irrationality
If you ever receive an email from ‘[email protected]’, please be aware that it is not from me. It comes from some clown who seems to want to pretend to be me.
How do I know? I received a short email from that very person. Here is its full text in all its beauty:
“You are the most bullshit person i know who claim to be a good doctor by putting other professions down. you are a killer because of your false information.”
What does that tell us about the identity of the author?
- He does not seem to be an admirer of my work.
- He feels strongly about something.
- He does not mince his words.
- He does not write very good English.
- He is not very well-informed [I do not think that I ever claimed to be a ‘good doctor’].
- He is factually wrong [I have not ever killed anyone for any reason].
What he presumably wants to express is that, in his view, the information I publish on this blog and perhaps elsewhere has the potential to kill patients. This is a somewhat disturbing assumption because the opposite is truly my intention.
It is a great pity that the author of these lines did not manage to be a little more specific.
- Does he [somehow, I presume the author is male] think that, by warning readers of all sorts of quackery and outright health fraud, I might kill someone?
- Does he believe that my repeated warnings about the lack of good evidence for alternative medicine drive patients into the arms of even more dangerous clinicians?
- Or is he just an unfortunate sufferer of a serious mental condition such as paranoia?
As I am totally in the dark here and cannot even begin to answer these questions, I will leave it to you, the readers of this post, to decide.
Or perhaps the author of this charming email wants to enlighten us?
The ‘INTERNATIONAL CHIROPRACTIC PEDIATRIC ASSOCIATION’ (ICPA) is, according to their website, ‘a nonprofit organization whose mission is to advance chiropractic by establishing evidence informed practice, supporting excellence in professional skills and delivering educational resources to the public. It fulfills this mission by engaging and serving family chiropractors worldwide through research, training and public education.’
It fulfils its mission by, amongst other things, tweeting links to other pro-chiropractic activities. It is via such a tweet that I recently found the Pathways to Family Wellness (PFW). This is a quarterly print and digital magazine whose mission is to support you and your family’s quest for wellness.
This sounds exciting, I thought, and decided to have a closer look. I found that, according to its website, the magazine ‘collaborates with consciousness leaders, cutting-edge scientists and researchers, families on their conscious path, holistic practitioners and dynamic non-profit organizations to bring the most current insights into wellness to our readers.’
The Executive Editor and Publisher of PFW is Dr. Jeanne Ohm. She has ‘practiced family wellness care since 1981 with her husband, Dr. Tom. They have six children who were all born at home and are living the chiropractic family wellness lifestyle. Ohm is an instructor, author, and innovator. Her passion is: training DC’s with specific techniques for care in pregnancy, birth & infancy, forming national alliances for chiropractors with like-minded perinatal practitioners, empowering mothers to make informed choices, and offering pertinent patient educational materials.’
My suspicion that this is an outlet of chiropractic nonsense is confirmed as I read an article by Bobby Doscher, D.C., N.D. on the subject of chiropractic treatment for children with neurological problems. The article itself is merely promotional and therefore largely irrelevant. But one short passage is interesting nevertheless, I thought:
Chiropractic Based on Scientific Fact
Since its beginning, chiropractic has been based on the scientific fact that the nervous system controls the function of every cell, tissue, organ and system of your body. While the brain is protected by the skull, the spinal cord is more vulnerable, covered by 24 moving vertebrae. When these bones lose their normal motion or position, they can irritate the nervous system. This disrupts the function of the tissues or organs these nerves control; this is called vertebral subluxation complex.
I thought this was as revealing as it was hilarious. Since such nonsensical notions are ubiquitous in the chiropractic literature, I am tempted to conclude that most chiropractors believe this sort of thing themselves. This makes them perhaps more honest but also more of a threat: sincere conviction renders a quack not less but more dangerous.
On the website of the Bristol University Hospital, it was just revealed that UK homeopathy seems to have suffered another blow:
“Homeopathic medicine has been available in Bristol since 1852, when Dr Black first started dispensing from premises in the Triangle. During the next 69 years the service developed and expanded culminating in the commissioning in 1921 of a new hospital in the grounds of Cotham House. The Bristol Homeopathic Hospital continued to provide a full range of services until 1986 when the in-patient facilities were transferred to the Bristol Eye Hospital, where they continue to be provided, and outpatient services were moved to the ground floor of the Cotham Hill site. In 1994, following the sale of the main building to the University by the Bristol and District Health Authority, a new purpose built Department was provided in the Annexe buildings of the main building, adjoining the original Cotham House. The NHS Homeopathic Service is now being delivered on behalf of University Hospital Bristol by the Portland Centre for Integrative Medicine (PCIM), a Community Interest Company.”
The Portland Centre for Integrative Medicine has joined Litfield House offering medical homeopathy with Dr Elizabeth Thompson. And this is how the new service is described [I have added references in the following unabridged quote in bold which refer to my comments below]:
Medical Homeopathy is a holistic [1] approach delivered by registered health care professionals that uses a low dose of an activated [2] natural [3] substance [4] to stimulate a self-healing response in the body [5]. At the first appointment the doctor will take time to understand problem symptoms that might be physical, emotional or psychological and then a treatment plan will be discussed between the patient and the doctor [6], with homeopathic medicines chosen for you or your child on an individual basis.
WHAT CONDITIONS ARE SUITABLE FOR MEDICAL HOMEOPATHY?
Homeopathy can be safely [7] used to improve symptoms and well-being across a wide range of long term conditions: from childhood eczema [8] and ADHD [9]; to adults with medically unexplained conditions [10]; inflammatory bowel disease [11], cancer [12] or chronic fatigue syndrome [13]; and other medical conditions, including obesity [14] and depression [15]. Some people use homeopathy to stay well [16] and others use it to help difficult symptoms and/ or the side effects of conventional treatments [17].
This looks like a fairly bland and innocent little advertisement at first glance. If we analyse it closer, however, we find plenty of misleading claims. Here are the ones that caught my eye:
- Homeopaths claim that their approach is holistic and thus aim at differentiating it from conventional health care. This is misleading because ALL good medicine is by definition holistic.
- Nothing is ‘activated’; homeopaths believe that succession releases the ‘vital force’ in a remedy – but this is little more than hocus-pocus from the dark ages of medicine.
- Nothing is natural about endlessly diluting and shaking a medicine, while pretending that this ritual renders it more active and effective. And nothing is natural about remedies such as ‘Berlin Wall’.
- It is misleading to speak about ‘substance’ in relation to homeopathic remedies, because they can be manufactured also from non-material stuff too; examples are remedies such as X-ray, sol [sun light] or lunar [moonlight].
- The claim that homeopathic remedies stimulate the self-healing properties of the body is pure phantasy.
- “The doctor will take time to understand problem symptoms that might be physical, emotional or psychological and then a treatment plan will be discussed between the patient and the doctor” – this also applies to any consultation with any health care practitioner.
- Homeopathy is not as safe as homeopaths try to make us believe; several posts on this blog have dealt with this issue.
- There is no good evidence to support this claim.
- There is no good evidence to support this claim.
- There is no good evidence to support this claim.
- There is no good evidence to support this claim.
- There is no good evidence to support this claim.
- There is no good evidence to support this claim.
- There is no good evidence to support this claim.
- There is no good evidence to support this claim.
- True, some people use anything for anything; but there is no sound evidence to show that homeopathy is an effective prophylactic intervention for any disease.
- Nor is there good evidence that it is effective to “help difficult symptoms and/ or the side effects of conventional treatments”.
So, what we have here is a short paragraph which, on closer inspection, turns out to be full of misleading statements, bogus claims and dangerous lies. Not a good start for a new episode in the life of the now dramatically down-sized homeopathic clinic in Bristol, I’d say. And neither is it a publication of which the Bristol University Hospital can be proud. I suggest they correct it as a matter of urgency; otherwise they risk a barrage of complaints to the appropriate regulators by people who treasure the truth a little more than they seem to do themselves.
Therapeutic touch (TT) is a popular ‘energy therapy’ which is based on the use of hand movements and detection of ‘energy field congestion’ to correct alleged imbalances that, in turn, are postulated to stimulate self-healing. The effectiveness of TT during radiotherapy for breast cancer is unknown, and this study was aimed at shedding some light on it.
Women undergoing adjuvant radiation for stage I/II breast cancer post surgery were recruited for this study. TT treatments were administered to patients in the experimental group three times per week following radiation therapy. The control group did not receive any TT. Both groups had conventional care in addition.
The effectiveness of TT was evaluated by documenting the ‘time to develop’ and the ‘worst grade of radiation’ dermatitis. Toxicity was assessed using NCIC CTC V3 dermatitis scale. Cosmetic rating was performed using the EORTC Breast Cosmetic Rating. The quality of life, mood and energy, and fatigue were assessed by EORTC QLQ C30, POMS, and BFI, respectively. The parameters were assessed at baseline, and serially during treatment.
A total of 49 patients entered the study (17 in the TT group and 32 in the control group). Median age in TT arm was 63 years and in control arm was 59 years. TT was considered feasible as all 17 patients screened completed TT treatment. There were no side effects observed with the TT treatments. In the TT group, the worst grade of radiation dermatitis was grade II in nine patients (53%). Median time to develop the worst grade was 22 days. In the control group, the worst grade of radiation dermatitis was grade III in 1 patient. However, the most common toxicity grade was II in 15 patients (47%). Three patients did not develop any dermatitis. Median time to develop the worst grade in the control group was 31 days. There was no difference between cohorts for the overall EORTC cosmetic score and there was no significant difference in before and after study levels in quality of life, mood and fatigue.
Based on these findings, the authors drew the following conclusions: This study is the first evaluation of TT in patients with breast cancer using objective measures. Although TT is feasible for the management of radiation induced dermatitis, we were not able to detect a significant benefit of TT on NCIC toxicity grade or time to develop the worst grade for radiation dermatitis. In addition, TT did not improve quality of life, mood, fatigue and overall cosmetic outcome.
Like all forms of ‘energy healing’, TT lacks any biological plausibility and is not clinically effective. At best, it can generate a placebo-response; but in this particular study it did not even manage that.
Is it not time to stop fooling patients with outright quackery?
Is it not time to stop spending scarce research resources on such nonsense?
Is it not time that editors stop considering such rubbish for publication?
Is it not time to stop allowing TT-proponents to undermine rationality?
Is it not time to make progress and move on?
If you start reading the literature on chiropractic, you are bound to have surprises. The paucity of rigorous and meaningful research is one of them. I am constantly on the look-out for such papers but am regularly frustrated. Over the years, I got the impression that chiropractors tend to view research as an exercise in promotion – that is promotion of their very own trade.
Take this article, for instance. It seems to be a systematic review of chiropractic for breastfeeding. This is an interesting indication; remember: in 1998, Simon Singh wrote in the Guardian this comment “The British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence. This organisation is the respectable face of the chiropractic profession and yet it happily promotes bogus treatments.” As a consequence, he got sued for libel; he won, of course, but ever since, chiropractors across the world are trying to pretend that there is some evidence for their treatments after all.
The authors of the new review searched Pubmed [1966-2013], Manual, Alternative and Natural Therapy Index System (MANTIS) [1964-2013] and Index to Chiropractic Literature [1984-2013] for the relevant literature. The search terms utilized “breastfeeding”, “breast feeding”, “breastfeeding difficulties”, “breastfeeding difficulty”, “TMJ dysfunction”, “temporomandibular joint”, “birth trauma” and “infants”, in the appropriate Boolean combinations. They also examined non-peer-reviewed articles as revealed by Index to Chiropractic Literature and conducted a secondary analysis of references. Inclusion criteria for their review included all papers on breastfeeding difficulties regardless of peer-review. Articles were excluded if they were not written in the English language.
The following articles met the inclusion criteria: 8 case reports, 2 case series, 3 cohort studies and 6 manuscripts (5 case reports and a case series) that involved breastfeeding difficulties as a secondary complaint. The findings revealed a “theoretical and clinical framework based on the detection of spinal and extraspinal subluxations involving the cervico-cranio-mandibular complex and assessment of the infant while breastfeeding.”
Based on these results, the authors concluded that chiropractors care of infants with breastfeeding difficulties by addressing spinal and extraspinal subluxations involving the cervico-cranio-mandibular complex.
Have I promised too much?
I had thought that chiropractors had abandoned the subluxation nonsense! Not really, it seems.
I had thought that systematic reviews are about evidence of therapeutic effectiveness! Not in the weird world of chiropractic.
I would have thought that we all knew that ‘chiropractors care of infants with breastfeeding difficulties’ and do not need a review to confirm it! Yes, but what is good for business deserves another meaningless paper.
I would have thought that the conclusions of scientific articles need to be appropriate and based on the data provided! It seems that, in the realm of chiropractic, these rules do not apply.
An appropriate conclusion should have stated something like THERE IS NO GOOD EVIDENCE THAT CHIROPRACTIC CARE AIDS BREASTFEEDING. But that would have been entirely inappropriate from the chiropractic point of view because it is not a conclusion that promotes the sort of quackery most chiropractors rely upon for a living. And the concern over income is surely more important than telling the truth!
The question why patients turn to homeopathy – or indeed any other disproven treatment – has puzzled many people. There has been a flurry of research into these issues. Here is the abstract of a paper that I find very remarkable and truly fascinating:
Interviews with 100 homeopathic patients in the San Francisco Bay Area show that for the most part the patients are young, white and well-educated, and have white-collar jobs; most had previously tried mainstream medical care and found it unsatisfactory. Among the reasons for their dissatisfaction were instances of negative side effects from medication, lack of nutritional or preventive medical counseling, and lack of health education. Experiences with conventional physicians were almost evenly divided: nearly half of the subjects reported poor experiences, slightly fewer reported good experiences. Three quarters of the patients suffered from chronic illness and about half considered their progress to be good under homeopathic care. The majority were simultaneously involved in other nontraditional health care activities.
If you read the full article, you will see that the authors make further important points:
- Patients who use alternative treatments are by no means ignorant or unsophisticated.
- Most of these patients use other treatments in parallel – but they seem to attribute any improvements in their condition to homeopathy.
- Dissatisfaction with conventional medicine seems the prime motivation to turn to homeopathy. In particular, patients need more time with their clinician and want to share the responsibility for their own health – and these needs are met by homeopaths better than by conventional doctors.
- Most homeopaths (63%) adhere to Hahnemann’s dictum that homeopathic remedies must never be combined with other treatments. This renders then potentially dangerous in many situations.
At this point you might say BUT WE KNEW ALL THIS BEFORE! True! Why then do I find this paper so remarkable?
It is remarkable mostly because of its publication date: 1978! In fact, it may well be the very first of hundreds of similar surveys that followed in the years since.
The questions I ask myself are these:
- IF WE KNEW ALL THIS SINCE ALMOST 40 YEARS, WHY HAVE WE NOT DONE MORE ABOUT IT?
- WHY ARE WE SO UNSUCCESSFUL IN GETTING THE FACTS THROUGH TO OUR PATIENTS?
- WHY HAVE WE NOT MANAGED TO IMPROVE CONVENTIONAL MEDICINE SUCH THAT PATIENTS STOP CONSULTING QUACKS?
- WHY ARE WE STILL CONDUCTING SURVEY AFTER SURVEY WHEN THE EMBARRASSING FACTS ARE PLAIN TO SEE?
Some people seem to believe that the field of alternative medicine resembles a quaint little cottage industry where money hardly matters. A new analysis shows how far from the truth this impression is.
In the 2007 US National Health Interview Survey, use of complementary health approaches, reasons for this use, and associated out of pocket (OOP) costs were captured in a nationally representative sample of 5,467 US adults. Ordinary least square regression models that controlled for co-morbid conditions were used to estimate aggregate and per person OOP costs associated with 14 painful health conditions.
The analyses suggest that individuals using complementary approaches spent a total of $14.9 billion OOP on these approaches to manage three painful conditions: arthritis, back pain and fibromyalgia. Around 7.5 billion of that total was spent on consulting practitioners such as chiropractors and acupuncturists. Total OOP expenditures seen in those using complementary approaches for their back pain ($8.7 billion) far outstripped that of any other condition, with the majority of these costs ($4.7 billion) resulting from visits to complementary providers. Annual condition-specific per-person OOP costs varied from a low of $568 for regular headaches, to a high of $895 for fibromyalgia. The total expenditure on complementary medicine was comparable to that on conventional care.
The authors concluded that adults in the United States spent $14.9 billion OOP on complementary health approaches (e.g., acupuncture, chiropractic, herbal medicines) to manage painful conditions including back pain ($8.7 billion). This back pain estimate is almost 1/3rd of total conventional healthcare expenditures for back pain ($30.4 billion) and 2/3rds higher than conventional OOP expenditures ($5.1 billion).
These are truly eye-watering sums. The obvious question is: IS THIS MONEY WELL-SPENT?
The short answer, I fear, is NO!
The alternative therapies in question are not based on compelling evidence in the management of these painful conditions. Some are clearly not better than placebo, and others are apparently supported by some research but its quality is hardly good enough to rely upon.
This level expenditure is both impressive and worrying. It highlights an enormous waste of resources, alerts us to an urgent need for truly rigorous research, and demonstrates how high the stakes really are.
All across the world we see initiatives to regulate alternative medicine. The most recent news in this sphere comes from Switzerland. The ‘Swissinfo’ website reported that the training of alternative medicine practitioners is to be regulated by creating a ‘COMPLEMENTARY MEDICINE DIPLOMA’.
The decision was welcomed by the Organisation of Swiss Alternative Medicine Professionals (OdA KT), which will conduct the exams for the diploma in question. The five therapies selected by the government for the complementary medicine diploma are yoga, ayurveda, shiatsu, craniosacral therapy and eutony. The first exams are expected to be held in 2016.
“Recognition by the state provides an important political basis for these therapies,” Christoph Q Meier, secretary general of OdA KT told swissinfo.ch. “The diploma will also improve the quality of therapy offered in Switzerland, as until now anybody could call themselves a therapist.” Meier estimates that there are between 12-15,000 practitioners of complementary therapies in Switzerland. Applicants for the national diploma will first have to pass a series of pre-exams. However, those with recognised qualifications and at least five years of experience could be exempt from the pre-exams. The exam is open to foreign nationals but will only be offered in German, French and Italian. In April this year, ayurveda was also included for a separate national diploma in naturopathy medicine along with Chinese and European traditional medicine, as well as homeopathy. Switzerland has around 3,000 naturopaths.
Whenever issues like this come up, I ask myself: IS REGULATION OF ALTERNATIVE MEDICINE A GOOD OR A BAD THING?
On the one hand, one might be pleased to hear that therapists receive some training and that not everyone who feels like it can do this job. On the other hand, it has to be said that regulation of nonsense will inevitably result in nonsense. What is more, regulation will also be misused by the practitioners to claim that their treatment is now well-established and supported by the government. This phenomenon can already be seen in the comments above and it misleads the public who understandably believe that, once a form of health care is regulated officially, it must be evidence-based.
So, what is the solution? I wish I knew the answer.
Any suggestion is welcomed.
When it comes to alternative medicine, the public relies heavily on the writings of health journalists. We therefore have to count ourselves lucky to have some that are outstanding in their ability to inform the public honestly, objectively and responsibly. Here is an excerpt of what one particularly gifted and ethical heath journalist (and consultant!!!) just published regarding the treatment of babies and kids on a highly visible, popular website:
Homeopathy, or homeopathic medicine, is based on the principle that “like cures like.” Instead of treating an individual’s illness, homeopathy treats individual symptoms with substances from plants and minerals that are highly diluted and “succussed,” or shaken to release energy, said Sara Chana Silverstein, a homeopath, master herbalist and an international board-certified lactation consultant…Although homeopathy isn’t meant to replace Western medicine, it can be a complementary or alternative approach for ailments like colds, the stomach flu and teething. For example, if your pediatrician has diagnosed your baby with an upper respiratory infection, there’s not much you can do other than offer lots of fluids, rest and possibly acetaminophen or ibuprofen. In this case, a homeopathic remedy might help. Plus, since antibiotic overuse and antimicrobial resistance remain a major concern in the U.S., and antibiotics often have side effects, homeopathy could help heal without the need for a prescription. In fact, a study in the journal Homeopathy found that homeopathy for ear infections was just as effective as conventional treatment but patients in the homeopathic group had a faster improvement in symptoms. Although some studies show promising results, more research is needed to determine who homeopathic remedies work best for and in what situations, said Dr. Hilary McClafferty, chair of the American Academy of Pediatrics’ Section on Complementary and Integrative Medicine…
“In the United, States, the homeopathic products that carry the label, HPUS—
Homeopathic Pharmacopeia of the United States— are prepared with a very standardized, procedural monograph. So there is a map and regulations that ensure what’s on the label is what’s in the bottle,” McClafferty said…The only adverse effect of homeopathy, according to Silverstein, is that if a baby consumed a remedy too frequently, such as every hour for 10 hours, they would “prove” the remedy, or create the symptoms the remedy was trying to heal. “But if you gave it to a child 3 times a day at a low dose, personally I do not believe it could injure a child in anyway whatsoever,” she said…Your best bet is to see a trained homeopath who will target individual symptoms and give you pellets in the size that’s appropriate for your child’s age, Silverstein said. The bottom line when it comes to deciding between homeopathy, a medication or another remedy? “You want to be well educated, conservative and in touch with your pediatrician,” McClafferty said.
Julie Revelant is a health journalist and a consultant who provides content marketing and copywriting services for the healthcare industry. She’s also a mom of two. Learn more about Julie at revelantwriting.com.
As I said: outstanding!
With so much sound information about homeopathy and its merits in the treatment of childhood conditions, we are inclined to forgive the few tiny errors and marginally misleading statements that might require corrections such as:
- homeopathy is very much meant as a replacement of conventional medicine by its inventor Hahnemann who was adamant that it must not be combined with other treatments because it is the only true healing art;
- there is no good evidence that homeopathy is anything else than a placebo for children or, indeed, for anyone else;
- the study in the journal ‘Homeopathy’ was lousy and does not allow any conclusions whatsoever about the effectiveness of homeopathy;
- to state “some studies show promising results” is very misleading; the totality of the reliable evidence is negative;
- more research is not needed to determine who benefits from homeopathy; there is no longer a debate about homeopathy within science;
- the label of a typical homeopathic preparation does not tell you what’s in the bottle, at best it tells you what used to be there;
- the main risk of homeopathy is that diseases are not treated effectively; in this way, homeopathy can kill.
Yes, these are but very minor flaws, I know. They should not distract from this journalist’s great achievement of getting her brilliantly informative article read by the widest possible audience. If Prince Charles offered an award for the best science writer of the year (why has he not yet thought of this publicity stunt?), she would certainly be a candidate.
An article in the Australian Journal of Pharmacy seems well worth mentioning on this blog. It throws some light on what is happening in Australia regarding an issue that I have repeatedly written about: the sale of homeopathic remedies by pharmacists.
Pharmaceutical Society of Australia have apparently published a ‘Complementary Medicines Position Paper’ which states that complementary medicines may be used as an adjunctive therapy with conventional medicines, provided there is evidence to support their use. The president of the PSA, Joe Demarte, says that the PSA is committed to supporting pharmacists help consumers make informed decisions regarding complementary medicines and continued to advocate strongly for a partnership approach with consumers to promote the Quality Use of Medicines and responsible self-medication. “This is a partnership between the pharmacist and the consumer where the pharmacist as the medicines expert can advise on the appropriate use of complementary medicines the consumer may be considering,” Demarte is quoted saying. He continues: “There is a wealth of information available about complementary medicines which can be confusing and the pharmacist can assist in ensuring that consumers are provided with the best available information about the current evidence for efficacy, as well as information on any potential side effects, drug interactions and risks of harm. In the event that a consumer chooses to use a product with limited evidence, the pharmacist must advise the consumer on the risks of rejecting or delaying treatments for which there is good evidence for safety and effectiveness. PSA strongly encourages all consumers considering taking complementary medicines to first consult their pharmacist for sound, evidence-based advice.”
So far so good – but what about disproven treatments such as homeopathy, I wonder.
Demarte says the PSA endorses the NHMRC report, released in March 2015, which found there were no health conditions for which there was reliable evidence that homeopathy was effective. And he states that the PSA does not support the sale of homeopathy products in pharmacies: “Our position is that pharmacists must use their professional judgement to prevent the supply of products with evidence of no effect.”
This surely is good news for all who stand up for evidence-based medicine and foremost for patients. It comes only a few months after the RPS Chief Scientist of the UK Royal Pharmaceutical Society, Professor Jayne Lawrence stated very similar things: “The public have a right to expect pharmacists and other health professionals to be open and honest about the effectiveness and limitations of treatments. Surely it is now the time for pharmacists to cast homeopathy from the shelves and focus on scientifically based treatments backed by clear clinical evidence.”
Now that we are (almost) all in perfect agreement, we only need one thing: adequate action by pharmacists!
