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

homeopathy

It has been reported that, between 1 January 2018 and 31 May 2018, there have been 587 laboratory confirmed measles cases in England. They were reported in most areas with London (213), the South East (128), West Midlands (81), South West (62), and Yorkshire/Humberside (53). Young people and adults who missed out on MMR vaccine when they were younger and some under-vaccinated communities have been particularly affected.

Public Health England (PHE) local health protection teams are working closely with the NHS and local authorities to raise awareness with health professionals and local communities. Anyone who is not sure if they are fully vaccinated should check with their GP practice who can advise them.

Dr Mary Ramsay, Head of Immunisation at PHE, said:

“The measles outbreaks we are currently seeing in England are linked to ongoing large outbreaks in Europe. The majority of cases we are seeing are in teenagers and young adults who missed out on their MMR vaccine when they were children. Anyone who missed out on their MMR vaccine in the past or are unsure if they had 2 doses should contact their GP practice to catch-up. This serves as an important reminder for parents to take up the offer of MMR vaccination for their children at 1 year of age and as a pre-school booster at 3 years and 4 months of age. We’d also encourage people to ensure they are up to date with their MMR vaccine before travelling to countries with ongoing measles outbreaks. The UK recently achieved WHO measles elimination status and so the overall risk of measles to the UK population is low, however, we will continue to see cases in unimmunised individuals and limited onward spread can occur in communities with low MMR coverage and in age groups with very close mixing.”

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And what has this to do with alternative medicine?

More than meets the eye, I fear.

The low vaccination rates are obviously related to Wakefield’s fraudulent notions of a link between MMR-vaccinations and autism. Such notions were keenly lapped up by the SCAM-community and are still being trumpeted into the ears of parents across the UK. As I have discussed many times, lay-homeopaths are at the forefront of this anti-vaccination campaign. But sadly the phenomenon is not confined to homeopaths nor to the UK; many alternative practitioners across the globe are advising their patients against vaccinations, e. g.:

Considering these facts, I wish Dr Mary Ramsay, Head of Immunisation at PHE, would have had the courage to add to her statement: IT IS HIGH TIME THAT ALTERNATIVE PRACTITIONERS DO MORE THAN A MEEK LIP SERVICE TO THE FACT THAT VACCINATIONS SAVE LIVES.

Is homeopathy effective for specific conditions? The FACULTY OF HOMEOPATHY (FoH, the professional organisation of UK doctor homeopaths) say YES. In support of this bold statement, they cite a total of 35 systematic reviews of homeopathy with a focus on specific clinical areas. “Nine of these 35 reviews presented conclusions that were positive for homeopathy”, they claim. Here they are:

Allergies and upper respiratory tract infections 8,9
Childhood diarrhoea 10
Post-operative ileus 11
Rheumatic diseases 12
Seasonal allergic rhinitis (hay fever) 13–15
Vertigo 16

And here are the references (I took the liberty of adding my comments in blod):

8. Bornhöft G, Wolf U, Ammon K, et al. Effectiveness, safety and cost-effectiveness of homeopathy in general practice – summarized health technology assessment. Forschende Komplementärmedizin, 2006; 13 Suppl 2: 19–29.

This is the infamous ‘Swiss report‘ which, nowadays, only homeopaths take seriously.

9. Bellavite P, Ortolani R, Pontarollo F, et al. Immunology and homeopathy. 4. Clinical studies – Part 1. Evidence-based Complementary and Alternative Medicine: eCAM, 2006; 3: 293–301.

This is not a systematic review as it lacks any critical assessment of the primary data and includes observational studies and even case series.

10. Jacobs J, Jonas WB, Jimenez-Perez M, Crothers D. Homeopathy for childhood diarrhea: combined results and metaanalysis from three randomized, controlled clinical trials. Pediatric Infectious Disease Journal, 2003; 22: 229–234.

This is a meta-analysis by Jennifer Jacobs (who recently featured on this blog) of 3 studies by Jennifer Jacobs; hardly convincing I’d say.

11. Barnes J, Resch K-L, Ernst E. Homeopathy for postoperative ileus? A meta-analysis. Journal of Clinical Gastroenterology, 1997; 25: 628–633.

This is my own paper! It concluded that “several caveats preclude a definitive judgment.”

12. Jonas WB, Linde K, Ramirez G. Homeopathy and rheumatic disease. Rheumatic Disease Clinics of North America, 2000; 26: 117–123.

This is not a systematic review; here is the (unabridged) abstract:

Despite a growing interest in uncovering the basic mechanisms of arthritis, medical treatment remains symptomatic. Current medical treatments do not consistently halt the long-term progression of these diseases, and surgery may still be needed to restore mechanical function in large joints. Patients with rheumatic syndromes often seek alternative therapies, with homeopathy being one of the most frequent. Homeopathy is one of the most frequently used complementary therapies worldwide.

Proper systematic reviews fail to show that homeopathy is an effective treatment for rheumatic conditions (see for instance here and here).

13. Wiesenauer M, Lüdtke R. A meta-analysis of the homeopathic treatment of pollinosis with Galphimia glauca. Forschende Komplementärmedizin und Klassische Naturheilkunde, 1996; 3: 230–236.

This is a meta-analysis by Wiesenauer of trials conducted by Wiesenauer.

My own, more recent analysis of these data arrived at a considerably less favourable conclusion: “… three of the four currently available placebo-controlled RCTs of homeopathic Galphimia glauca (GG) suggest this therapy is an effective symptomatic treatment for hay fever. There are, however, important caveats. Most essentially, independent replication would be required before GG can be considered for the routine treatment of hay fever. (Focus on Alternative and Complementary Therapies September 2011 16(3))

14. Taylor MA, Reilly D, Llewellyn-Jones RH, et al. Randomised controlled trials of homoeopathy versus placebo in perennial allergic rhinitis with overview of four trial series. British Medical Journal, 2000; 321: 471–476.

This is a meta-analysis by David Reilly of 4 RCTs which were all conducted by David Reilly. This attracted heavy criticism; see here and here, for instance.

15. Bellavite P, Ortolani R, Pontarollo F, et al. Immunology and homeopathy. 4. Clinical studies – Part 2. Evidence-based Complementary and Alternative Medicine: eCAM, 2006; 3: 397–409.

This is not a systematic review as it lacks any critical assessment of the primary data and includes observational studies and even case series.

16. Schneider B, Klein P, Weiser M. Treatment of vertigo with a homeopathic complex remedy compared with usual treatments: a meta-analysis of clinical trials. Arzneimittelforschung, 2005; 55: 23–29.

This is a meta-analysis of 2 (!) RCTs and 2 observational studies of ‘Vertigoheel’, a preparation which is not a homeopathic but a homotoxicologic remedy (it does not follow the ‘like cures like’ assumption of homeopathy) . Moreover, this product contains pharmacologically active substances (and nobody doubts that active substances can have effects).

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So, positive evidence from 9 systematic reviews in 6 specific clinical areas?

I let you answer this question.

The ‘Pharmaceutical Journal’ just published a ‘pro/contra’ piece discussing whether UK community pharmacists should be selling homeopathic remedies to the public. Here are the essential parts of both arguments:

PRO

… I do not believe there is good scientific evidence to validate homeopathic remedies as medicines, but it is important to provide patients with choice in an informed environment — pharmacists and pharmacy teams are able to provide this expertise.

It is better for the public to buy these products from a reputable source where the community pharmacist — the expert on medicines — can provide professional advice, which is not available from unregulated online suppliers or other non-healthcare outlets…

So, I’m not here to argue the science: I argue that some people can benefit from homeopathy.

We ought to explore homeopathy’s placebo effect. Placebos are often dismissed as fakes, but they seem to act on the same brain pathways that are targeted by ‘real’ treatments. I wonder whether, through the placebo effect, homeopathy has a role to play in mental health treatment and pain relief. Whether for anxiety, mild-to-moderate depression, sleeplessness or stress, taking a little white tablet may benefit the patient, have fewer side effects than conventional medication, cause no harm, and is better than an excess of alcohol or illegal drugs.

Of course, homeopathy should not replace conventional medicines, and people should continue to be vaccinated, should use their inhalers and take their insulin. Homeopathy should not be funded on the NHS, but we do not live in a nanny state.

The clinical efficacy of many other products sold in the pharmacy is also questionable, but we still provide them. One example is guaifenesin for chesty coughs, which, at over-the-counter strength, provides a suboptimal dose. Many people are sceptical of the benefits of vitamin and mineral supplements. Bach flower remedies claim to tackle stress. We drink herbal tea for its ‘health’ benefits or buy fortified cereals because they are ‘better for you’, but these benefits are not clinically proven.

If the public finds comfort in a complementary therapy — whether it is acupuncture, reflexology, vitamins or homeopathy — I am happy to offer that choice, as long as the chosen therapies do no harm, and people continue to take their prescribed medicines.

If the patient wants my professional advice, I will explain that homeopathic medicines are not clinically proven but they may help certain conditions. I will probably recommend a different product, but at least I am there to do so.

You will not find a pharmacist in a health shop or on the internet, but in the community pharmacy you will find a highly qualified medicines expert, who will advise and inform, and who truly cares about the public’s health.

 

CONTRA

… given pharmacy’s heavy promotion of homeopathy, I feared that the profession was in danger of losing science as its bedrock.

… in 2009, a London-based pharmacy was supplying homeopathic ‘swine flu formula’. This was a dangerous practice but government agencies failed to regulate it effectively or to close it down.

In 2010, the then professional standards director at Boots, Paul Bennett (now chief executive, Royal Pharmaceutical Society), appeared before the Science and Technology Committee in its discussion of homeopathy’s availability on the NHS. Bennett stood by the sale of homeopathic remedies in Boots’ stores: “It is about consumer choice for us,” he said. I disagree with this argument.

Like the sale of cigarettes in US pharmacies, homeopathy threatens to fatally damage the reputation of community pharmacy. Pharmacies that sell homeopathic remedies give them unjustified credibility. Informed patient choice should be king; if pharmacists, pharmacy staff and shelf-barkers fail to clearly inform customers that homeopathic remedies are no more effective than placebo, we have acted unethically.

Yet Boots, perhaps alarmed by the number of subsequent protests against homeopathy outside its stores, got the message. Its website now reflects a more scientific approach: the homeopathic remedies it supplies state that they are “without approved therapeutic indications”. Boots also seems to have modified its range and offering of homeopathic remedies. So there is hope for community pharmacy.

Homeopathic remedies are still sold in pharmacies only because they make a profit. Sales in pharmacy are nonsense because, as most homeopathic practitioners claim, it is not possible to sell homeopathic remedies in isolation of a homeopathic consultation. The consultation determines the remedy. Off-the-shelf homeopathy is a relatively recent phenomenon.

The remedies are no more effective compared with placebo, anyway. Systematic reviews from the Cochrane Library — the gold standard of medical science — have considered homeopathy in the treatment of dementia, asthma and attention deficit hyperactivity disorder, all of which have confirmed the placebo effect. Irritatingly, supporters of homeopathy will always, in any debate, quote a bunkum study that shows some possible efficacy. Some might argue that placebo, or suggestion, is effective therapy, so why not use it? We must question the ethics of this approach.

Pharmacists act immorally when they sell the products without making clients aware that homeopathy does not work.

… I find that most pharmacists, when asked, appreciate that homeopathy has no scientific basis and provides merely a placebo effect. I sincerely hope that with this insight, pharmacy will finally clear its shelves of this expensive hocus pocus for good.

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I find both pieces quite weak and poorly argued. In fact, the ‘pro’ – arguments are quite laughable and could easily be used for teaching students the meaning and use of logical fallacies. In my view, all that needs to be pointed out here is this:

  1. Homeopathy is based on implausible assumptions.
  2. Despite 200 years of research and around 500 clinical trials, there is still no proof that highly diluted homeopathic remedies have effects beyond placebo.
  3. Therefore, selling them to the naïve public, while pretending they are real medicines, is dishonest, arguably fraudulent and certainly not the behaviour one would expect of a healthcare professional.
  4. Pharmacists who nevertheless sell these remedies as medicines are in breach of their very own regulations.

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Strangely enough, when trying to find the relevant passage from the code of ethics for UK pharmacists, I struggled. The General Pharmaceutical Council’s ‘Standards fro Pharmacy Professionals‘ merely states this:

People receive safe and effective care when pharmacy professionals reflect on the application of their knowledge and skills and keep them up-to-date, including using evidence in their decision making. A pharmacy professional’s knowledge and skills must develop over the course of their career to reflect the changing nature of healthcare, the population they provide care to and the roles they carry out. There are a number of ways to meet this standard and below are examples of the attitudes and behaviours expected.

People receive safe and effective care when pharmacy professionals:

  • recognise and work within the limits of their knowledge and skills, and refer to others when needed
  • use their skills and knowledge, including up-to-date evidence, to deliver care and improve the quality of care they provide
  • carry out a range of continuing professional development (CPD) activities relevant to their practice
  • record their development activities to demonstrate that their knowledge and skills are up to date
  • use a variety of methods to regularly monitor and reflect on their practice, skills and knowledge

This, I admit, is not as clear as I had hoped (if my memory serves me right, this used to be much more explicit; in case anyone knows of a more suitable section in the code of ethics, please let me know); but it does preclude selling placebos, while pretending they are effective medicines.

I have been alerted to this website; it is truly remarkable! Here is but one example, the section with advice on ‘reducing the risk of vaccine damage’:

START OF QUOTE

1. Give vitamin A before the measles vaccine (MMR).Vitamin A has been shown to reduce death in measles sufferers by 50% so will support the body in its dealing with the measles vaccine. The WHO is now giving out Vitamin A pills along with the vaccine! Consider high doses (5,000 IU or more) the day before, on the day and the day after vaccination.

2. Give increased vitamin C before and after all vaccines. Vitamin C is known to help eliminate heavy metals. Consider high doses (3,000-5,000 mg per day) the day before, day of, and day after.

3. Consider detox programs after vaccination. These include homeopathy (before and after each vaccination), supplements, especially vitamin C, probiotics etc. It can take up to a year to detox the system but it is worth the investment (Autistic children are usually highly toxic – See Treating Autism).

4. Reconsider the routine use of Calpol or similar before or after vaccination. A rise in body temperature is the immune systems healthy response to any attack. Suppressing this reaction will impair its’ ability to deal with the load imposed upon it by the vaccine. Links have been made with the use of Calpol etc after the MMR and autism because the body needs to raise a high temperature to deal with measles. Complications can arise if temperature is bought down too early in cases of measles. See ‘Dealing with Fever Naturally’ under the Health section of this site.

5. Avoid antibiotic use where possible.

Delay vaccines, especially the MMR, within up to 6 months of antibiotics.

The strength of the gut is compromised and the gut is 70% of the immune system. Autistic children often have Gut and Bowel disorders. Antibiotics during pregnancy & breast feeding can also compromise the child’s immune system.

Try not to use antibiotics, as there are links with increased asthma in the vaccinated and also with the overuse of antibiotics in children. Asthma kills 1,300 people a year in the UK and rates have doubled in the last 40 years. This is far higher than the mortality rates as a result of contracting contagious diseases before the vaccines! In the years leading up to the vaccination program between 30-50 people died of measles, for example. Nearly 200 children under 14 years now die of Asthma. Asthma UK puts this this condition down to lack of childhood infections! For most children, as they recover from illness, their immune system is strengthened. The UK, US, New Zealand, Cuba and Australia lead the world with Asthma (Vaccinated populations). Asthma UK says that ‘the goal would be to find a suitable vaccine to provide the beneficial effects of early life infection’!!!

6. Use Probiotics to strengthen the gut, in capsule form rather than from a drinking yogurt product which usually contains sugar and other additives.

7. Consider giving long term Vit B6 as “One of the components of the MMR is Neomycin. This is an antibacterial drug that is used to suppress gastrointestinal bacteria before surgery to avoid infection. …This antibiotic interferes with the absorption of Vitamin B6. An error in the uptake of Vitamin B6 can cause a rare form of epilepsy and children become mentally retarded. Vitamin B6 is the major vitamin for processingamino acids, which are the building blocks of all proteins and a few hormones. There are studies around which support the theory of treating autistic children with Vitamin B6.”

END OF QUOTE

Let me briefly comment on these 7 points.

  1. I am not aware of good evidence supporting this claim.
  2. I am not aware of good evidence supporting this claim.
  3. I am not aware of good evidence supporting this claim.
  4. I am not aware of good evidence supporting this claim.
  5. I am not aware of good evidence supporting this claim.
  6. I am not aware of good evidence supporting this claim.
  7. I am not aware of good evidence supporting this claim.

Of course, I may have missed some important evidence; if that is the case, I would appreciate someone showing it to me in the comments section below, so that we can all benefit from it.

The above advice is from the ‘ARNICA’ group (as the name suggests, they are close to or even led by homeopaths). They believe that the non-vaccinated child is potentially healthier than the vaccinated child.  

They also claim they  want to reduce the fear often felt by parents with their young children on health issues, whether that is to learn how to look after children when they have a fever, or to suggest ways to reduce the adverse reactions from vaccines.

I respectfully suggest that they are dismally failing in their aims. In fact, they seem to promote fear and issue bogus advice.

Grace Dasilva-Hill has just published an article entitled “Autism/ADHD and Vaccines – are we walking a tightrope whilst blindfolded?“. Who is Grace Dasilva-Hill, you will ask.

She is a professional registered homeopath, based in Charing – East Kent, UK. She has been in practice since 1997. During this time she has developed a busy practice, alongside teaching, running students’ clinics and tutorials. She was a team member of the Ghana Homeopathy Project soon after it started, and later became their treasurer as well. Grace has published in the Journal Homeopathy in Practice, and HPathy. She also is an ‘Energy EFT Master Practitioner Trainer’ and a ‘qualified CEASE therapist’.

And what is the Ghana Homeopathy Project ? It is an organization whose goal is the establishment of homeopathy as a recognised part of the health care system in Africa and Ghana in particular. Their objective is the relief and prevention of disease. They support the development of homeopathic education and wish to make homeopathy available to deprived communities as a valid and affordable form of treatment.

The lengthy article by Grace Dasilva-Hill re-hashes all the bogus arguments about immunisation that you could ever wish for. I will show you only what she calls her ‘conclusions’:

START OF QUOTE

…at the present time we have only just scratched the surface of the issue of autism and ADHD; my aim in this article is to challenge the reader to pause, reflect and ask: do vaccines do more good than harm, or it is actually the other way round? Just who is considered to be responsible for my health and that of my family – my doctor, my country’s government or myself? Do we need to stand up as a profession, and be more pro-active?

The big question seems to be, are we not only failing our patients but also the greater good of the world’s populations, unless we question and do not just ‘accept’ what science and medicine tells us, especially as ‘vested interests’ seem to have such a strong influence on what we are told?
The health journalist Phillip Day has done just that in his book ‘Health Wars’ – he argues how the multinationals have a vested interest in keeping all of us ill, for this is the only way that they can continue making money. His propositions are supported by Goldman Sacks Bank which recently stated that they would not invest in the alternative health industry because it tends to cure people, so there is little profit to be made from it.

I invite you to become an advocate for those who are unable or who are too young to ask questions, or to stand up for themselves, or whose parents don’t have the knowledge or tenacity to challenge.
Children and young adults suffering with autism, ADHD, ASD, deserve our loyalty, support and action.

In the UK, we recently shared the anguish and pain felt by baby Alfie Evans’ parents and family. It is impossible for anyone who is caring to witness such horror, and not to ask any questions. Hopefully we will learn much from this very sad event. There are questions not only about causative factors (ie. the role that vaccinations may have played), but also the issue of parental rights versus the State’s perceived protectionist rights.

What has been happening in the field of healthcare is fast becoming unsustainable. On the other hand Homeopathy has so much to offer, being a sustainable form of medicine not influenced by market forces.

One could argue that one of the reasons why the denialists want to see the demise of homeopathy and other natural modalities, is that more and more people are choosing these modes of healthcare in place of conventional medicine which is reductionist in approach and only has drugs to offer.

I find myself wondering whether there is a need for something radically different to happen. As a profession, do we need to do something collectively? Do we need to stand up more, do we need to speak up more? How do we go about doing this? I know that I am asking more questions than providing answers, and this is because at the moment I don’t have the answers either. But I have a deep and sincere desire to do my best to make a difference that will be both worthwhile and sustainable.
I would like to believe that others in our community would like to do the same for the bigger benefit of sustainable and effective healthcare for all.

Footnote: I have just carried out an impromptu, unrepresentative survey of homeopathic colleagues on a homeopathic professional group. I asked them if they knew of any health care professionals (doctors, nurses, midwives) who did not vaccinate their children. Most of those who replied, surprisingly said that they do know of at least one doctor, or nurse or midwife who did not vaccinate their children, and they added that these professionals keep this quiet. I certainly know of two medical doctors who do not vaccinate their children, and again they do not talk about it. It was shared with me in confidence.

END OF QUOTE

Of course, these words are not really ‘conclusions’, they are just a continuation of a barmy rant.

And yes, such articles exist in abundance. Many homeopaths are active campaigners against vaccination.

The Society of Homeopaths (SoH), the professional UK organisation for lay homeopaths, has recently stated that it is unethical for a homeopath to advise a patient against the use of conventional vaccines…  This could not be clearer! Yet, I suspect that the homeopaths put out such statements mainly to cover their backs and subsequently they do what they feel like – and they rarely feel like supporting vaccinations.

They obviously try to give the impression that lay homeopaths are not antivaxers. I fear, however, this impression is wrong: as we have discussed repeatedly on this blog, many homeopaths do advise their patients against immunisation. And many claim that homeopathic immunisations are an effective alternative. It takes not long to find even VIP-members of the SoH putting parents off from immunising their kids. And thanks to the Ghana Homeopathy and several similar projects, this is happening not just in the UK but also in Africa and elsewhere.

Is that not irresponsible?

In my view, it is!

Is that not illegal?

Apparently not, because such homeopaths usually add a clever disclaimer; Grace Dasilva-Hill for instance states that  Any information obtained here is not to be construed as medical OR legal advice. The decision to vaccinate and how you implement that decision is yours and yours alone. 

While researching my previous post, I came across this website. It is so wonderful that I just have to show you some excerpts:

START OF QUOTE

…there really are people who spend a lot of time and energy attacking homeopathy from the sidelines of the Internet and in print. They call themselves “skeptics”. Who are they and how did they originate?

…The skeptical movement is an offshoot of the Communist Party. (Really: see the top two links below.) Its top organizers were hired by pharmaceutical company and medical industry representatives to recruit malcontents in bars to spread hate propaganda against non-conventional medical systems. One of the first such skeptic groups referred to itself as “Skeptics in the Pub”. Not surprisingly, their rants against homeopathy sound like the drunken cacophony of soccer hooligans.

A “who’s who” tour would not be complete if we neglected to mention Sense about Science. This group features a prominent spokesperson who is an advertising “consultant” to pharmaceutical and oil companies. It’s been scrubbed from their website as of this writing, but they get large donations from Big Pharma.

It’s impossible not to encounter ties to the prevailing medical industry among any of the individuals or groups who currently identify themselves with the skeptic moniker. The mainstream media, which depend on advertising revenues from pharmaceutical companies and are always in search of a scandal are often co-opted by business interests that have little regard for the welfare of the average individual…

Media skeptics frequently and fraudulently make claims that there are “no studies” that support homeopathy (or any other non-conventional treatment) and therefore no evidence to support its efficacy. This is, to put it plain, a lie. As well as 200 years and roughly 25,000 volumes of clinical literature, there are almost 200 random controlled trials that indicate a positive outcome for Homeopathy, even though this form of investigation is not compatible with homeopathic methodology, which individualizes treatments, and many more studies of other types showing positive outcomes. (See Homeopathy’s Best Research.)…

Since media skeptics are not researchers, scientists or people with any solid knowledge of any body of medical endeavour, it’s a foregone conclusion that this virtual Popcorn Gallery of respondents is completely insensible to any form of rational dialogue. As much as they would like to think that they have a mission in upholding the tenets of “science”, their propaganda tactics do not make them a party to the dialogue between holistic medical systems such as homeopathy and sincere scientific investigation.

To quote Josef Stalin, they are “useful idiots” for the propaganda machine, but are not bona fide participants.

END OF QUOTE

As though this is not funny enough, the site also lists several ‘Supporting Organizations’:

Forgive me, if this post is long and a bit tedious, but I think it is important.

The claims continue that I am a dishonest falsifier of scientific data, because the renowned Prof R Hahn said so; this, for instance, is from a Tweet that appeared a few days ago

False claims, Edzard Ernst is the worst. Says independent researcher prof Hahn in his blog. His study: https://www.ncbi.nlm.nih.gov/pubmed/24200828 
His blog (German translation) http://www.homeopathy.at/betruegerische-studien-um-homoeopathie-als-wirkungslos-darzustellen…

The source of this permanent flow of defamations is Hahn’s strange article which I have tried to explain several times before. As the matter continues to excite homeopaths around the world, I have decided to give it another go. The following section (in bold) is directly copied from Hahn’s infamous paper where he evaluated several systematic reviews of homeopathy.

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In 1998, he [Ernst] selected 5 studies using highly diluted remedies from the original 89 and concluded that homeopathy has no effect [5].

In 2000, Ernst and Pittler [6] sought to invalidate the statistically significant superiority of homeopathy over placebo in the 10 studies with the highest Jadad score. The odds ratio, as presented by Linde et al. in 1999 [3], was 2.00 (1.37–2.91). The new argument was that the Jadad score and odds ratio in favor of homeopathy seemed to follow a straight line (in fact, it is asymptotic at both ends). Hence, Ernst and Pittler [6] claimed that the highest Jadad scores should theoretically show zero effect. This reasoning argued that the assumed data are more correct than the real data.

Two years later, Ernst [7] summarized the systematic reviews of homeopathy published in the wake of Linde’s first metaanalysis [2]. To support the view that homeopathy lacks effect, Ernst cited his own publications from 1998 and 2000 [5, 6]. He also presented Linde’s 2 follow-up reports [3, 4] as being further evidence that homeopathy equals placebo. 

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And that’s it! Except for some snide remarks (copied below) in the discussion section of the article, this is all Hahn has to say about my publications on homeopathy; in other words, he selects 3 of my papers (references are copied below) and (without understanding them, as we will see) vaguely discusses them. In my view, that is remarkable in 3 ways:

  • firstly, there I have published about 100 more papers on homeopathy which Hahn ignores (even though he knows about them as we shall see below);
  • secondly, he does not explain why he selected those 3 and not any others;
  • thirdly, he totally misrepresents all the 3 articles that he has selected.

In the following, I will elaborate on the last point in more detail (anyone capable of running a Medline search and reading Hahn’s article can verify the other points). I will do this by repeating what Hahn states about each of the 3 papers (in bold print), and then explain what each article truly was about.

HERE WE GO

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FIRST ARTICLE

In 1998, he [Ernst] selected 5 studies using highly diluted remedies from the original 89 and concluded that homeopathy has no effect [5].

This paper [ref 5] was a re-analysis of the Linde Lancet meta-analysis (unfortunately, this paper is not available electronically, but I can send copies to interested parties). For this purpose, I excluded all the studies that did not

  • use homeopathy following the ‘like cures like’ assumption (arguably those studies are not trials of homeopathy at all),
  • use remedies which were not highly diluted and thus contained active molecules (nobody doubts that remedies with pharmacologically active substances can have effects),
  • that did not get the highest rating for methodological quality by Linde et al (flawed trials are known to produce false-positive results).

My methodology was (I think) reasonable, pre-determined and explained in full detail in the article. It left me with 5 placebo-controlled RCTs. A meta-analysis across these 5 trials showed no difference to placebo.

Hahn misrepresents this paper by firstly not explaining what methodology I applied, and secondly by stating that I ‘selected’ the 5 studies from a pool of 89 trials. Yet, I defined my inclusion criteria which were met by just 5 studies.

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SECOND ARTICLE

In 2000, Ernst and Pittler [6] sought to invalidate the statistically significant superiority of homeopathy over placebo in the 10 studies with the highest Jadad score. The odds ratio, as presented by Linde et al. in 1999 [3], was 2.00 (1.37–2.91). The new argument was that the Jadad score and odds ratio in favor of homeopathy seemed to follow a straight line (in fact, it is asymptotic at both ends). Hence, Ernst and Pittler [6] claimed that the highest Jadad scores should theoretically show zero effect. This reasoning argued that the assumed data are more correct than the real data.

The 1st thing to notice here is that Hahn alleges we had ‘sought to invalidate’. How can he know that? The fact is that we were simply trying to discover something new in the pool of data. The paper he refers to here has been discussed before on this blog. Here is what I stated:

This was a short ‘letter to the editor’ by Ernst and Pittler published in the J Clin Epidemiol commenting on the above-mentioned re-analysis by Linde et al which was published in the same journal. As its text is not available on-line, I re-type parts of it here:

In an interesting re-analysis of their meta-analysis of clinical trials of homeopathy, Linde et al conclude that there is no linear relationship between quality scores and study outcome. We have simply re-plotted their data and arrive at a different conclusion. There is an almost perfect correlation between the odds ratio and the Jadad score between the range of 1-4… [some technical explanations follow which I omit]…Linde et al can be seen as the ultimate epidemiological proof that homeopathy is, in fact, a placebo.

Again Hahn’s interpretation of our paper is incorrect and implies that he has not understood what we actually intended to do here.

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THIRD ARTICLE

Two years later, Ernst [7] summarized the systematic reviews of homeopathy published in the wake of Linde’s first metaanalysis [2]. To support the view that homeopathy lacks effect, Ernst cited his own publications from 1998 and 2000 [5, 6]. He also presented Linde’s 2 follow-up reports [3, 4] as being further evidence that homeopathy equals placebo. 

Again, Hahn assumes my aim in publishing this paper (the only one of the 3 papers that is available as full text on-line): ‘to support the view that homeopathy lacks effect’. He does so despite the fact that the paper very clearly states my aim: ‘This article is an attempt to critically evaluate all such papers published since 1997 with a view to defining the clinical effectiveness of homeopathic medicines.‘ This discloses perhaps better than anything else that Hahn’s article is not evidence, but opinion-based and not objective but polemic.

Hahn then seems to resent that I included my own articles. Does he not know that, in a systematic review, one has to include ALL relevant papers? Hahn also seems to imply that I merely included a few papers in my systematic review. In fact, I included all the 17 that were available at the time. It might also be worth mentioning that numerous subsequent and independent analyses that employed similar methodologies as mine arrived at the same conclusions as my review.

_____________________________________________________________________________

Despite Hahn’s overtly misleading statements, he offers little real critique of my work. Certainly Hahn does not state that I made any major mistakes in the 3 papers he cites. For his more vitriolic comments, we need to look at the discussion section of his article where he states:

Ideology Plays a Part

Ernst [7] makes conclusions based on assumed data [6] when the true data are at hand [3]. Ernst [7] invalidates a study by Jonas et al. [18] that shows an odds ratio of 2.19 (1.55–3.11) in favor of homeopathy for rheumatic conditions, using the notion that there are not sufficient data for the treatment of any specific condition [6]. However, his review deals with the overall efficacy of homeopathy and not with specific conditions. Ernst [7] still adds this statistically significant result in favor of homeopathy over placebo to his list of arguments of why homeopathy does not work. Such argumentation must be reviewed carefully before being accepted by the reader.

After re-studying all this in detail, I get the impression that Hahn does not understand (or does not want to understand?) the research questions posed, nor the methodologies employed in my 3 articles. He is remarkably selective in choosing just 3 of my papers (his reference No 7 cites many more of my systematic reviews of homeopathy), and he seems to be determined to get the wrong end of the stick in order to defame me. How he can, based on his ‘analysis’ arrive at the conclusion that ” I have never encountered any scientific writer who is so clearly biased (biased) as this Edzard Ernst“, is totally beyond reason.

In one point, however, Hahn seems to be correct: IDEOLOGY PLAYS A PART (NOT IN MY BUT IN HIS EVALUATION).

_____________________________________________________________________________

REFERENCES AS CITED IN HAHN’S ARTICLE

5 Ernst E: Are highly dilute homeopathic remedies placebos? Perfusion 1998;11:291.

6 Ernst E, Pittler MH: Re-analysis of previous metaanalysis of clinical trials of homeopathy. J Clin Epidemiol 2000;53:1188.

7 Ernst E: A systematic review of systematic reviews of homeopathy. Br J Clin Pharmacol 2002;54:577–582.

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For more information about Hahn, please see two comments on my previous post (by Björn Geir who understands Hahn’s native language).

This is also where you can find the only comment by Hahn that I am aware of:
Robert Hahn on Saturday 17 September 2016 at 09:50

Somebody alerted me on this website. Dr. Ernst spends most of his effort to reply to my article in Forsch Komplemetmed 2013; 20: 376-381 by discussing who I might be as a person. I hoped to see more effort being put on scientific reasoning.

1. For the scientific part: my experience in scientific reasoning of quite long and extensive. I am the most widely published Swede in the area of anesthesia and intensive care ever. Those who doubt this can look “Hahn RG” on PubMed.

2. For the religious part that, in my mind, has nothing to do with this topic, is that my wife developed a spiritualistic ability in the mid 1990:s which I have explored in four books published in Swedish between 1997 and 2007. I became convinced that much of this is true, but not all. The books reflect interviews with my wife and what happened in our family during that time. Almost half of all Swedes believe in afterlife and in the existence of a spiritual world. Dr. Ernsts reasoning is typical of skeptics, namely that a person with a known religious belief in not to trust – i.e. a person cannot have two sides, a religious and a scientific. I do not agree with that, but the view has led to that almost no scientist dares to tell his religious beliefs to anyone (which Ernst enforces by his reasoning). Besides, I am not very religious person at all, although the years spent writing these books was quite an interesting period of my life. In particular the last book which involved past-life memories that I had been revived during self-hypnotims. I am interested in exploring many sorts of secrets, not only scientific. But all types of evidence must be judged according to its own rules and laws.

3. Why did I write about homeopathy? The reason is a campaign led by skeptics in some summers ago. Teenagers sat in Swedish television and expressed firmly that “there is not a single publication showing that homeopathy works – nothing!”. I wonder how these young boys could know that, and suspected that had simply been instructed to say so by older skeptics . I looked up the topic on PubMed and soon found some positive papers. Not difficult to find. Had they looked? Surely not. I was a frequent blogger at the time, and wrote three blogs summarizing meta-analyses asking the question whether homeopathy was superior to placebo (disregarding the underlying disease). The response for my readers was impressive and I was eventually urged to write it up in English, which I did. That is the background to my article. I have no other involvement in homeopathy.

4. Me and Dr Ernst. I came across his name when scanning articles about homeopathy, and decided to look a bit deeper into what he had written. The typical scenario was to publish meta-analyses but excluding almost all material, leaving very little (of just a scant part of the literature) to summarize. No wonder there were no significant differences. If there were still significant differences the material was typically considered by him to be still too small or too imprecise or whatever to make any conclusion. This was quite systematic, and I lost trust in Ernst´s writings. This was pure scientific reasoning and has nothing to do with religion or anything else.

// Robert Hahn

_________________________________________________________________________

Lastly, if you need more info about Hahn, you might also want to read this.

The HRI is an innovative international charity created to address the need for high quality scientific research in homeopathy… HRI is dedicated to promoting cutting research in homeopathy, using the most rigorous methods available, and communicating the results of such work beyond the usual academic circles… HRI aims to bring academically reliable information to a wide international audience, in an easy to understand form. This audience includes the general public, scientists, healthcare providers, healthcare policy makers, government and the media.

This sounds absolutely brilliant!

I should be a member of the HRI!

For years, I have pursued similar aims!

Hold on, perhaps not?

This article makes me wonder:

START OF QUOTE

… By the end of 2014, 189 randomised controlled trials of homeopathy on 100 different medical conditions had been published in peer-reviewed journals. Of these, 104 papers were placebo-controlled and were eligible for detailed review:
41% were positive (43 trials) – finding that homeopathy was effective
5% were negative (5 trials) – finding that homeopathy was ineffective
54% were inconclusive (56 trials)

How does this compare with evidence for conventional medicine?

An analysis of 1016 systematic reviews of RCTs of conventional medicine had strikingly similar findings2:
44% were positive – the treatments were likely to be beneficial
7% were negative – the treatments were likely to be harmful
49% were inconclusive – the evidence did not support either benefit or harm.

END OF QUOTE

The implication here is that the evidence base for homeopathy is strikingly similar to that of real medicine.

Nice try! But sadly it has nothing to do with ‘reliable information’!!!

In fact, it is grossly (and I suspect deliberately) misleading.

Regular readers of this blog will have spotted the reason, because we discussed (part of) it before. Let me remind you:

_______________________________________________________________________________

A clinical trial is a research tool for testing hypotheses; strictly speaking, it tests the ‘null-hypothesis’: “the experimental treatment generates the same outcomes as the treatment of the control group”. If the trial shows no difference between the outcomes of the two groups, the null-hypothesis is confirmed. In this case, we commonly speak of a negative result. If the experimental treatment was better than the control treatment, the null-hypothesis is rejected, and we commonly speak of a positive result. In other words, clinical trials can only generate positive or negative results, because the null-hypothesis must either be confirmed or rejected – there are no grey tones between the black of a negative and the white of a positive study.

For enthusiasts of alternative medicine, this can create a dilemma, particularly if there are lots of published studies with negative results. In this case, the totality of the available trial evidence is negative which means the treatment in question cannot be characterised as effective. It goes without saying that such an overall conclusion rubs the proponents of that therapy the wrong way. Consequently, they might look for ways to avoid this scenario.

One fairly obvious way of achieving this aim is to simply re-categorise the results. What, if we invented a new category? What, if we called some of the negative studies by a different name? What about INCONCLUSIVE?

That would be brilliant, wouldn’t it. We might end up with a simple statistic where the majority of the evidence is, after all, positive. And this, of course, would give the impression that the ineffective treatment in question is effective!

How exactly do we do this? We continue to call positive studies POSITIVE; we then call studies where the experimental treatment generated worst results than the control treatment (usually a placebo) NEGATIVE; and finally we call those studies where the experimental treatment created outcomes which were not different from placebo INCONCLUSIVE.

In the realm of alternative medicine, this ‘non-conclusive result’ method has recently become incredibly popular . Take homeopathy, for instance. The Faculty of Homeopathy proudly claim the following about clinical trials of homeopathy: Up to the end of 2011, there have been 164 peer-reviewed papers reporting randomised controlled trials (RCTs) in homeopathy. This represents research in 89 different medical conditions. Of those 164 RCT papers, 71 (43%) were positive, 9 (6%) negative and 80 (49%) non-conclusive.

This misleading nonsense was, of course, warmly received by homeopaths. The British Homeopathic Association, like many other organisations and individuals with an axe to grind lapped up the message and promptly repeated it: The body of evidence that exists shows that much more investigation is required – 43% of all the randomised controlled trials carried out have been positive, 6% negative and 49% inconclusive.

Let’s be clear what has happened here: the true percentage figures seem to show that 43% of studies (mostly of poor quality) suggest a positive result for homeopathy, while 57% of them (on average the ones of better quality) were negative. In other words, the majority of this evidence is negative. If we conducted a proper systematic review of this body of evidence, we would, of course, have to account for the quality of each study, and in this case we would have to conclude that homeopathy is not supported by sound evidence of effectiveness.

The little trick of applying the ‘INCONCLUSIVE’ method has thus turned this overall result upside down: black has become white! No wonder that it is so popular with proponents of all sorts of bogus treatments.

__________________________________________________________________________________

But one trick is not enough for the HRI! For thoroughly misinforming the public they have a second one up their sleeve.

And that is ‘comparing apples with pears’  – RCTs with systematic reviews, in their case.

In contrast to RCTs, systematic reviews can be (and often are) INCONCLUSIVE. As they evaluate the totality of all RCTs on a given subject, it is possible that some RCTs are positive, while others are negative. When, for example, the number of high-quality, positive studies included in a systematic review is similar to the number of high-quality, negative trials, the overall result of that review would be INCONCLUSIVE. And this is one of the reasons why the findings of systematic reviews cannot be compared in this way to those of RCTs.

I suspect that the people at the HRI know all this. They are not daft! In fact, they are quite clever. But unfortunately, they seem to employ their cleverness not for informing but for misleading their ‘wide international audience’.

When NHS England announced several months ago that they plan to stop the reimbursement of homeopathy, UK homeopaths were understandably upset and decided to launch a legal challenge to this decision. Yesterday, the result of this challenge has been published in a NHS press-release:

START OF QUOTE

NHS chief Simon Stevens has today welcomed the High Court’s decisive rejection of a legal challenge by the British Homeopathic Association to overturn plans to no longer routinely fund homeopathy on the NHS.

As part of action to clamp down on waste, over the last two years NHS England has taken action to curb prescriptions for medicines that can be bought over the counter or are of low value.

At the end of last year NHS England published guidance to curb prescriptions for 18 ineffective, unsafe or low clinical priority treatments, such as coproxamol, some dietary supplements, herbal treatments and homeopathy, saving up to £141 million a year. Earlier this year NHS England published a further list of 35 minor, short-term conditions for which over the counter medicines should not routinely be prescribed, saving around a further £100 million a year.

Savings form a key building block of the NHS’s 10 point efficiency plan contained in the Next Steps on the NHS Five Year Forward View, published in March 2017.

NHS chief, Simon Stevens said: “There is no robust evidence to support homeopathy which is at best a placebo and a misuse of scarce NHS funds.

“So we strongly welcome the High Court’s clear cut decision to kick out this costly and spurious legal challenge.”

Guidance on items which should not be routinely prescribed in primary care is available on the NHS England website.

END OF QUOTE

The reaction of UK homeopaths was as swift and deluded as it was predictable. The British Homeopathy Association, for instance, commented thus:

… The charity’s main claims against NHS England were that the consultation misrepresented homeopathy and therefore was unfair; and a report used in the consultation to inform the public was so complicated it would deter rather than encourage people to respond. Although the judge found there were sufficient grounds for a judicial review, after four days of lengthy legal arguments he dismissed the claims. Margaret Wyllie, BHA Chair, said the case highlighted how health bosses were unfairly manipulating the consultation process and making decisions about healthcare services without genuine patient engagement. “That NHS England attracted fewer than 3,000 responses from patients to a national consultation that ran for three months highlights its failure to genuinely engage with the public on important decisions about healthcare provision. Although 18 medicines were under review the only negative statement in NHS England’s press release promoting its public consultation was about homeopathy. The statement was so prejudicial it was widely reported in the media that the decision to deny patients homeopathic medicines had already been taken. How the judge failed to recognise that this was a deliberate attempt by NHS England to unfairly influence the public is astonishing,” said Mrs Wyllie.

In The Telegraph, Wyllie is quoted saying: It appears NHS England can fail to engage with patients properly on removing services and get away with it. That is not good enough, for it is important to remember that the real losers in this case are the patients who are now being refused a treatment on which they have come to depend.”

One can only marvel at the lack of insight and self-criticism. I should to add that the BHA is a charity; with this court case, they have wasted significant amounts of public money for their own, hopelessly misguided interests. To me, this indicates that they no longer deserve a charitable status.

Personally, I had very little doubt that the court would decide as it did. The evidence was simply overwhelming and indisputable. In the written judgement, the judge stated that “I am satisfied that NHSE was rigorous in the discharge of the duty to have “due regard” to relevant matters, and that it was entitled, on the evidence before it, to conclude that the Guidance would not have an adverse impact on the statutory equality objectives, but rather, as the Analysis found, “would [enable] patients to have access to the most effective medications to achieve the best outcomes”.

 

In all this, the open questions, in my view, were whether

  1. Prince Charles, the prime defender of quackery in the UK, would intervene,
  2. and whether his intervention might change anything.

So, did he try to intervene?

I do not know. It could be that, after all the hoo-ha about his spider memos, he now is a little more cautions about meddling in health politics. It could also be that, as he is getting ready to become king, he wants to keep a low profile about his more bizarre ideas. Lastly, it could be that his opinion does not weigh as heavily as I had feared.

In any case, The High Court ruling is most welcome and unquestionably just, progressive, and long-overdue. I applaud all who have worked hard to bring it about, and am sure that (most of) my readers agree.

Personally, I find our good friend Dana Ullman truly priceless. There are several reasons for that; one is that he is often so exemplarily wrong that it helps me to explain fundamental things more clearly. With a bit of luck, this might enable me to better inform people who might be thinking a bit like Dana. In this sense, our good friend Dana has significant educational value.

Recently, he made this comment:

According to present and former editors of THE LANCET and the NEW ENGLAND JOURNAL OF MEDICINE, “evidence based medicine” can no longer be trusted. There is obviously no irony in Ernst and his ilk “banking” on “evidence” that has no firm footing except their personal belief systems: https://medium.com/@drjasonfung/the-corruption-of-evidence-based-medicine-killing-for-profit-41f2812b8704

Ernst is a fundamentalist whose God is reductionistic science, a 20th century model that has little real meaning today…but this won’t stop the new attacks on me personally…

END OF COMMENT

Where to begin?

Let’s start with some definitions.

  • Evidence is the body of facts that leads to a given conclusion. Because the outcomes of treatments such as homeopathy depend on a multitude of factors, the evidence for or against their effectiveness is best based not on experience but on clinical trials and systematic reviews of clinical trials (this is copied from my book).
  • EBM is the integration of best research evidence with clinical expertise and patient values. It thus rests on three pillars: external evidence, ideally from systematic reviews, the clinician’s experience, and the patient’s preferences (and this is from another book).

Few people would argue that EBM, as it is applied currently, is without fault. Certainly I would not suggest that; I even used to give lectures about the limitations of EBM, and many experts (who are much wiser than I) have written about the many problems with EBM. It is important to note that such criticism demonstrates the strength of modern medicine and not its weakness, as Dana seems to think: it is a sign of a healthy debate aimed at generating progress. And it is noteworthy that internal criticism of this nature is largely absent in alternative medicine.

The criticism of EBM is often focussed on the unreliability of the what I called above the ‘best research evidence’. Let me therefore repeat what I wrote about it on this blog in 2012:

… The multifactorial nature of any clinical response requires controlling for all the factors that might determine the outcome other than the treatment per se. Ideally, we would need to create a situation or an experiment where two groups of patients are exposed to the full range of factors, and the only difference is that one group does receive the treatment, while the other one does not. And this is precisely the model of a controlled clinical trial.

Such studies are designed to minimise all possible sources of bias and confounding. By definition, they have a control group which means that we can, at the end of the treatment period, compare the effects of the treatment in question with those of another intervention, a placebo or no treatment at all.

Many different variations of the controlled trial exist so that the exact design can be adapted to the requirements of the particular treatment and the specific research question at hand. The over-riding principle is, however, always the same: we want to make sure that we can reliably determine whether or not the treatment was the cause of the clinical outcome.

Causality is the key in all of this; and here lies the crucial difference between clinical experience and scientific evidence. What clinician witness in their routine practice can have a myriad of causes; what scientists observe in a well-designed efficacy trial is, in all likelihood, caused by the treatment. The latter is evidence, while the former is not.

Don’t get me wrong; clinical trials are not perfect. They can have many flaws and have rightly been criticised for a myriad of inherent limitations. But it is important to realise that, despite all their short-comings, they are far superior than any other method for determining the efficacy of medical interventions.

There are lots of reasons why a trial can generate an incorrect, i.e. a false positive or a false negative result. We therefore should avoid relying on the findings of a single study. Independent replications are usually required before we can be reasonably sure.

Unfortunately, the findings of these replications do not always confirm the results of the previous study. Whenever we are faced with conflicting results, it is tempting to cherry-pick those studies which seem to confirm our prior belief – tempting but very wrong. In order to arrive at the most reliable conclusion about the efficacy of any treatment, we need to consider the totality of the reliable evidence. This goal is best achieved by conducting a systematic review.

In a systematic review, we assess the quality and quantity of the available evidence, try to synthesise the findings and arrive at an overall verdict about the efficacy of the treatment in question. Technically speaking, this process minimises selection and random biases. Systematic reviews and meta-analyses [these are systematic reviews that pool the data of individual studies] therefore constitute, according to a consensus of most experts, the best available evidence for or against the efficacy of any treatment.

END OF QUOTE

Other criticism is aimed at the way EBM is currently used (and abused). This criticism is often justified and necessary, and it is again the expression of our efforts to generate progress. EBM is practised by humans; and humans are far from perfect. They can be corrupt, misguided, dishonest, sloppy, negligent, stupid, etc., etc. Sadly, that means that the practice of EBM can have all of these qualities as well. All we can do is to keep on criticising malpractice, educate people, and hope that this might prevent the worst abuses in future.

Dana and many of his fellow SCAMers have a different strategy; they claim that EBM “can no longer be trusted” (interestingly they never tell us what system might be better; eminence-based medicine? experience-based medicine? random-based medicine? Dana-based medicine?).

The claim that EBM can no longer be trusted is clearly not true, counter-productive and unethical; and I suspect they know it.

Why then do they make it?

Because they feel that it entitles them to argue that homeopathy (or any other form of SCAM) cannot be held to EBM-standards. If EBM is unreliable, surely, nobody can ask the ‘Danas of this world’ to provide anything like sound data!!! And that, of course, would be just dandy for business, wouldn’t it?

So, let’s not be deterred  or misled by these deliberately destructive people. Their motives are transparent and their arguments are nonsensical. EBM is not flawless, but with our continued efforts it will improve. Or, to repeat something that I have said many times before: EBM is the worst form of healthcare, except for all other known options.

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