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EDITORIALS: Gene Feder and Tessa Katz Randomised controlled trials for homoeopathy BMJ 2002; 324: 498-499 [Full text]

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Three Questions

David T Parry   (1 March 2002)

scientific thinking

Robert W Leckridge   (1 March 2002)

Homeopathy and the NHS

michael foley   (2 March 2002)

Sensationalist cover! Did I buy The Sun or BMJ?

mandi s martin   (3 March 2002)

One Thing Only I Know, and That is That I Know Nothing.

B. M. HEGDE   (3 March 2002)

Evaluation Essential

A P J Lake   (5 March 2002)

The dilemma of the double-blinded placebo controlled trial solution

Adrian W CHENG   (5 April 2002)

Three Questions 1 March 2002
David T Parry, Flexible Learning Advisor Auckland University of Technology Private Bag 920006 Auckland 1020 New Zealand Send response to journal: Re: Three Questions	It is regrettable that the homeopathy debate devides people into often hostile camps. To my mind there are three outstanding questions: 1) Does any particular homeopathic prepartion produce better results than placebo ? One of the clinical questions posed of any conventional drug before release onto the market. 2) How does homeopathy work in the physical sense? Assuming the answer to 1 is positive, then this question becomes extremely interesting. I would suggest that even if homeopathic remedies are shown to have an effect, then understanding of these processes would allow the development of more effective ones. 3) If large numbers of people are taking homeopathic remedies, surely research funding will be available from those benefiting commercially from their sale ? Companies selling many other products sponsor research on efficacy ( for example horticultural suppliers etc.) without the requirement for licencing by regulatory bodies. Compared to a conventional drug, homeopathic remedies do not require many of the stages of testing, and so product development can be much cheaper.
scientific thinking 1 March 2002
Robert W Leckridge, Associate Specialist Glasgow Homeopathic Hospital G12 0XQ Send response to journal: Re: scientific thinking	This editorial provides a necessary balance to the unscientific thinking of the headline on the front page of this issue of the BMJ. "Homeopathy for dust mite allergies? No, it's a waste of time." Such a headline might sit nicely on the front page of a tabloid newspaper but what is it doing on the front page of a scientific journal? The editorial rightly calls for pragmatic trials comparing the effect and cost effectiveness of orthodox and homeopathic treatments." The single trial of homeopathic immunotherapy published today is not such a trial, nor does it show that homeopathy for dust mite allergies is "a waste of time". Without debating the scientific points of the paper itself, it shows simply that giving 3 homeopathic tablets of house dust mite over a single 24 hour period shows no benefit over placebo when measured over the following 6 week period. Even the conclusion of your editors in "What this study adds" only concludes "In this study homeopathic remedies were no better than placebo ...." setting that against the context of "What is already known on this topic" that "Homeopathic remedies probably have an effect that is greater than placebo." How do you justify ignoring the conclusions of this editorial and your own conclusions about the house dust mite paper and printing the headline "No, it's a waste of time."?
Homeopathy and the NHS 2 March 2002
michael foley, consultant anaesthetist James Cook University Hospital, Middlesbrough TS4 3BW Send response to journal: Re: Homeopathy and the NHS	The recent debates generated by lack of evidence for benefit of screening for breast and prostate cancer are generic with the argument for lack of effectiveness for homeopathy. How does one demonstrate a lack of benefit in the face of wishful thinking by both customers and providers, particularly when the latter have a financial interest in a positive outcome? And, as an anaesthetist and non-user of any of these services, why should I care? The answer is given by Feder and Katz who point out that it is 'possible to refer patients to homeopathic specialists in the NHS or refer to general practitioners who prescribe homeopathically'. Consumers of resources within this service should have a duty to demonstrate a benefit from any consultations or treatments provided and the fundholders should have a duty to withold funds in the absence of such evidence. If the customers then wish to purchase treatment which is not beneficial they will of course be free to do so and the homeopaths, iridologists, colonic irrigationists and the rest can flourish. As this article points out, meta-analysis of results of trials of homeopathic treatments suggest benefit greater than placebo in some cases but this can easily be discounted by publication bias. Statistically, some trials of homeopathic treatments will show some benefit, even when the real effect of the treatment is zero, and these are the trials most likely to have the results published. The homeopaths argue that their treatments are not amenable to statistical analysis in the same way as conventional medicine, in part because 'most trials of homeopathic medicines do not individualise treatment, the hallmark of homeopathic practice'. I can give an example from my own practice, anaesthesia for coronary artery surgery, where treatment is tailored to individuals, whose coronary anatomy is unique,yet where statistical analysis demonstrates an aggregate beneficial effect from treatment. This is how medicine works, patients are individuals yet patterns can be recognised and this allows us to base our diagnostic and therapeutic interventions upon solid ground. Why should homeopathy be allowed to hide behind a smokescreen which is denied to conventional medicine and why should the NHS fund such treatment in the absence of any evidence of useful effect? The answer is that the providers have a lot to gain, in terms of financial reward and intellectual acceptance and, like the poor, quacks will always be with us.
Sensationalist cover! Did I buy The Sun or BMJ? 3 March 2002
mandi s martin, homeopath Bliss Health Centre, London W11 Send response to journal: Re: Sensationalist cover! Did I buy The Sun or BMJ?	re: BMJ volume 324; page 520 Having read the above article I felt the need to express my disappointment at the way this subject matter has been presented. I read that thanks were given to the medical homeopathic research community, in particular David Reilly and I am curious to know exactly what his input was in this research. Having been a homeopath for some time, with a very integrated approach, I am a little confused about what homeopathic prescription was used in this double blind trial. I understand that house mite dust was potentised for this study. What exactly is meant by ‘homeopathic immunotherapy’? The suggestion that patients received ‘standard homeopathic intervention’ is a contradiction in terms as good homeopathic treatment is based upon treating each patient as an individual case. Whilst I read and understood the results and the discussion of this study, my feelings towards the cover piece ‘Homeopathy for dust mite allergies? No, it’s a waste of time p520 is that it is more than a little misleading and sensationalist journalism. The homeopathic treatment for patients with dust mite allergies would rarely be to potentise house mite dust itself. Homeopaths in general would not use this ‘homeopathic immunotherapy’ when treating allergies of any kind. In treating patients with these allergies, a thorough case taking would suggest the correct remedy and each patient would be treated individually. My personal experience with treating patients with homeopathy for asthma and dust mite allergies has been very positive and the suggestion that it is a ‘waste of time’ is rather deceptive. When will there be funding and support available for a homeopathic/placebo double blind randomised controlled trial that is run by professional homeopaths and scientists together using an integrated approach? The public are frequently turning to homeopathy and seem to experience improved conditions, surely that is a good enough reason to work together to find
One Thing Only I Know, and That is That I Know Nothing. 3 March 2002
B. M. HEGDE, Vice Chancellor MANIPAL-INDIA.576 119. Send response to journal: Re: One Thing Only I Know, and That is That I Know Nothing.	Dear Sir, The above saying of Socrates seems to apply to me when I think of Controlled Trials. I remember to have read that "with the beginning of controlled trials, the last word in the history of medicine has been written." Each time I study a controlled trial, and then audit the real life situation, I get a gut feeling that all is not well in this area. Time-evolution, in a dynamic system like the human body, does depend on the total knowledge of the initial state. When we compare two cohorts of people, what are we controlling? We are able to control only a small fraction of their phenotypical features. But man is not just a small part of his phenotype, for predicting his future. We doctors have been predicting the unpredictable all along! The major portion of man's whole, his genotype and his consciousness, not to speak of a large part of his phenotype also, could never be controlled in all our controlled studies! If that be so, how on earth are we drawing such definite conclusions from our controlled studies? Once, when I asked this question in an international conference, to a "famous" professor (who later I learnt had been sponsored by a drug company); while laughing the question off, added that I should have known that randomisation does exactly that. How I wish he were right! I always have this nagging feeling that smoething is missing in medical science where we apply elegant linear mathematical rules to a non-linear dynamic system like the human body, that is continuously run by food and oxygen. How I wish medicine had followed physics to the realm of quantum level, rather than continue with reductionism. The new field of quarks and superstrings should not surprise anyone if one were to ponder over the enigmatic workings of the human body. Will someone enlighten me on my question please? May be, I "know nothing," as Socrates rightly said hundreds of years ago. Most of the guidelines for drug therapy, based on these controlled studies, have been found to be faithful to drug company interests. The published reactions to the JNC V guidelines, wherein diuretics were included as the first line drugs in hypertension, are interesting examples to cite. The reactions rubbished the idea of diuretics being included as the first line drugs, if my memory does not fail me! Now we know that diuretics are not that bad after all. They are probably very good and deserve the place. Thanking you. bmhegde.
Evaluation Essential 5 March 2002
A P J Lake, Consultant Anaesthetist Glan Clwyd Hospital, Rhyl. LL18 5UJ. Send response to journal: Re: Evaluation Essential	Who wants to know the results? Anyone with their patient's best interest at heart rather than their own prejudice, surely. If doctors from either camp do not consider the results of clinical trials then they do not deserve to be accorded the privilege of patient's trust. We are obliged to practice Evidence Based Medicine in the pursuit of 'primum non nocere'. Treatment requires resourcing and funding has to be found with an opportunity cost. Patients to make an informed choice require good quality information. This divide between the traditional and homeopathic approaches requires to be informed by well conducted trials and good science but a stumbling block, as identified in the responses to Lewith's article, is, it seems, individualised treatment but that does not have to be the case. Randomised, double-blind studies, as appropriate, should be carried out in both clinical settings, individualised, comparing the homeopathic remedy with either placebo or standard. The study treatments would require to be made up on the day and a homeopath would need to shadow to individualise but such constraints should not prove insurmountable. Where there's a will, there's a way.
The dilemma of the double-blinded placebo controlled trial solution 5 April 2002
Adrian W CHENG, Resident medical officer First Year Basic Physicians Training Program 3011 Send response to journal: Re: The dilemma of the double-blinded placebo controlled trial solution	Most debates about the validation of homeopathic remedies by the Scientific Method are divided by two opposing views/arguments. 1. Homoeopaths argue: That homoeopathic remedies are not directly ammenable to such scrutiny because this approach contradicts the fundamental essence of homoeopathic theory and that is, to individualise a remedy to a particular person rather than a particular pathology. This is consistent with their philosophy. 2.Traditional Doctors argue: That without such validation it is not possible to ascribe any therapeutic benefit to such any particualr homoeopathic remedy. The solution to this dilemma would appear quite simple. Rather than test the therapeutic effect of any particular individual homoepathic remedy itself for any specific pathology, such as allergic rhinitis, a trial could simply examine the difference between placebo and a homoepathic intervention (whichever remedy was chosen by the qualified, experienced practitioner).