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

irrationality

This seems to be the question that occupies the minds of several homeopaths.

Amazed?

So was I!

Let me explain.

In 1997, Linde et al published their now famous meta-analysis of clinical trials of homeopathy which concluded that “The results of our meta-analysis are not compatible with the hypothesis that the clinical effects of homeopathy are completely due to placebo. However, we found insufficient evidence from these studies that homeopathy is clearly efficacious for any single clinical condition. Further research on homeopathy is warranted provided it is rigorous and systematic.”

This paper had several limitations which Linde was only too happy to admit. The authors therefore conducted a re-analysis which, even though published in an excellent journal, is rarely cited by homeopaths. Linde et al stated in their re-analysis of 2000: “there was clear evidence that studies with better methodological quality tended to yield less positive results.” It was this phenomenon that prompted me and my colleague Max Pittler to publish a ‘letter to the editor’ which now – 15 years later – seems the stone of homeopathic contention.

A blog-post by a believer in homeopathy even asks the interesting question: Did Professor Ernst Sell His Soul to Big Pharma? It continues as follows:

Edzard Ernst is an anti-homeopath who spent his career attacking traditional medicine. In 1993 he became Professor of Complementary Medicine at the University of Exeter. He is often described as the first professor of complementary medicine, but the title he assumed should have fooled no-one. His aim was to discredit medical therapies, notably homeopathy, and he then published some 700 papers in ‘scientific’ journals to do so.

Now, Professor Robert Hahn, in his blog, has made an assessment of the quality of his work… In the interests of the honesty and integrity in science, it is an important assessment. It shows, in his view, how science has been taken over by ideology (or as I would suggest, more accurately, the financial interests of Big Corporations, in this case, Big Pharma). The blog indicates that in order to demonstrate that homeopathy is ineffective, over 95% of scientific research into homeopathy has to be discarded or removed! 

So for those people who, like myself, cannot read the original German, here is an English translation of the blog…

“I have never seen a science writer so blatantly biased as Edzard Ernst: his work should not be considered of any worth at all, and discarded” finds Sweden’s Professor Robert Hahn, a leading medical scientist, physician, and Professor of Anaesthesia and Intensive Care at the University of Linköping, Sweden.

Hahn determined therefore to analyze for himself the ‘research’ which supposedly demonstrated homeopathy to be ineffective, and reached the shocking conclusion that:

“only by discarding 98% of homeopathy trials and carrying out a statistical meta-analysis on the remaining 2% negative studies, can one ‘prove’ that homeopathy is ineffective”.

In other words, all supposedly negative homeopathic meta-analyses which opponents of homeopathy have relied on, are scientifically bogus…
 
 Who can you trust? We can begin by disregarding Edzard Ernst. I have read several other studies that he has published, and they are all untrustworthy. His work should be discarded… 

In the case of homeopathy, one should stick with what the evidence reveals. And the evidence is that only by removing 95-98% of all studies is the effectiveness of homeopathy not demonstrable…

So, now you are wondering, I am sure: HOW MUCH DID HE GET FOR SELLING HIS SOUL TO BIG PHARMA?

No? You are wondering 1) who this brilliant Swedish scientist, Prof Hahn, is and 2) what article of mine he is criticising? Alright, I will try to enlighten you.

PROFESSOR HAHN

Here I can rely on a comment posted on my blog some time ago by someone who can read Swedish (thank you Bjorn). He commented about Hahn as follows:

A renowned director of medical research with well over 300 publications on anesthesia and intensive care and 16 graduated PhD students under his mentorship, who has been leading a life on the side, blogging and writing about spiritualism, and alternative medicine and now ventures on a public crusade for resurrecting the failing realm of homeopathy!?! Unbelievable!

I was unaware of this person before, even if I have lived and worked in Sweden for decades.

I have spent the evening looking up his net-track and at his blog at roberthahn.nu (in Swedish).

I will try to summarise some first impressions:

Hahn is evidently deeply religious and there is the usual, unmistakably narcissistic aura over his writings and sayings. He is religiously confident that there is more to this world than what can be measured and sensed. In effect, he seems to believe that homeopathy (as well as alternative medical methods in general) must work because there are people who say they have experienced it and denying the possibility is akin to heresy (not his wording but the essence of his writing).

He has, along with his wife, authored at least three books on spiritual matters with titles such as (my translations) “Clear replies from the spiritual world” and “Connections of souls”.

He has a serious issue with skeptics and goes on at length about how they are dishonest bluffers[sic] who willfully cherry-pick and misinterpret evidence to fit their preconceived beliefs.

He feels that desperate patients should generally be allowed the chance that alternative methods may offer.

He believes firmly in former-life memories, including his own, which he claims he has found verification for in an ancient Italian parchment.

His main arguments for homeopathy are Claus Linde’s meta analyses and the sheer number of homeopathic research that he firmly believes shows it being superior to placebo, a fact that (in his opinion) shows it has a biological effect. Shang’s work from 2005 he dismisses as seriously flawed.

He also points to individual research like this as credible proof of the biologic effect of remedies.

He somewhat surprisingly denies recommending homeopathy despite being convinced of its effect and maintains that he wants better, more problem oriented and disease specific studies to clarify its applicability. (my interpretation)

If it weren’t for his track record of genuine, acknowledged medical research and him being a renowned authority in a genuine, scientific medical field, this man would be an ordinary, religiously devout quack.

What strikes me as perhaps telling of a consequence of his “exoscientific” activity, is that Hahn, who holds the position of research director at a large city trauma and emergency hospital is an “adjungerad professor”, which is (usually) a part time, time limited, externally financed professorial position, while any Swedish medical doctor with his very extensive formal merits would very likely hold a full professorship at an academic institution.

END OF QUOTE

MY 2000 PAPER THAT SEEMS TO IRRITATE HAHN

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.

And that is, as far as I can see, the whole mysterious story. I cannot even draw a conclusion – all I can do is to ask a question:

DOES ANYONE UNDERSTAND WHAT THEY ARE GOING ON ABOUT?

We used to call it ‘alternative medicine’ (on this blog, I still do so, because I believe it is a term as good or bad as any other and it is the one that is easily recognised); later some opted for ‘complementary medicine’; since about 15 years a new term is en vogue: INTEGRATED MEDICINE (IM).

Supporters of IM are adamant that IM is not synonymous with the other terms. But how is IM actually defined?

One of IM’s most prominent defenders is, of course Prince Charles. In his 2006 address to the WHO, he explained: “We need to harness the best of modern science and technology, but not at the expense of losing the best of what complementary approaches have to offer. That is integrated health – it really is that simple.”

Perhaps a bit too simple?

There are several more academic definitions, and it seems that, over the years, IM-fans have been busy moving the goal post quite a bit. The original principle of ‘THE BEST OF BOTH WORLDS’ has been modified considerably.

  • IM is a “comprehensive, primary care system that emphasizes wellness and healing of the whole person…” [Arch Intern Med. 2002;162:133-140]
  • IM “views patients as whole people with minds and spirits as well as bodies and includes these dimensions into diagnosis and treatment.” [BMJ. 2001; 322:119-120]

During my preparations for my lecture at the 16th European Sceptics Congress in London last week (which was on the subject of IM), I came across a brand-new (September 2015) definition. It can be found on the website of the COLLEGE OF MEDICINE  This Michael Dixon-led organisation can be seen as the successor of Charles’ ill-fated FOUNDATION FOR INTEGRATED HEALTH; it was originally to be called COLLEGE FOR INTEGRATED MEDICINE. We can therefore assume that they know best what IM truly is or aspires to be. The definition goes as follows:

IM is a holistic, evidence-based approach which makes intelligent use of all available therapeutic choices to achieve optimal health and resilience for our patients.

This may sound good to many who are not bothered or unable to think critically. It oozes political correctness and might therefore even impress some politicians. But, on closer scrutiny, it turns out to be little more than offensive nonsense. I feel compelled to publish a short analysis of it. I will do this by highlighting and criticising the important implications of this definition one by one.

1) IM is holistic

Holism has always been at the core of any type of good health care. To state that IM is holistic misleads people into believing that conventional medicine is not holistic. It also pretends that medicine might become more holistic through the addition of some alternative modalities. Yet I cannot imagine anything less holistic than diagnosing patients by merely looking at their iris (iridology) or assuming all disease stems from subluxations of the spine (chiropractic), for example. This argument is a straw-man, if there ever was one.

2) IM is evidence-based

This assumption is simply not true. If we look what is being used under the banner of IM, we find no end of treatments that are not supported by good evidence, as well as several for which the evidence is squarely negative.

3) IM is intelligent

If it were not such a serious matter, one could laugh out loud about this claim. Is the implication here that conventional medicine is not intelligent?

4) IM uses all available therapeutic choices

This is the crucial element of this definition which allows IM-proponents to employ anything they like. Do they seriously believe that patients should have ALL AVAILABLE treatments? I had thought that responsible health care is about applying the most effective therapies for the condition at hand.

5) IM aims at achieving optimal health

Another straw-man; it implies that conventional health care professionals do not want to restore their patients to optimal health.

In my lecture, which was not about this definition but about IM in general, I drew the following six conclusions:

  1. Proponents of IM mislead us with their very own, nonsensical terminology and definitions.
  2. They promote two main principles: use of quackery + holism.
  3. Holism is at the heart of all good medicine; IM is at best an unnecessary distraction.
  4. Using holism to promote quackery is dishonest and counter-productive.
  5. The integration of quackery will render healthcare not better but worse.
  6. IM flies in the face of common sense and medical ethics; it is a disservice to patients.

On a blog about alternative medicine, the issue of ‘pseudoscience’ can never be far. Several posts have already focussed specifically on this topic. Recently, I came across an excellent article on homeopathy (which is well worth reading in full). It concluded by listing the techniques commonly used in pseudoscience.

I think this is important and relevant to much of the discussions about alternative medicine. Therefore I take the liberty to cite it here in full. According to the authors of this article, John Timmer, Matt Ford, Chris Lee, and Jonathan Gitlin, the techniques are as follows:

  • Ignore settled issues in science: We know a great deal about the behavior of water (and evolution, and other contentious topics), but there are many efforts to introduce new science without ever addressing the existing body of knowledge. As such, many of the basic tenets of topics such as homeopathy appear to be ungrounded in reality as we understand it.
  • Misapplication of real science: Quantum mechanics is an undeniably successful description of parts of the natural world, but the limitations of its applicability are widely recognized by the scientific community, if not the general public. Pseudoscientists such as homeopaths appear to cynically target this sort of ignorance by applying scientific principles to inappropriate topics.
  • Rejection of scientific standards: Over the centuries, science has established standards of evidence and experiment to ensure that data remains consistent and reproducible. But these strengths are presented as weaknesses that make science impervious to new ideas, a stance that is often accompanied by…
  • Claims of suppression: Pseudoscience is rejected because it does not conform to the standards held by the scientific community. That community is depicted as a dangerous hegemony that rejects new ideas in order to perpetuate a stifling orthodoxy. This happens in spite of many examples of radical ideas that have rapidly gained not only acceptance, but major prizes, when they were properly supported by scientific evidence.
  • A conclusion/evidence gap: Many areas of pseudoscience do not set out to examine a phenomenon but rather have the stated goal of supporting a preordained conclusion. As such, they often engage in excessive logical leaps when the actual data is insufficient to support the desired conclusion.
  • Focusing on the fringes: All areas of science have anomalous data and anecdotal findings that are inconsistent with the existing understanding. But those anomalies should not obscure the fact that the vast majority of current data does support the predominant theories. In the hands of a pseudoscientist, these unconnected edge cases are presented as a coherent body of knowledge that supports the replacement of existing understandings.

Perhaps the clearest theme running through many areas of pseudoscience, however, is the attempt to make a whole that is far, far greater than the sum of its parts. Enlarging a collection of terminally-flawed trivia does not somehow strengthen its scientific significance. This is especially true when many of the components of the argument don’t form a coherent whole. For example, quantum entanglement, structured water, and silica are essentially unrelated explanations, and any support for one of them makes no difference to the others. Yet, somehow, presenting them all at once is supposed to make the case for water’s memory harder to dismiss.

END OF QUOTE

No, this post is not about the pop duo ‘EURYTHMICS’, it is about ‘EURYTHMY’ which pre-dates the pop duo by a few decades.

Eurythmy is a movement therapy of anthroposophic medicine which, according to its proponents, has positive effects on a person’s physical body, spirit, and soul. It is involves expressive movements developed by Rudolf Steiner in conjunction with Marie von Sivers in the early 20th century. It is used as a performance art, in education, especially in Steiner schools, and – as part of anthroposophic medicine – for therapeutic purposes. Here is what one pro-eurymthy website tells us about it:

Eurythmy is one of Rudolf Steiner’s proudest achievements. To better understand what Steiner says about eurythmy, you should read his self-titled “A Lecture on Eurythmy” Not always one to boast, Steiner says:

EURYTHMY has grown up out of the soil of the Anthroposophical Movement, and the history of its origin makes it almost appear to be a gift of the forces of destiny.

Steiner, Rudolf. A Lecture on Eurythmy, 1923

Clearly, Steiner felt that eurythmy was something very special, and of great importance. As such, eurythmy is a tool of Anthroposophy used to reveal and bring about a certain “spiritual impulse” in our age:


Read
Online
For it is the task of the Anthroposophical Movement to reveal to our present age that spiritual impulse which is suited to it.I speak in all humility when I say that within the Anthroposophical Movement there is a firm conviction that a spiritual impulse of this kind must now, at the present time, enter once more into human evolution. And this spiritual impulse must perforce, among its other means of expression, embody itself in a new form of art. It will increasingly be realised that this particular form of art has been given to the world in Eurythmy.

Steiner, Rudolf. A Lecture on Eurythmy

 

The question is, of course,  whether as a therapy eurythmy works. A recent publication might give an answer.

The aim of this systematic review was to update and summarize the relevant literature on the effectiveness of eurythmy in a therapeutic context since 2008. It is thus an up-date of a previously published review. This paper  found 8 citations which met the inclusion criterion: 4 publications referring to a prospective cohort study without control group (the AMOS study), and 4 articles referring to 2 explorative pre-post studies without control group, 1 prospective, non-randomized comparative study, and 1 descriptive study with a control group. The methodological quality of studies ranged in from poor to good, and in sample size from 5 to 898 patients. In most studies, EYT was used as an add-on, not as a mono-therapy. The studies described positive treatment effects with clinically relevant effect sizes in most cases.

For the up-date, different databases like PubMed, MEDPILOT, Research Gate, The Cochrane Library, DIMDI, Arthe and also the journal databases Der Merkurstab and the European Journal of Integrative Medicine were searched for prospective and retrospective clinical trials in German or English language. There were no limitations for indication, considered outcome or age of participants. Studies were evaluated with regard to their description of the assembly process and treatment, adequate reporting of follow-ups, and equality of comparison groups in controlled trials.

Eleven studies met the inclusion criteria. These included two single-arm, non-controlled pilot studies, two publications on the same non-randomized controlled trial and one case study; six further studies referred to a prospective cohort study, the Anthroposophic Medicine Outcome Study. Most of these studies described positives treatment effects with varying effect sizes. The studies were heterogynous according to the indications, age groups, study design and measured outcome. The methodological quality of the studies varied considerably.

The authors who all come from the Institute of Integrative Medicine, anthroposophical University of Witten/Herdecke in Germany draw the following conclusions: Eurythmy seems to be a beneficial add-on in a therapeutic context that can improve the health conditions of affected persons. More methodologically sound studies are needed to substantiate this positive impression.

I am puzzled! How on earth could they reach this conclusion? There is not a single trial that would  allow to establish cause and effect!!! The way I read the evidence from the therapeutic trials included in this and the previous reviews, the only possible conclusion is that EURYTHMY IS A WEIRD THERAPY FOR WHICH THERE IS NOT GOOD EVIDENCE WHATSOEVER.

A recent article promised to provide details of the ’10 most mind-numbingly stupid alternative therapies’. Naturally I was interested what these might be. In descending order they are, according to the author of the most enjoyable piece:

10 VEGA TESTING

9 REIKI

8 CRYSTAL HEALING

7 URINE THERAPY

6 DETOXIFYING FOOT PADS

5 WHEAT-GRASS ENEMAS

4 PSYCHIC SURGERY

3 OZONE THERAPY

2 CUPPING THERAPY

1 HOMEOPATHY

This is quite a list, I have to admit. Despite some excellent choices, I might disagree with a few of them. Detoxifying foot pads will take care of a common and most annoying problem: smelly feet; therefore it cannot be all bad. And drinking your own urine can even be a life-saver! Lets assume someone has a kidney or bladder cancer. Her urine might, at one stage, be bright red with blood. The urine therapy enthusiast would realise early that something is wrong with her, go and see a specialist, get early treatment and save her life. No, no no, I cannot fully condemn urine therapy!

The other thing with the list is that one treatment which is surely mind-bogglingly stupid is missing: CHELATION THERAPY.

I have previously written about this form of treatment and pointed out that some practitioners of alternative medicine (doctors, naturopaths, chiropractors and others) earn a lot of money claiming that chelation therapy (a well-established mainstream treatment for acute heavy metal poisoning) is an effective therapy for cardiovascular and many other diseases. However, this claim is both implausible and not evidence-based. Several systematic reviews of the best evidence concluded less than optimistically:

…more controlled studies are required to determine the efficacy of chelation therapy in cardiovascular disease before it can be used broadly in the clinical setting.

The best available evidence does not support the therapeutic use of EDTA chelation therapy in the treatment of cardiovascular disease.

Given the potential of chelation therapy to cause severe adverse effects, this treatment should now be considered obsolete.

The available data do not support the use of chelation in cardiovascular diseases.

Despite all this, the promotion of chelation continues unabated. An Australian website, ironically entitled ‘LEADERS IN INTEGRATIVE MEDICINE’, might stand for many others when it informs its readers about chelation therapy. Here is a short passage:

Chelation therapy has the ability to remove the calcium from artery plaques as well as remove toxic ions, reduce free radical damage and restore circulation to all tissues of the body. A growing number of physicians use chelation therapy to reverse the process of atherosclerosis (hardening of the arteries) and as an alternative to angioplasty and bypass surgery.

Chelation therapy is a treatment to be considered for all conditions of reduced blood flow (coronary artery disease, cerebral vascular disease, peripheral vascular disease, angina, vertigo, tinnitus, senility), any situations of heavy metal toxicity or tissue overload and various chronic immune system disorders such as rheumatoid arthritis. Intravenous vitamin C is useful for the treatment of chronic and acute infections, fatigue, pre- and post-surgery and to boost the immune system while undergoing cancer therapies.

Not bad, isn’t it. How come such mind-numbing stupidity escaped the author of the above article? Was it an oversight? Was the choice just too overwhelming? Or did he not think chelation was all that funny? I ought to mention that it is not at all harmless like sampling your own urine or having a Reiki healer sending some ‘healing energy’.

Whatever the reason, I hope for an up-date of the list, he will consider chelation as a seriously mind-numbing contender.

While my last post was about the risk following some naturopaths’ advice, this one is about the effectiveness of naturopathic treatments. This is a complex subject, not least because naturopaths use a wide range of therapies (as the name implies, they pride themselves of employing all therapeutic means supplied by nature). Some of these interventions are clearly supported by good evidence; for instance, nobody would doubt the effectiveness of a healthy diet or the benefits of regular exercise. But what about all the other treatments naturopaths use? The best approach to find an answer might be to assess not each single therapy but to evaluate the entire package of the naturopathic approach, and not a single study but all such trials.

This is precisely what US researchers have recently done. The purpose of this interesting, new systematic review was to compile and consolidate research that has investigated the whole practice of naturopathic medicine as it is practiced in community settings in order to better assess the quantity and quality of the research, and clinical effect, if any.

In order to get included into the review, studies had to report results from multi-modal treatment delivered by North American naturopathic doctors. The effect size for each study was calculated; no meta-analysis was undertaken.

Fifteen studies met the authors’ inclusion criteria. They covered a wide range of chronic diseases. Most studies had low to medium risks of bias including acknowledged limitations of pragmatic trials. Effect sizes for the primary medical outcomes varied and were statistically significant in 10 out of 13 studies. A quality of life metric was included in all of the RCTs with medium effect size and statistical significance in some subscales.

The authors concluded that previous reports about the lack of evidence or benefit of naturopathic medicine (NM) are inaccurate; a small but compelling body of research exists. Further investigation is warranted into the effectiveness of whole practice NM across a range of health conditions.

This sounds like good news for naturopathy! However, there are several important caveats:

  • the authors seem to have only looked at US studies (naturopathy is a European tradition!),
  • the searches were done three years ago, and more recent data were thus omitted,
  • the authors included all sorts of investigations, even uncontrolled studies; only 6 were RCTs,
  • rigorous trials were very scarce; and for each condition, they were even more so,
  • the authors mention the PRISMA guidelines for systematic reviews implying that they followed them but, in fact, they did not.

My biggest concern, however, is something else. It relates to the interventions tested in these studies. The authors claim that their results table provides full details on this issue but this is unfortunately not true. All we have by way of an explanation is the authors’ remark that the interventions tested in the studies of their review included diet counseling and nutritional recommendations, specific home exercises and physical activity recommendations, deep breathing techniques or other stress reduction strategies, dietary supplements including vitamins, hydrotherapy, soft-tissue manual techniques, electrical muscle stimulation, and botanical medicines.

Survey data from two US states tell us that the most commonly prescribed naturopathic therapeutics are botanical medicines (51% of visits in Connecticut, 43% in Washington), vitamins (41% and 43%), minerals (35% and 39%), homeopathy (29% and 19%) and allergy treatments (11% and 13%). They also inform us that the mean length of a consultation with an US naturopath is about 40 minutes.

I think, this puts things into perspective. If I advise a patient with diabetes or hypertension or coronary heat disease to follow an appropriate diet, exercise and to adhere to some stress reduction program, if in addition I show empathy and compassion during a 40 minute consultation and make sure that my advise is taken seriously and subsequently adhered to, the outcome is likely to be positive. Naturopaths may elect to call this package of intervention ‘naturopathy’, however, I would call it good conventional medicine.

The problem, I think is clear: good therapeutic advice is effective but it is not naturopathy, and it cannot be used to justify the use of doubtful interventions like homeopathy or all sorts of dodgy supplements. Testing whole treatment packages of this nature can therefore lead to highly misleading results, particularly if the researchers draw unwarranted conclusions about specific schools of health care.

When I come across a study with the aim to “examine the effectiveness of acupuncture to relieve symptoms commonly observed in patients in a hospice program” my hopes are high. When I then see that its authors are from the ‘New England School of Acupuncture’, the ‘All Care Hospice and the ‘Tufts University School of Medicine, Boston, my hopes for a good piece of science are even higher. So, let’s see what this new paper has to offer.

A total of 26 patients participated in this acupuncture ‘trial’, receiving a course of weekly treatments that ranged from 1 to 14 weeks. The average number of treatments was five. The Edmonton Symptom Assessment Scale (ESAS) was used to assess the severity of pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being, and dyspnoea. A two-tailed, paired t test was applied to the data to compare symptom scores pre- versus post-acupuncture treatment. Patients enrolled in All Care Hospice’s home care program were given the option to receive acupuncture to supplement usual care offered by the hospice team. Treatment was provided by licensed acupuncturists in the patient’s place of residence.

The results indicated that 7 out of 9 symptoms were significantly improved with acupuncture, the exceptions being drowsiness and appetite. Although the ESAS scale demonstrated a reduction in symptom severity post-treatment for both drowsiness and appetite, this reduction was not found to be significant.

At tis stage, I have lost most of my hopes for good science. This is not a ‘trial’ but a glorified case-series. There is no way that the stated aim can be pursued with this type of methodology. There is no reason whatsoever to assume that the observed outcome can be attributed to acupuncture; the additional attention given to these patients is but one of several factors that are quite sufficient to explain their symptomatic improvements.

This is yet another disappointment then from the plethora of ‘research’ into alternative medicine that, on closer inspection, turns out to be little more than thinly disguised promotion of quackery. These days, I can bear such disappointments quite well – after all, I had many years to get used to them. What I find more difficult to endure is the anger that overcomes me when I read the authors’ conclusion: Acupuncture was found to be effective for the reduction and relief of symptoms that commonly affect patient QOL. Acupuncture effectively reduced symptoms of pain, tiredness, nausea, depression, anxiety, and shortness of breath, and enhanced feelings of well-being. More research is required to assess the long-term benefits and symptom reduction of acupuncture in a palliative care setting.

This is not disappointing; in my view, this is scientific misconduct by

  • the authors,
  • the institutions employing the authors,
  • the ethics committee that has passed the ‘research’,
  • the sponsors of the ‘research’,
  • the peer-reviewers of the paper,
  • the journal and its editors responsible for publishing this paper.

The fact that this sort of thing happens virtually every day in the realm of alternative medicine does not render this case less scandalous, it merely makes it more upsetting.

This article is hilarious, I think. It was written by Heike Bishop, a homeopath who works in Australia. Here she tries to advise colleagues how best to defend homeopathy and how to deal effectively with the increasingly outspoken criticism of homeopathy. Below is the decisive passage from her article; I have not changed or omitted a word, not even her grammatical or other mistakes [only the numbers in brackets were inserted by me; they refer to my comments added below]:

Getting up in the morning and hearing that all the television and radio station report that it is dangerous for people to see their homoeopath, is utterly heart breaking. Even more so because I grew up in East Germany where the government suppressed free speech and anything that was off the beaten path [1]. So what can we do in times like these?

First of all, watch out for Government inquiries. History has shown that they are usually not favourable towards homoeopathy [2] unless you live in Switzerland [3]. It is vitally important in times like these to put differences aside amongst our professional peers. Every association should be mobilised to take an active and ONGOING role to educate and advertise the benefits of homoeopathy [4]. If things have gone too far already, talk about freedom of choice [5]. Write articles and join blogs talking about what you can do specifically for certain conditions [6].  Encourage your patients to tell their success stories in blogs and other social media forums [7]. It is in most cases utterly useless to engage in any conversation [8] online with trolls [9].

Try to develop a calloused skin when it comes to criticism. Your patients don’t want to hear how difficult it is to be a homeopath [10], they want you to be in control and to be reassured that their treatment continues [11]. When someone asks you to comment on an attack on homoeopathy, put your best smile on and state how threatened the pharmaceutical industry must be to resort to such tactics [12].

Staphysagria is indeed a good remedy. Hahnemann also knew its benefits and even alternated it with Arsenicum the day his first wife died and he got a letter that the hospital built in his name allowed patients to choose their treatment between allopathy and homoeopathy [13]. That was the only time he took two remedies on the same day! [14]

Find out what you can about your country’s own internet trolls [15]. However, don’t underestimate their effectiveness in swaying popular opinion [16]. There is no denying that their methods are very effective [17]. It doesn’t matter how ludicrous their comments are, don’t go into direct explanation [18]. Learn from the enemy [19] and repeat a positive message over and over again so it can’t be contorted [20].

Our colleges should support post-graduate studies featuring marketing and media courses [21]. I once met a Homoeopath from the UK and she pointed out that part of the training in the UK is for students to hold homoeopathic first aid courses to promote homoeopathy [22]. Everyone is different – some of us are happy to stand in front of an audience others choose the pen as their sword [23]. The main thing is to do something to save the image of our healing art [24].

  1. Is she implying that facing criticism of homeopathy is akin to living in a totalitarian state? Or that criticism is a violation of free speech?
  2. I wonder why this is so – nothing to do with the evidence, I presume?
  3. Does she refer to the famous ‘Swiss Government report’ which was not by the Swiss Government at all?
  4. ‘Advertise and educate’ seems to be homeopathic speak for ‘MISLEAD’
  5. Good idea! Freedom of choice is a perfect argument (in this case, my choice would be to have a bottle of champagne at around 6 pm every day – on the NHS, of course).
  6. Certain conditions??? And I thought homeopaths do not treat conditions, only whole people.
  7. And forbid them to disclose stories where things did not work out quite so well?
  8. Very wise! Conversations are fraught with the danger of being found wrong.
  9. Critics are not critics but ‘trolls’ – makes sense.
  10. I would have thought that practising as a homeopath is not difficult at all – in most countries, they don’t even check whether you can spell the name correctly.
  11. Is it not rather the homeopath who wants the treatment to continue – after all, it is her livelihood?
  12. Ah yes, BIG PHARMA, the last resort of any quack!
  13. Did she not just praise patient choice as an important virtue?
  14. Hahnemann was famously cantankerous and argumentative all his life; does that mean that his remedies did not work?
  15. Homeopaths might need that for your ad hominem attacks.
  16. Never underestimate the power of truth!!!
  17. This might show that it is you and not the ‘trolls’ who are ludicrous.
  18. Particularly as there are no direct explanations for homeopathy.
  19. First the critics were ‘trolls’, now they have been upgraded to ‘enemy’! Is it really a war?
  20. You need to repeat it at least regularly so that eventually you believe it yourself.
  21. Are marketing and media a substitute for evidence?
  22. Really, first aid? Do homeopaths know what this is? Obviously not!
  23. But real clinicians, homeopaths call them allopaths, are quite happy simply with effective treatments that help patients to improve.
  24. And I thought the main thing was to treat patients with the most effective therapies available.

ENOUGH JOKING AND SARCASM!

There is, of course, a very serious message in all of this: when under pressure, homeopaths seem to think of all sorts of things in their (and homeopathy’s) defense – some more rational than others – but the ideas that criticism might be a good way to generate progress, and that a factual debate about the known facts might improve healthcare, do not seem to be amongst them.

The notion that the use homeopathy instead of real medicine might save money (heavily promoted by homeopaths and their followers, often to influence health politics) has always struck me as being utterly bizarre: without effectiveness, it is hard to imagine cost-effectiveness. Yet the Smallwood report (in)famously claimed that the NHS would save lots of money, if GPs were to use more homeopathy. At the time, I thought this was such a serious and dangerous error that I decided to do something about it. My objection to the flawed report might have prevented it being taken seriously by anyone with half a brain, but sadly it also cost me my job (the full story can be read here).

Later publications perpetuated the erroneous idea of homeopathy’s cost-effectiveness. For instance, an Italian analysis (published in the journal ‘Homeopathy’) concluded that homeopathic treatment for respiratory diseases (asthma, allergic complaints, Acute Recurrent Respiratory Infections) was associated with a significant reduction in the use and costs of conventional drugs. Costs for homeopathic therapy are significantly lower than those for conventional pharmacological therapy. Again, this paper was so badly flawed that, other than some homeopaths, nobody seemed to have taken the slightest notice of it.

Now a new article has been published on this very subject. The aim of this study was to compare the health care costs for patients using additional homeopathic treatment (homeopathy group) with the costs for those receiving usual care (control group).

Cost data provided by a large German statutory health insurance company were retrospectively analysed from the societal perspective (primary outcome) and from the statutory health insurance perspective. Patients in both groups were matched using a propensity score matching procedure based on socio-demographic variables as well as costs, number of hospital stays and sick leave days in the previous 12 months. Total cumulative costs over 18 months were compared between the groups with an analysis of covariance (adjusted for baseline costs) across diagnoses and for six specific diagnoses (depression, migraine, allergic rhinitis, asthma, atopic dermatitis, and headache).

Data from 44,550 patients (67.3% females) were available for analysis. From the societal perspective, total costs after 18 months were higher in the homeopathy group (adj. mean: EUR 7,207.72 [95% CI 7,001.14-7,414.29]) than in the control group (EUR 5,857.56 [5,650.98-6,064.13]; p<0.0001) with the largest differences between groups for productivity loss (homeopathy EUR 3,698.00 [3,586.48-3,809.53] vs. control EUR 3,092.84 [2,981.31-3,204.37]) and outpatient care costs (homeopathy EUR 1,088.25 [1,073.90-1,102.59] vs. control EUR 867.87 [853.52-882.21]). Group differences decreased over time. For all diagnoses, costs were higher in the homeopathy group than in the control group, although this difference was not always statistically significant.

The authors of this paper (who have a long track record of being pro-homeopathy) concluded that, compared with usual care, additional homeopathic treatment was associated with significantly higher costs. These analyses did not confirm previously observed cost savings resulting from the use of homeopathy in the health care system.

The next time someone does a (no doubt costly) cost-effectiveness analysis of an ineffective treatment, it would be good (and cost-effective) to remember: WITHOUT EFFECTIVENESS, THERE CAN BE NO COST-EFFECTIVENESS.

“So what? We all know that homeopathy is nonsense,” I hear some people argue, “at the same time, it is surely trivial. Let those nutters do what they want; at least it is not harmful!”

If you are amongst the many consumers who think so, please read this announcement that arrived in my inbox today:

The first International Conference:

Homeoprophylaxis:

A Worldwide Choice HP

The NON-TOXIC form of disease prevention 

Are you questioning the pressure to vaccinate?

Is there another way to protect your children? 

Do you have another choice?

YES YOU DO!

Homeoprophylaxis or Homeopathic Immunization 

Healthcare Professionals!!

Learn how to incorporate homeoprophylaxis into your existing practise 

Parents!!

Learn how you can get a homeoprophylactic program going for your family 

Everyone!!

Learn how homeoprophylaxis is a gentle, nontoxic alternative for you to choose 

Where: Dallas, Texas, USA

When: October 2-4, 2015 

Reserve your place TODAY to hear speakers from around the world. 

  • Dr Isaac Golden (Australia) – 20 years of HP research
     
  • Neil Miller (USA) – vaccines and infant mortality rates
     
  • Dr Harry van der Zee (the Netherlands) – HP for epidemics
     
  • Dr Tetyana Obukhanuch – how the healthy immune system works
     
  • Ravi Roy& Carola Lage Roy (Germany) – HP in Europe
     
  • Alan Phillips, JD (USA) – legalities of vaccine exemptions
     
  • Ananda More (Canada) – “In Search of Evidence” movie
     
  • And special guest, Dr Andrew Wakefield

I THINK I CAN REST MY CASE.

In the realm of alternative medicine, we encounter many therapeutic claims that beggar belief. This is true for most modalities but perhaps for none more than chiropractic. Many chiropractors still adhere to Palmer’s gospel of the ‘inate’, ‘subluxation’ etc. and thus they believe that their ‘adjustments’ are a cure all. Readers of this blog will know all that, of course, but even they might be surprised by the notion that a chiropractic adjustment improves the voice of a choir singer.

This, however, is precisely the ‘hypothesis’ that was recently submitted to an RCT. To be precise, the study investigated the effect of spinal manipulative therapy (SMT) on the singing voice of male individuals.

Twenty-nine subjects were selected among male members of a local choir. Participants were randomly assigned to two groups: (A) a single session of chiropractic SMT and (B) a single session of non-therapeutic transcutaneous electrical nerve stimulation (TENS). Recordings of the singing voice of each participant were taken immediately before and after the procedures. After a 14-day wash-out period, procedures were switched between groups: participants who underwent SMT on the first occasion were now subjected to TENS and vice versa. Recordings were assessed via perceptual audio and acoustic evaluations. The same recording segment of each participant was selected. Perceptual audio evaluation was performed by a specialist panel (SP). Recordings of each participant were randomly presented thus making the SP blind to intervention type and recording session (before/after intervention). Recordings compiled in a randomized order were also subjected to acoustic evaluation.

No differences in the quality of the singing on perceptual audio evaluation were observed between TENS and SMT.

The authors concluded that no differences in the quality of the singing voice of asymptomatic male singers were observed on perceptual audio evaluation or acoustic evaluation after a single spinal manipulative intervention of the thoracic and cervical spine.

Laughable? Yes!

There is nevertheless an important point to be made here, I feel: some claims are just too silly to waste resources on. Or, to put it in more scientific terms, hypotheses require much more than a vague notion or hunch.

To set up, conduct and eventually publish an RCT as above requires expertise, commitment, time and money. All of this is entirely wasted, if the prior probability of a relevant result approaches zero. In the realm of alternative medicine, this is depressingly often the case. In the final analysis, this suggests that all too often research in this area achieves nothing other than giving science a bad name.

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