’s easy to learn, practical to apply, it avoids controversy and it takes full account of the previously much-neglected needs of the SCAM fraternity.

One of the many issues that needs addressing about chiropractic is its safety. On this blog, we have had dozens of posts and debates on this topic. Today, I want to try and summarise them by providing a fictitious dialogue between a critic and a chiropractor.

Here we go:

Critic (CR): It seems to me that most of the chiros I talk to are convinced that their hallmark therapy, spinal manipulation, is risk-free.

Chiro (CH): Hallmark therapy? Not true! Osteopaths, physios, doctors they all use spinal manipulation.

CR: I know, but name me a profession that employs it more regularly than you chiros.

CH: In any case, it is as good as risk-free; nothing is totally devoid of risk, but chiropractic spinal manipulation (CSMT) is generally very safe, because we are better trained at it than the others.

CR: Do you say that because you believe it or because you know it?

CH: I know it.

CR: That means you have the evidence to prove it?

CH: Yes, of course. Over the years, I have treated over a thousand patients and never heard of any problems.

CR: Without a monitoring system of adverse events that occur after chiropractic spinal manipulation, this is pretty meaningless.

CH: Monitoring systems do not establish causality.

CR: No, but they are a start and can tell you whether there is a problem that requires looking into.

CH: Let me remind you please that the question of safety is foremost an issue for conventional medicine; this is why a monitoring system is useful for drugs. We actually do not need one, because CSMT is safe.

CR: Are you sure?

CH: Yes, V DabbsW J Lauretti have shown this very clearly in their seminal paper comparing drug treatments with chiropractic. 

CR: The much-cited paper by Dabbs and Lauretti is out-dated, poor quality, and heavily biased. It provides no sound basis for an evidence-based judgement on the relative risks of cervical manipulation and NSAIDs. The notion that cervical manipulations are safer than NSAIDs is therefore not based on reliable data. Thus, it is misleading and irresponsible to repeat this claim. Is there not a better comparison for supporting your point?

CH: Not as far as I know. But you can trust our collective experience: CSMT is safe!

CR: Don’t you think that the issue is too important to rely purely on experience? Your collective experience can be very misleading, you know.

CH: Then tell me why chiros pay only a fraction of the insurance premium compared to doctors.

CR: Yes, that is the argument many chiros love. But it also is a very poor one: doctors treat patients who are often very ill, while chiros treat mostly sore backs. Don’t you think that explains a lot about the difference in insurance premiums?

CH: Perhaps, but if you claim CSMT to be harmful, how about you supporting your claim with evidence?

CR: Sure, the best is to review systematically all prospective studies on the topic; and if you do this, the conclusion is that data from prospective studies suggest that minor, transient adverse events occur in approximately half of all patients receiving spinal manipulation. The most common serious adverse events are vertebrobasilar accidents, disk herniation, and cauda equina syndrome. Estimates of the incidence of serious complications range from 1 per 2 million manipulations to 1 per 400,000. Given the popularity of spinal manipulation, its safety requires rigorous investigation.

CH: I bet these are studies done by people who are against chiropractic.

CR: No, actually the primary studies were all done by chiropractors.

CH: Minor transient problems! These are merely what we expect; things often need to get worse before they get better.

CR: Imagine that a drug company claims such BS about the side-effects of a new drug.

CH: But that’s different!

CR: In what way?

CH: Big Pharma is only out to make money.

CR: And chiros?

CH: That’s different too.

CR: What about the serious adverse events like vertebrobasilar accidents, disk herniation, and cauda equina syndrome? Are you going to deny they exist?

CH: Some of those serious complications, while rare, are conditions that existed prior to CSMT being performed with the practitioner missing it upon initial examination.

CR: How do you know?

CH: I know this from experience.

CR: I already told you that experience is unreliable.

CH: Then show me the evidence that I am wrong.

CR: No, you have to come up with the evidence; the burden of proof is evidently on your shoulders.

CH: Whatever! As long as there is no good evidence, I cannot accept that serious complications are a real problem.

CR: That’s just fine: you say “as long as there is no good evidence…” and, at the same time, you prevent good evidence from emerging by preventing a decent AE monitoring system.

CH: I always knew that one cannot have a reasonable discussion with you. I consider that I have won this debate; this issue is now closed.

 

At present, we see a wave of promotion of Traditional Chinese Medicine (TCM) as a treatment of corona-virus infections. In this context, we should perhaps bear in mind that much of the Chinese data seem to be less than reliable. Moreover, I find it important to alert people to a stern warning recently published by two Australian experts. Here is the crucial passage from their paper:

We wish to highlight significant concerns regarding the association between traditional herbal medicines and severe, non-infective interstitial pneumonitis and other aggressive pulmonary syndromes, such as diffuse alveolar haemorrhage and ARDS which have emerged from Chinese and Japanese studies particularly during the period 2017−2019. Initially the association between traditional herbal therapies and pneumonitis was based on isolated case reports. These included hypersensitivity pneumonitis associated with the use of traditional Chinese or Japanese medicines such as Sai-rei-to, Oren-gedoku-to, Seisin-renshi-in and Otsu-ji-to (9 references in supplemental file). Larger cohorts and greater numbers now support this crucial relationship. In a Japanese cohort of 73 patients, pneumonitis development occurred within 3 months of commencing traditional medicine in the majority of patients [], while a large report from the Japanese Ministry of Health, Labor and Welfare, described more than 1000 cases of lung injury secondary to traditional medications, the overwhelming majority of which (852 reports) were described as ‘interstitial lung disease [].

Currently the constituent of traditional herbal medicines which is considered most likely to underlie causation of lung disease is Scutellariae Radix also known as Skullcap or ou-gon, which has been implicated through immunological evidence of hypersensitivity as well as circumstantial evidence, being present in all of those medicines outlined above []. Notably, skullcap is a constituent of QPD as used and described in the paper by Ren et al. relating to COVID-19 []. Scutellariae Radix-induced ARDS and COVID-19 disease share the same characteristic chest CT changes such as ground-glass opacities and airspace consolidation, therefore distinguishing between lung injury due to SARS-CoV-2 and that secondary to TCM may be very challenging. The potential for iatrogenic lung injury with TCM needs to be acknowledged []…

Morbidity and mortality from COVID-19 are almost entirely related to lung pathology []. Factors which impose a burden on lung function such as chronic lung disease and smoking are associated with increased risk for a poor outcome. Severe COVID-19 may be associated with a hypersensitivity pneumonitis component responsive to corticosteroid therapy []. Against this background the use of agents with little or no evidence of clinical efficacy and which have been significantly implicated in causing interstitial pneumonitis that could complicate SARS-CoV-2 infection, should be considered with extreme caution.

In conclusion, the benefits of TCM in the treatment of COVID-19 remain unproven and may be potentially deleterious. We recognise that there is currently insufficient evidence to prove the role of TCM in the causation of interstitial pneumonitis, however the circumstantial data is powerful and it would seem prudent to avoid these therapies in patients with known or suspected SARS-CoV-2 infection, until the evidence supports their use.

Declaration of Competing Interest: There are no conflicts to declare.

I have discovered ‘Google Scholar’!

Yes, of course, I knew about it, but I never used it much. In particular, I did not know it has a huge page just on me. So I had a good look at it (who would be able to resist?) and found many things of interest – for instance, the fact that (as of yesterday) my papers have been cited a total of 86 759 times, and that 4 of them have been cited more that a thousand times.

Here they are:

Interactions between herbal medicines and prescribed drugs AA Izzo, E Ernst

Drugs 61 (15), 2163-2175
1517* 2001
Fibrinogen as a cardiovascular risk factor: a meta-analysis and review of the literature

E Ernst, KL Resch
Annals of internal medicine 118 (12), 956-963
1491 1993
Influence of context effects on health outcomes: a systematic review

Z Di Blasi, E Harkness, E Ernst, A Georgiou, J Kleijnen
The Lancet 357 (9258), 757-762
1458 2001
The prevalence of complementary/alternative medicine in cancer: a systematic review

E Ernst
Cancer: Interdisciplinary International Journal of the American Cancer …
1124 1998

Two things are perhaps noteworthy here, I feel:

  1. Only 2 of the 4 papers are on research in so-called alternative medicine (SCAM).
  2. In the 4th paper, they forgot to add Barrie Cassileth who was its co-author.

Scanning my own articles, the real revelation was how much I owe to others, how many co-workers I have had, how many of them I had completely forgotten about, and how many have already gone forever.

So, allow me to take this opportunity to honour those who have passed away (in the order they appear on the page).

  • ARPAD MATRAI was a brilliant scientist, Olympic swimmer for Hungary, and close friend. He came to London in 1980 to work in my lab. After I had left, I attracted him to Munich where we had several hugely productive years together – until he died of leukaemia in 1988.
  • JOHN DORMANDY see here.
  • VERONIKA FIALKA was my senior registrar in Vienna and became a good friend. After I had left Vienna, she took over my position as head of the department. We then somehow lost contact and, one day, I received the sad news of her early death.
  • NASSIM KANJI was my PhD student at Exeter. She did very well, and we published several papers on autogenic training together.
  • PETER FISHER see here.
  • GEORGE LEWITH see here.
  • CHRIS SILAGY was a brilliant GP and researcher. We did not have much contact except for one paper we had together.
  • JOHN GARROW see here.
  • ANDREW HERXHEIMER see here.
  • WALLACE SAMPSON was a famous and brilliant US sceptic. We had various contacts and shared one paper.
  • P T FLUTE was head of haematology at St George’s Hospital, London while I worked there. I remember him as kind and supportive.

I owe more gratitude to these (and all my other) co-authors than I will ever be able to express.

 

In the wake of both the NEJM and the LANCET withdrawing two potentially influential papers due unanswered questions about the source and reliability of the data, one has to ask how good or bad the process of peer review is.

Peer review is the evaluation of work by one or more people with similar competences as the producers of the work (peers). It functions as a form of self-regulation by qualified members of a profession within the relevant field. It normally involves multiple steps:

  1. Authors send their manuscript to a journal of their choice for publication.
  2. The journal editor has a look at it and decides whether to reject it straight away (for instance, because the subject area is not of interest) or whether to send it out to referees for examination (often to experts suggested by the authors of the submission).
  3. The referees (usually 2 or 3) have the opportunity to reject or accept the invitation to review the submission.
  4. If they accept, they review the paper and send their report to the editor (usually following a deadline).
  5. The editor tries to come to a decision about publication; often the referees are not in agreement, and a further referee has to be recruited.
  6. Even if the submission is potentially publishable, the referees will have raised several points that need addressing. In such cases, the editor sends the submission back to the original authors asking them to revise the article.
  7. The authors do their revision (often following a deadline) and re-submit their paper.
  8. Now the editor can decide to either publish it or send it back to the referees asking them whether they feel their criticisms have been adequately addressed.
  9. Depending on the referees’ verdicts, the editor makes the final decision and informs all the involved parties accordingly.
  10. If the paper was accepted, it then goes into production.
  11. When this process is finished, the authors receive the proofs for final a check.
  12. Eventually, the paper is published and the readers of the journal may scrutinise it.
  13. Often this prompts comment which may get published.
  14. In this case, the authors of the original paper may get invited to write a reply.
  15. Finally the comments and the reply are published in the journal side by side.

The whole process takes time, sometimes lots of time. I have had papers that took almost two years from submissions to publications. This delay seems tedious and, if the paper is important, unacceptable (if it is not important, it should arguably not be published at all). Equally unacceptable is the fact that referees are expected to do their reviewing for free. The consequence is that many referees do their reviewing less than well.

When I was still at Exeter, I had plenty of opportunity to see the problems of peer review from the reviewers perspective. At a time, I accepted about 5 reviews per week, and in total I surely have reviewed over 1000 papers. I often recommended inviting a statistician to do a specialist review of the stats. Only rarely were such suggestions accepted by the journal editors. Very often I recommended rejecting a submission because it was rubbish, and occasionally, I told the editor that there was a strong suspicion of the paper being fraudulent. The editors very often (I estimate in about 50% of cases) ignored my suggestions and comments and published the papers nonetheless. If the editor did follow my advice to reject a paper, I regularly saw it published elsewhere later (usually in a less well-respected journal). Several times, an author of a submission contacted me directly after seeing my criticism of his paper. Occasionally this resulted in unpleasantness, once or twice even in threats. Eventually I realised that improving the publications in the realm of SCAM was a Sisyphean task, became quite disenchanted with all this and accepted less and less reviews. Today, I do only very few.

I had even more opportunity to see the peer review process from the author’s perspective. All authors must have suffered from unfair or incompetent reviews and most will have experienced the frustrations of the endless delays. Once (before my time in alternative medicine) a reviewer rejected my paper and soon after published results that were uncannily similar to mine. In alternative medicine, researchers tend to be rather emotional about their subject. Imagine, for instance, the review you might get from Dana Ullmann of a trial of homeopathy that fails to show what he believes in.

Finally, since 40 years, I have also had the displeasure of experiencing peer review as an editor. This often seemed like trying to sail between the devil and the deep blue sea. Editors want to fill their journals with the best science they can find. But all too often, they receive the worst science they can imagine. They are constantly torn by tensions pulling them in opposite directions. And they have to cope not just with poor quality submissions but also with reviewers who miss deadlines and do their work badly.

So, peer review is fraught with problems! The trouble is that there are few solutions that would keep a better check on the reliability of science. Peer review, it often seemed to me, is the worst idea, except for all others. If peer review is to survive (and I think it probably will), there are a few things that could, from my point of view, be done to improve it:

  1. Make it much more attractive for the referees. Payment would be the obvious thing – and by Jove, the big journals like the LANCET and NEJM could afford it. But recognising refereeing academically would be even more important. At present, academic careers depend largely of publications; if they also depended on reviewing, experts would queue up to do it.
  2. The reports of the referees should get independently evaluated according to sensible criteria. These data could be conflated an published as a criterion of academic standing. Referees who fail to to a good job would spoil their chances to get re-invited for this task.
  3. Speed up the entire process. Waiting months on months is hugely counter-productive for all concerned.
  4. Today many journals ask authors for the details of experts who are potential reviewers of their submission and then send the paper in question to them for review. I find this ridiculous! No author I know of has ever resisted the temptation to name people who are friends or owe a favour. Journals should afford the extra work to find who the best independent experts on any particular subject are.

None of this is simple or fool-proof or even sure to work well, of course. But surely it is worth trying to get peer-review right. The quality of future science depends on it.

Can I invite you to join me in a little thought experiment?

Think of a totally useless therapy. I would suggest homeopathy but there are always some who would disagree with this classification. I need a TOTALLY useless therapy, and one where we ALL can agree on the label.

What about ‘Potentised Toe-Nail Powder’ (PoToNaPo)?

PoToNaPo is made from nail clippings, thoroughly sterilised, ground to a powder, serially diluted and potentised. Does anyone claim this remedy to be effective for any condition?

No?

Splendid!

So, we all agree that PoToNaPo is completely ineffective.

Now imagine some charlatan claiming that PoToNaPo is a highly effective cancer cure. Let’s furthermore imagine that he is very successful with his claim.

(No, this is not far fetched! Think of Laetrile, Essiac, etc.)

Imagine our charlatan makes millions with PoToNaPo.

There would soon be some opposition to his quackery. The FDA would issue a statement that PoToNaPo is unproven. Perhaps the NEJM would publish an editorial saying something similar. Ethicists would frown publicly. And many sceptics would head to the pubs where clever guys would give talks about ‘the scandal of PoToNaPo’.

We all know it would happen, because it has happened with PoToNaPo-like remedies many times before.

______________

Now imagine a different scenario, namely one in which our charlatan does not claim that PoToNaPo is a cancer cure; imagine instead he had claimed that PoToNaPo is a holistic medicine that boosts your well-being via re-balancing your vital energies which, in turn, helps with anxiety which in turn might have positive effects on things like mild chronic pain, depressive mood, tension headache, insomnia, erectile dysfunction and many more symptoms of daily life.

Let’s furthermore imagine that our charlatan is very successful with these claims.

No, this is not far fetched! Think of … well … think of any SCAM really.

Imagine the charlatan makes millions with PoToNaPo.

What would happen?

  • He would be invited to conferences on integrative medicine.
  • Become an honorary member/sponsor of the ‘College of Medicine and Integrated Health’.
  • He would be interviewed on the BBC.
  • The Daily Mail would publish advertorials.
  • HRH would perhaps invite him for tea.
  • Trump might hint that PoToNaPo cures virus infections.
  • Ainsworth might buy his patent.
  • There could even be a gong waiting for him.
  • And yes … some sceptics would mutter a bit, but the public would respond: what’s the harm?

We all know that things of this nature might happen, because they have happened before with PoToNaPo-like remedies.

__________________

So what’s the difference?

In both scenarios, our charlatan has marketed the same bogus remedy, PoToNaPo.

In both scenarios, he has made unsubstantiated, even fraudulent claims.

Why does he get plenty of stick in the 1st and becomes a hero in the 2nd case?

Yes, I know, the difference is the nature of the claims. But the invention, production, marketing and selling of a bogus treatment, the lying, the deceit, the fraud, the exploitation of vulnerable people are all the same.

Why then are we, as a society, so much kinder to the charlatan in the 2nd scenario?

I think we shouldn’t be; it’s not logical or consequent. I feel we should name, shame and punish both types of charlatans. They are both dangerous quacks, and it is our ethical duty to stop them.

END OF THOUGHT EXPERIMENT

 

Hard to believe but apparently true: it has been reported that the state government of Kerala distributed homeopathic medicines to people across the state as ‘immunity boosters’. A total of 4.5 million samples have already been distributed.

Map

No, these reports were not dated 1 April!

They are only two days old.

Dr. B Vijayakumar, a member of the State level expert group of the Indian Homoeopathic Medical Association (IHMA’s) revealed that homoeopathy has had a long history in treating and preventing epidemics ever since its inception including those such as Dengue, Chikungunya, Chickenpox and Typhoid. “Its effectiveness in the management of viral diseases has proved beyond doubt many a time. Homeopathy, being one of the most sought after the alternative system of medicine all over the world.”

VK Prasanth, MLA who has been the former mayor of Thiruvananthapuram was the first to launch the distribution of homeopathic medicine in his constituency. “The centre has recognised the homoeopathy medicine to boost the immunity and thereby work as a preventive. When I associated with it, first I was criticised, but now the medicine is in high demand across the state.” said Prasanth.

The Indian Homoeopathic Medical Association (IHMA) is part of the Kerala Government’s RAECH (Rapid Action Epidemic Control Cell, Homoeopathy) programme which officially looks after all the epidemic activities in Kerala.

The government of Kerala even has a ‘Department of Homeopathy. Its stated vision is:

  • Permanent establishment of Homoeopathic Health care facility to all Panchayaths in our state.
  • To open more specialities OP’S in vulnerable locations like coastal belt, tribal areas, metros etc. And Speciality IP’s In our district Hospitals.
  • To extent elaborate laboratory facilities in our district hospitals.
  • To formulate Research & Development wing in Department of Homoeopathy.
  • Computerization of all Dispensaries.
  • As per the Central Govt. Decision and Direction by Supreme Court primary Health care in the periphery i.e. Panchayats shall be designed in such a way that all the three systems i.e. Homoeopathy, Allopathy and Ayurveda Should come under one roof.

We have, of course, discussed the track record of homeopathy in epidemics before on this blog. It is simply not true that the evidence is convincing. It is also not true that homeopathy has ever been shown to boost any parameter indicative of the immune response. It is finally also untrue that there is good evidence that any homeopathic remedy is an effective treatment of any viral infection (or any other condition).

Guest post by Christian Lehmann

It’s the end of February. We see the first death, in the Oise department, near Paris, of a French citizen who has not recently travelled abroad. For doctors concerned about what is happening in China, this is the red alert. In spite of of the little notices posted by the health minister, Agnes Buzyn, at airports, the coronavirus has made it onto French soil. Nobody knows at that point how it will spread. Almost nobody, apart from those responsible for it, yet knows that France has completely run down its stocks of masks. Doctors themselves do know that the health service has only held out, for as long as it has, on the backs of its care personnel. Some are assessing the scale of what is to come.

The announcement by Didier Raoult about the spectacular effectiveness of a synthetic antimalarial, chloroquine, has brought enormous relief, followed immediately for many of us health professionals by growing doubts about an accumulation of errors: Raoult denies any toxicity, urges people to “fall upon” a medication requiring sensitive handling. When we locate the Chinese article on which Didier Raoult is basing his crisis communication, we are stupefied. No need for specialised knowledge in statistical methodology to understand that there is something seriously wrong. No numerical data. Nobody knows what dosage has been given, to what type of patient, nor how many have been treated. The article has not been “peer reviewed”, that is to say reviewed by professional equals; decoded, it has the effect of a simple announcement. So of course at this chaotic time we tell ourselves that, given a revelation of such importance, the Chinese wanted to act as quickly as possible, to inform the whole world. And Didier Raoult, who routinely advises, as he explains with delicious modesty, the Chinese, « the world’s best virologists », has probably been entitled to the first fruits of this revelation.

On Youtube, on 28 February, he posts a weird interview, “Why would the Chinese be mistaken?”, in which he repeatedly takes up his interviewer with obvious irritation. “No, that’s not the question that you should be asking me. You should be asking me….” An informal group of doctors and tweeters pass around the link. We are rubbing our eyes in disbelief. What Didier Raoult is passing off as an interview is nothing more then an audience accorded to one of his media aides. We advise him, sarcastically, to make a professional cut of the video before broadcasting it. An hour later the video disappears and returns in a more professional form which could create the illusion of a genuine interview. And rapidly, in the Press which is beginning to turn its microphones towards the Professor from Marseille, he modifies his stance, without ever acknowledging the radical changes.

Chloroquine, spectacular and miraculous only yesterday, disappears as if by magic, replaced from one day to the next by hydroxychloroquine (Plaquenil), a different medicine, less common. Though its chemical structure is close to that of the antimalarial medication, hydroxychloroquine is used primarily in rheumatic conditions such as rheumatoid polyarthritis, or immune conditions such as lupus. So at least it isn’t lying around in large quantities in medicine cabinets. And its cardiac toxicity, very real, is slightly lower then that of chloroquine. Didier Raoult puts forward HCQ as an immense discovery, continuing in his usual manner to ridicule his detractors. “The doctors who criticise me are neither in my field nor up to my weight”. He flays the inaction of embittered petty health officials, only fit to follow the diktats of the authorities, who, bogged down in their catastrophic crisis management, dare not intervene. And his posturing as a refractory Gaul, a loudmouth taking on the system, gains sympathy, from those to whom he gives hope, from those who understand that the State does not tell them everything, and from those looking for a hero to fit in with their stereotypes: the man on his own against the establishment, the White Knight taking on Big Pharma, the Hippocratic colossus besieged by hordes of soulless ants.

No one among those who hold out their microphones to him, not one asks him the question which we are all asking, GPs, cardiologists, pharmaceutical specialists, emergency specialists, resuscitation specialists – by what sleight of hand has Didier Raoult exchanged his miracle medicine, in 48 hours, openly and publicly? And how is it that no one has noticed the sleight-of-hand? Has this man who makes such a big deal of his image on social networks suddenly become aware of the risk of being confronted about chloroquine with a justifiable public outcry and with deaths by self-medication?

While the World Health Organisation is sounding alarm bells, in the context of overall mistrust with regard to scientific opinion, of confrontation with regard to government, of growing awareness ( belated and sometimes disproportionate) of the influence of Big Pharma, and as the initial fear gives way to real panic for some with the registration of each new case, Didier Raoult piles up Facebook likes, fans, sites to his glory. And for us, fearful, begins the long registration of flagrant mistruths delivered as revealed truths, which this professor will never have the honestly to set right.

For Didier Raoult, a minimum of intellectual integrity would demand that he admits having changed horses in midstream. That he admits that the concern of his despised detractors was well founded, with respect to chloroquine to which many have access without knowing its dangers ( Nivaquine is very often used in suicides). And, because Didier Raoult withdraws nothing, he continues to stash away all the profits of his media coverage. Every supporter of the Wise Man of Marseille piles in with testimony. Their brother, sister, uncle, the father-in-law of their hairdresser has been taking the Professor’s medicine ( Which one? ) for eight years in Africa and has never had a problem, so that’s the real proof that his detractors are just jealous, or, even worse, backed by “the lobbies”.

And untiringly we repeat the fundamental truths:

  • Yes chloroquine has existed for years
  • Yes it is widely used
  • But for a different treatment, the prevention of malaria
  • And in dosages 5 to 10 times smaller
  • And in large dosages it causes cardiac arrest
  • And it has never been effective in fighting a virus
  • Not this virus nor any other
  • And the same is true for hydroxychloroquine
  • In fact it’s rather the opposite

In fact what is being patiently stated by the upholders of the scientific method is very counter-intuitive, almost inaudible, because they are telling worried and disorientated people, who have put their trust and their hope in one man, that in his assertions………nothing makes sense.

These are exceptional times and they need exceptional measures. Therefore, I am yet again deviating from my policy of focussing exclusively on SCAM and welcome my French colleague Dr Lehmann posting a series of articles on the hydroxychloroquine story.

Guest post by Christian Lehmann

 

THE ELEPHANT IN THE ROOM

This pandemic diary was begun just before lock down, already four weeks ago, and yet I have scarcely touched on the elephant in the room. Our personal elephant is called Didier Raoult. White-haired with age, venerable in appearance, he has been number one in the press, constantly in capitals in online news headlines, waking hopes, feeding passions. And arousing the interest of a plethora of epidemiologists of renown, from Valerie Boyer to Donald Trump, by way of Alain Soral and Alexandre Benalla.

Everything begins on 25 February 2020, when the microbiology professor from Marseille posts his famous video “Coronavirus, game over”, since more modestly re-baptised “Coronavirus, towards a way out of the crisis?”.

Standing in front of a student audience out of camera, Didier Raoult reveals “a last-minute scoop, a very important piece of news”: the Chinese, whom he regularly advises, rather than seeking a vaccine or new products have been “repositioning”, trying old molecules, “known, old, without toxicity,” among them chloroquine, which has shown itself to be effective in a daily dose of 500 mg per day “with a spectacular improvement and it is recommended for all clinically positive cases of coronavirus. This is excellent news, it is probably the easiest respiratory infection of all to treat” Here, the whole roomful laughs, with pleasure, with relief, and I remember sharing these sentiments, briefly, but completely. Because this was 26th of February, because like others I felt confusedly that the reassurances with which Agnes Buzyn ( then the French Health Minister) was inundating us were built on sand, and that the virus would only laugh at little notices in airports.

I knew Didier Raoult only by name, as a columnist in Point, I had read some of his articles and I had felt simultaneously soothed by his smooth eloquence, attracted by some of his iconoclastic stances, but also sometimes rather irritated by his Mandarin-style fake cool posturing. At the end of February, I immediately reposted the video in the medical forums, on the walls of worried friends, explaining that, if the suggestions of Didier Raoult were confirmed, we would have escaped with a scare which would soon be dispelled by this “magic bullet”, this “game changer”.

Then between two consultations in my GP’s office, later that afternoon, I watched that video “Game Over” again. How could such an important piece of news have reached me by means of a Youtube video? Where were the overseas publications, the much vaunted Chinese study, the releases from AgenceFrancePresse, Reuters, the first articles from the New York Times and the Guardian, proclaiming from the rooftops that the pandemic we had so much feared was in fact only a technical hitch, easily controllable by a widely available drug. It was at that second viewing that I balked. As a GP who had worked in cardiac resuscitation some years ago, I was brought up short by hearing Didier Raoult talking up a medicine “well known, and devoid of any toxicity”. If chloroquine or Nivaquine, to give it its commercial name, is celebrated for the prevention of malaria, it is also a medicine known for its frightening toxicity as soon as the dose is exceeded, with the risk of irreversible visual damage and extremely serious problems with cardiac rhythm which can prove fatal. To say that chloroquine is without toxicity problems is in fact an error, all the more so because the dose suggested by “the Chinese”, without an iota of proof at this stage, is five times larger than the customary dose, 500 mg instead of 100 mg.

Deeply uneasy, I’m in discussion with doctor friends on Twitter when the video makes its appearance there. We know nothing at this point about Didier Raoult’s past, or about his Marseille Institute. Neither the enmity felt towards him by the Parisian intelligentsia represented by Agnes Buzyn and her husband, nor the fact that his institute has just lost its INSERM and CNRS accreditations, nor the stance adopted by him a month earlier explaining that coronavirus would never escape from China and that it was ridiculous to get worked up about it because “the world has gone mad, something or other happens and three Chinese die and that brings about a world-scale alert”.

Some of us, practitioners and first responders, knew well the toxicity of chloroquine, that it was to be handled with care, and that was about all we said on Twitter. It was already too much. The next day in a 20 minute interview Didier Raoult brushed away his detractors. “Malicious gossip, I don’t give a damn about it. When a medication has been shown to work on 100 people while all the world is busy having a nervous breakdown, and there’s some idiots who say there’s no certainty that it works, I’m not interested! It would honestly be medical misconduct not to use chloroquine to treat Chinese coronavirus”. And he drives the point home. “People who have lived in Africa like me took chloroquine every day. Everybody who went to hot countries took it throughout their time there, and for two months after they came home. Billions of people have taken this medication. And it costs nothing: ten centimes per pill. It is a medication which is extremely reliable and it’s the cheapest imaginable. So this is super amazing news. Everybody who learns about these benefits should fall upon it.” This is no longer a mistake, this is grave medical misconduct. Nobody who knows about therapeutics would use such words so lightly.

Cardiologists, resuscitation specialists, emergency doctors, GPs, public-health specialists, we are all alarmed. Our first warnings are vehement and rational, reaffirming the toxicity of chloroquine in cardiology, and the majority of us insisting on the senseless and significant risk which Didier Raoult is running. Because it is familiar, prescribed for long stays in Africa in packages of 100 tablets, chloroquine is lying around in many medicine cabinets. To declare as a fact that we should “fall upon it” in this agonising pandemic context is to encourage unrestrained self medication, and to endanger life. Incoherent, dangerous, this announcement disturbs us deeply. Incredulous, not for a moment do we imagine just what Didier Raoult will unleash, nor that the nightmare had already begun.

 

I have known for a long time that homeopathy can be dangerous, not least through the neglect of effective treatments for seriously ill patients. But I did not know that it can cause a bone fracture – until yesterday, that is.

Yes, you have understood me correctly! Here is the first case-report of a homeopathy-induced bone fracture:

My sister in law has two charming elderly ladies as neighbours. They are now in their 90ies and have, over the years, become very frail. She therefore has taken to looking after them where she can. Since the two sisters rarely leave their home these days, they have developed a new hobby: ordering things they find attractive through the post; it seems to be their greatest pleasure and has frequently led to complications that could easily fill a book of short stories.

Recently, an advertisement caught they eyes. It proclaimed in no uncertain terms that, even at their advanced age, they could re-gain some strength and energy through a specific homeopathic remedy (Boiron, I suspect, but I cannot be sure). This, of course, sounded far too good to not give it a try, and the two sisters promptly ordered what seemed to the the answer to their prayers.

The little package arrived yesterday, and the excitement must have been palpable. The more impatient of the two sisters insisted to try the wonder drug straight away. With her hands shaking in anticipation, she opened the tiny vial of globuli. Overwhelmed by trepidation, she spilled the entire content of globuli on the floor.

‘That’s bad but not disastrous’, she thought. Trying to pick them up, she stepped on some of them. As our frail hero weighs not even 50kg, the globuli acted like the ball-bearings or a pair of roller-skates. Her feet flew off, she lost her balance and landed abruptly and painfully on her side under the kitchen table covered by a table lamp and a chair.

The second sister rushed to help but proved to be too frail to get the patient back on her feet. This is when my sister in law was phoned and, ignoring the current lock-down, arrived with her husband to the rescue. What they saw was a scene of utter devastation: Globuli everywhere, their elderly neighbour moaning on the floor covered with various items she has tried to hold on to when attempting to prevent the fall. Together they managed to get the patient back up, but soon realised that she was badly injured. An ambulance was called and in the local hospital an X-ray confirmed the diagnosis: rib fracture.

I am glad to say, the old lady – my best wishes to her and her sister! – is now back home and recovering well. Little does she know that she is about to enter the history books of medicine as the first ever documented case of ‘homeopathy-induced rib fracture’.

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