UK homeopathy awareness week

June 14th – 21st 2010 [and 2012] is the UK homeopathy awareness week, so I thought it might be a good idea to try and raise awareness of homeopathy.

Cinchona

Homeopathy is based on the principle of similia similibus curantur (likes are cured by likes). The hypothesis is that symptoms of illness are caused by a derangement of the ‘vital force‘ assumed to be present in a living organism and substances which elicit the same derangement (i.e. symptoms) will rid the body of the illness. This was originally identified in the context of homeopathy by Hahnemann with reference to cinchona bark (source of quinine) and malaria. The previous proposed mechanism of effectiveness of quinine against malaria was its bitterness, but Hahnemann sensibly identified that other bitter substances did not offer the same protection. Instead, after taking cinchona and experiencing a reaction similar to the reaction he associated with malaria, he hypothesised that it was this similarity in symptoms that made cinchona bark effective.

Modern homeopaths still use a similar method to identify their treatments. When in a healthy state they try a preparation and keep a detailed diary of any effects that they feel the treatment has on them. This is called ‘proving’ although what it is supposed to prove is hard to determine since there are no rigorous controls in place and the results are not statistically tested to see if they are anything other than random. Consider the perceived effects of taking peregrine falcon blood for example:

Short statement on peregrine falcons:

The Peregrine Falcon is widely renowned for its incredible speed. Estimates vary, but commonly cited top velocities are in the range of 290-320 km/h (180-200 mph), achieved only during the characteristic swoop (hunting dive)…the Peregrine Falcon is the fastest creature on earth.

Observation during proving:

‘Drove back from the party (had some wine but not so much) quite fast but well, changing speed as necessary. It seemed faster to the others in the car than to me.’

I heartily recommend reading the entire page about the proving of peregrine falcon blood – it is an education into how homeopaths derive their information about the treatments they prescribe (and it is ludicrous to the point of hilarity). Is this really a rigorous approach to testing healthcare products or is this more about symbolism, appeal to the mystical and delusion?

Evidence based medicine occasionally does use elements of similia similbus curantur such as with inoculation and vaccination – where a small or denatured dose of a disease causing agent is introduced with the intent of stimulating an autoimmune response that will prevent the full blown disease from becoming established should the person come into contact with a large active dose of the pathogen.

Foxglove

Also, many physiologically active compounds have medicinal uses because they act on particular organs and metabolic pathways via a biochemical route that can have apparent similarities to the illness being treated. For example, digoxin is a cardiac glycoside found in foxgloves that decreases heart rate and increases force of heart contraction – fatal in large doses, but useful for treating atrial fibrillation in small doses – so at a very gross level this could be considered ‘like treating (rather than curing) like’. It is also vaguely plausible that a substance which elicits a physiological response which mimics symptoms of an illness that arise as part of the body’s immune response (such as raising temperature) may have the effect of fighting an infection (although I have not seen any evidence for this).

Hahnemann’s experience with cinchona happened in 1790 when the medical community of the time was still dominated by the miasma theory and humourism of the Middle Ages. Vitalism was a standard of the medical profession at the time, with good health being dependent on balancing the four vital humours. The idea of a biochemical autoimmune system did not take shape until a century later, but when it did it revolutionised the medical field, bringing about treatments with previously unprecedented success (eradication of smallpox anyone?). Hahnemann had no idea about the mechanism by which the body actually heals itself, he also had no idea that malaria was not caused by a miasma, but by a microscopic parasitic protist of the genus Plasmodium.

Plasmodium falciparum – the protozoan that causes malaria

In short Hahnemann was trying to fit his limited observations into a theoretical framework consistent with the body of assumed knowledge available at the time. The same way that scientists have always worked. However, over time the body of knowledge has changed – vitalism has been rejected as evidence has been amassed which demonstrates that all of the functions historically proposed for vital energy are demonstrably biochemical in nature. Disease is now well recognised as being caused by bacteria, viruses, proteins and biochemical abnormalities rather than by derangement of ‘vital energy’. The idea of a vitalistic treatment for a biochemical problem seems rather at odds with the facts, particularly since there is no evidence to suggest that vital energy even exists. Sticking with malaria, we now know that the antimalarial component of cinchona is quinine, which is no longer effective as an antimalarial due to the resistance evolved by Plasmodium – how such immunity might have evolved in response to vital energy is hard to fathom.

Homeopathy also subscribes to the principle that the smaller the dose, the more effective it is at influencing the vital energy – to the point where homeopathic remedies are diluted until they no longer contain even one molecule of their active ingredient. Indeed it would take a ball of water the size of the solar system to contain one molecule of active ingredient in the more ‘potent’ homeopathic remedies – making them even less tangible than the Emperor’s new clothes. Of course this idea of smaller doses having a bigger effect flies in the face of everything that is demonstrated in evidence based medicine, where dose dependent effects increase with increasing dose size, through a therapeutic window until a plateau is reached or there is an overdose. The Ten23 campaign was all about this misplaced faith in super-dilution.

If homeopaths were able to demonstrate that vital energy exists then homeopathy might have a theoretical leg to stand on, as would chiropractic and a suite of Ayruvedic medicines, but without any evidence for vital energy they remain theoretically unfounded. Interestingly, mainstream medicine was once based on the concept of vital energy, which has only been discarded due to improvements in experimental methods. Vital energy is one of those strange forces in nature that becomes harder to see the harder you look for it – probably because it only exists as a cultural concept that has no relevance in the physical world. This erosion of evidence for vital energy not only leaves homeopathic theory unfounded, but necessarily rejected.

Headstone for 9 month-old girl who died because her parents chose homeopathy over conventional treatments

Theory aside, if there was strong evidence for efficacy of homeopathic remedies then there would be very good reason to question the laws of physics and our current understanding of biology and medicine. However, there is no persuasive evidence for homeopathy’s efficacy. As such it seems bizarre that people still hold on to this outdated and superseded faith-based system of medicine; but then again there are still Flat Earthers, Faith healers and people who drink their own pee, so I suppose it’s no great surprise. There are dangers however – if people choose to use homeopathy in place of medicines that have evidence of efficacy, they run the risk of harm or even death – and I think that’s something everyone should be aware of.

If you love homeopathy…

I was recently struck by an odd blog post “If you love homeopathy – don’t vote Liberal Democrat!”

This is a post which berates Dr. Evan Harris MP for all manner of misdemeanours, not least his strong and vocal position against homeopathy. The blogger (one Sue Young) goes so far as to quote two articles from the GMC code that she feels Dr. Harris is contravening through his activities [update 14th Feb 2010 – apparently the blog post was based on a letter written by Lionel Milgrom, see Gimpy’s blog for details]. I wrote a comment relating to the fact that the overriding focus of the GMC guidelines is care to patients and it seems that Dr. Harris is fulfilling his duty to the GMC by attempting to “protect and promote the health of patients and the public” by illuminating the lack of evidence for the efficacy of homeopathy. It appears (unsurprisingly) that my comment did not make it through the comment review process, so I have posted it (and my follow-up) below.

It is not the berating of Dr. Harris that struck me as odd, nor the call to boycott the Liberal Democrats – it is the use of the term “if you love homeopathy”. This is a bit incongruous. I can understand someone loving what they do; after all I love my job, but I wouldn’t think to rely on my (admittedly irrational) fondness for dead animals as a way of motivating people to see things from my perspective. Moreover, “love” has some important connotations – not least unconditional acceptance or bias. It is here that we begin to see where the problem with homeopathy really lies.

I have said before (a couple of times) that homeopaths are believers in a 200 year old doctrine – which is why homeopathy has not changed appreciably in those two centuries. It is the inability to see past their love for their discipline that has meant that it has not been allowed to adapt and evolve. As a result homeopaths keep practicing their art with complete faith in its efficacy, despite the fact that evidence has repeatedly shown that homeopathy does not work appreciably beyond placebo (unless the studies assessing it are of low quality). Even where studies conclude that homeopathy is not effective, there are examples of homeopaths cherry-picking statements and citing them as support.

Rather like a parent is biased towards their child because of their love, homeopaths are biased towards their discipline. Evidence against the efficacy of homeopathy merely makes homeopaths feel more defensive. Logical refutation of the principles of homeopathy leads homeopaths to doubt well established facts about physics and biology rather than change their assumptions about homeopathy. It’s like a parent being confronted with video footage of their child shoplifting and responding by saying “but my child would never do that – you must be mistaken”. This is not how science works. This is certainly not how medicine should work.

Until homeopaths can put aside their love of homeopathy they simply cannot be trusted to work with the best interests of their patients in mind. Ignoring or twisting evidence to make it fit what is already believed is not beneficial. If homeopathy is ever going to be more than a dogmatic anachronism it needs to start accepting criticism and more to the point it needs to start recognising the inherent bias introduced by those that love homeopathy.

My comments:

It should be pointed out here that article 46 and 47 is not intended to defend the actions of colleagues who do not fulfil the duties of a doctor registered with the General Medical Council:

“Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and you must:

Make the care of your patient your first concern

Protect and promote the health of patients and the public

Provide a good standard of practice and care

Keep your professional knowledge and skills up to date

Recognise and work within the limits of your competence

Work with colleagues in the ways that best serve patients’ interests“

It seems that Dr. Harris is fulfilling his duty to the GMC by attempting to “protect and promote the health of patients and the public” by illuminating the lack of evidence for the efficacy of homeopathy.

My follow up comment:

I see that you only publish comments that support your opinion. How wonderfully hypocritical in a blog about bias, but I suppose it’s only to be expected that a homeopath will cherry-pick what they want to hear.

One lump or two?

One lump or two? 'High potency' homeopathic pillules are nothing but sugar

The 10:23 campaign seems to be stirring up a wasps nest amongst homeopaths – fortunately these wasps have a venom so dilute that they are incapable of doing much more than make an angry buzz. I would feel sorry for them if they weren’t so adamant that their flimsy belief system is capable of treating serious illnesses like type I diabetes, gangrene, appendicitis, AIDS, malaria, etc. (you don’t believe that they make such claims? check out Nancy Malik’s twitter account: http://twitter.com/DrNancyMalik).

Of course, some homeopaths have taken up the #ten23 hashtag and are fighting a spirited (and sometimes spiritual) battle against the arrayed forces of science, scepticism and general doubt (as is their right). Needless to say their response does tend to rely heavily on bombast, unfounded statements from anecdote and links to videodotes or webpages promoting homeopathy, although seldom to anything resembling rigorous, peer-reviewed scientific studies (the odd basket of carefully picked cherries does turn up). But of course, science is clearly lagging behind – in the words of one homeopath twitterer (@HomHeals):

Homeopathy – Waiting for Science to Catch Up!

This made me chuckle, because it put me in mind of other unfounded beliefs that science has caught up with and subsequently shredded with Ockham’s Razor – like Jack the Ripper in a lab coat.

Approximation of my mental image of science armed with Ockham's Razor, hunting down woo. DISCLAIMER This is in no way meant to represent a threat of physical violence - I abhor such things.

Scary science is gonna get you! DISCLAIMER This is in no way meant to represent a threat of physical violence

But of course, it’s not like that. There is no dichotomy between science and homeopathy. Science is a process whereby evidence is assessed in a systematic, repeatable way and ideas are accepted or rejected on the basis of the outcome, whilst homeopathy is a set of beliefs based on a defining principles established by Samuel Hahnemann 200 year ago. These principles as a set have simply failed to stand up to scientific testing, so homeopathy finds no support from science. This means that for homeopaths to continue doing their thing, they need to reject the principles of the scientific method (i.e. reliance on evidence), rather than change their ideas about homeopathy. In response to the rhetorical question posed by John Maynard Keynes:

When the facts change, I change my mind. What do you do, sir?

A homeopath would probably respond by saying:

“I ignore the facts – they’re not my facts anyway, they’re facts made up by people who are colluding to besmirch the name of homeopathy and I have anecdotal evidence that is far more convincing than your double-blind, randomised, placebo controlled trial anyway. And your facts are just made up by big pharma, which doesn’t work and it kills people. You’re just a bunch of allopaths who don’t recognise the true faith of homeopathy. So there.”

What is particularly vexing about debate with homeopaths is their inevitable retreat into logical fallacies and long outdated arguments. They make statements about homeopathy being better than allopathy, when allopathy was a phrase coined by Hahnemann 200 years ago for the Hippocratic, Galenic etc. schools of medicine, long since made defunct by Germ Theory in the 1880s and the rise of modern evidence-based medicine, which has been around for less than 40 years.

In effect, modern medicine has successfully overhauled the established medical opinion of Hahnemann’s time by virtue of being more effective. If homeopathy was as effective as homeopaths make out, it’s surprising that it isn’t the method that has been adopted as the best form of treatment available – after all it has been around longer and it’s cheaper to produce because it doesn’t require all that pesky testing. Moreover, it sells in huge amounts – but popularity is not a robust indicator of efficacy by any means, as I’m sure any homeopath could tell you… if they weren’t so obsessed with popularity.

Before this post turns into a huge rant or a serial refutation of the nonsensical arguments used by homeopaths, I will try to make my point. 10:23 is about what is in a ‘high potency’ homeopathic preparation (of 30C or more). These products are marked as having active ingredients, but the dilution of whatever ingredients might have been in the solution at the outset is so great as to go far beyond the Avogadro constant – in short there is less than a single molecule weight of the ingredient in the solution. This solution is then dropped on sugar and allowed to evaporate. So should it be marked as being an active ingredient? It’s rather like a bag of sugar listing Tyrannosaurus rex as one of its ingredients, because there is a possibility that one molecule of water that dried on one grain of sugar was once in contact with a T. rex (see here for a clear summary of the homeopathic process).

Despite the lack of any robust support for efficacy of super-high concentration homeopathic products, the UK’s leading high street pharmacist, Boots, sells these products with the full knowledge that they are not shown to work:

I have no evidence before me to suggest that they are efficacious, and we look very much for the evidence to support that…

(Paul Bennett, Professional Standards Director of Boots speaking at the Science & Technology Committee Homeopathy inquiry 25th Nov 2009 – full transcript here)

This seems wrong. It seems as though a trusted company is betraying people’s trust – falling back on caveat emptor (let the buyer beware) rather than maintaining the standards of what they sell. Imagine if Boots started selling travel sickness pills that contained no active ingredient, just sugar. This would be a placebo and it would be unethical (and probably illegal) for Boots to sell the product. Which may explain why Boots don’t indicate what the homeopathic pillules they sell are for. In effect, they do sell travel sickness pills that contain no active ingredient, just sugar (it’s called Aconite 30C) but they get around the ethical and legal problems using the disclaimer:

Boots Aconite 30c is a homeopathic medicinal product without approved therapeautic indications.

Contains ingredients:

Active Ingredients: 30c Aconitum napellus

Also contains: Sucrose & lactose

(taken from Boots website)

It would be interesting to see if the listed ingredients would actually stand up in a court of law, given the lack of any molecules of Aconitum napellus in the product – it’s rather like an apple pie with no apple.

The 10:23 campaign is intended to make this point in the public eye, to raise awareness of what super high dilution homeopathic pillules actually consist of – nothing but sugar. That’s why I will be taking part in the London leg of the homeopathic overdose at 10:23 this Saturday. Perhaps it will make the point publicly enough to persuade Boots that they shouldn’t be misleading the public by stocking homepathic remedies that are not shown to work and are listed as having active ingredients, yet they contain nothing but sugar.

“One lump or two?” Not for me thanks – I’m cutting down on woo.

WTF is homeopathy?

My first exposure to the word ‘Homœopathic’ was at Hampton House, a hall of residence at Bristol University which was an ex-homœopathic hospital (and is now the student medical centre). All I knew was that it was a magnificent building that used to be a hospital of some sort – but I never really thought about what the ‘Homœopathic’ bit meant – I just assumed it was another branch of medicine. Continue reading →

Mail online – ‘Homeopathy works!’ Part II

Right (rolls up sleeves), I said I would try to track down the reference that the Mail Online used in their comment adverse and misleading article by Jenny Hope, so that I could comment further. It has been tracked down – not by me I am ashamed to admit, but by EoR who commented on a blog about the same article at Thinking is Real.

Here it is in all its glory in the BMJ ( 19 August 2000) pp. 321:471-476 . Notice the date? It’s nine years old, which explains why I couldn’t find it – after all, it was supposed to be news, so I foolishly expected it to be new. Silly me. Continue reading →

Mail online – ‘Homeopathy works!’

Irresponsible reporting from the Mail? Big surprise. I rather doubt that they will publish my comments, so I have reproduced them below. 1000 words isn’t really enough to highlight what’s wrong with their article, but it’s a start. I will track down the reference to make more informed comment if time and circumstances allow.

Here’s the article: Continue reading →