Homoeopathy multinational Boiron threatens amateur Italian bloggerBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5197 (Published 12 August 2011) Cite this as: BMJ 2011;343:d5197
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I do not know anything about any issues with the Boiron Co. All I
need to say is that I don't think magic exists so the manufacturer must
have used a logical reasoning in creating "oscillococcinum". All I know is
it does work 100% when taken as it says at the first signs of a flu. We
and many we know have taken it for over 10 yrs. when those around us have
had the worst cases of flu and we're starting to feel bad. So either
scientific or magic, it cuts symptoms and duration of flu better than any
meds I had taken and far from giving any side effects, it actually
improves the general feeling while we are getting through the flu.
Competing interests: No competing interests
Mark Struthers, I don't particularly like Cochrane Reviews because
they fetishize the prospective double-blind placebo controlled clinical
trial (PDBPCCT) to the point of methodolatry. PDBPCCT are good, and
necessary, but are not capable of demonstrating that a treatment is
useless, as for example homeopathy and are not ethical when the
intervention being tested is of known positive benefit, as for example flu
Healthy adults are the group at least risk from flu, yet the Cochrane
Review does show positive health effects from vaccination. Groups at
higher risk, such as the elderly show even greater benefits, with a 27%
reduction in hospitalizations and a 50% reduction in mortality.  I
would say these results on are nothing to sneeze at because they represent
713,872 person-seasons of intervention.
A trial such as this can not be done in a prospective blinded
fashion. It would be completely unethical to subject placebo recipients
to serious risks of harm and death from flu. Not surprisingly, when the
Cochrane Review looked at the issue of flu vaccination in the elderly they
reject all non-PDBPCCT and so they end up looking at only a total of 1,348
participants. Not surprisingly this number is insufficient and the
Cochrane Review calls for trials which cannot be ethically done.
There are problems with non-PDBPCCTs for determining efficacy, there
may be unknown issues that bias the results. That is why looking at
the science behind the intervention (as in Science Based Medicine) is more
important than blindly following the PDBPCCT mantra and throwing up our
hands when such data is not available. Clinicians who desire to treat
their patients ethically and responsibly have to make recommendations
without perfect knowledge. This is where understanding science is
important to the practice of medicine. Less then perfect knowledge does
not justify inaction, or worse, exploiting patients with made-up fantasy
treatments with no credible mechanism or prior plausibility.
We know what causes flu; the influenza virus. We know what prevents
people from getting illness when exposed to the influenza virus;
sufficient immune response to suppress viral replication. We know how to
trigger an immune response to flu virus antigens; vaccinate with viral
antigens. We have a reasonable understanding of how the immune system
works, and when good protection is observed in some groups, a level of
protection can be inferred in other groups. The Cochrane Review on flu
vaccination in children shows good protection. We know that flu
spreads by human-human contacts. Children congregate in schools during
flu season. Children are a probable link between unrelated adults.
Vaccinating children for flu (which is effective) will likely reduce
transmission of flu to other groups. Are there PDBPCCT demonstrating
reduced transmission of flu to unrelated adults when children are
vaccinated? No, there are not and there will not be any because such
trials would be unethical, so ethical researchers won't run them, ethical
funding agencies won't fund them and ethical journals won't publish them.
Ethical clinicians will still vaccinate for flu because there is good (not
perfect) evidence that it does more good than harm.
What is the "theory" behind oscillococcinum and flu? A homeopath
imagined he saw the causal agent of flu, oscillating bacteria, in the
blood of flu victims (influenza virus is too small for his equipment to
have resolved), then later imagined he saw the same oscillating bacteria
spontaneously generate at high levels in duck heart and liver and reasoned
(???) that if he diluted this duck heart/liver by a factor of 10e200 (i.e.
1 gram in a sphere of water 1.3e49 light years in diameter (yes some
1.3e38 times the estimated diameter of the observable Universe)), and then
put drops of this magic water on sugar pills, that he would have something
that would magically cure flu. I say magic because there is nothing in
physics, chemistry, physiology or derived through a rational thought
process that suggests a mechanism other than magic.
A recent review, somewhat more extensive than the Cochrane Review
does not support an increase of 1 chance per million for Guillain-Barr?
syndrome following flu vaccination. Background rates are somewhat less
than that and they say "[t]he evidence is inadequate to accept or reject a
causal relationship between influenza vaccine and GBS. 
As safe as you believe oscillococcinum to be, it can't be safer than
doing nothing. If there are no trials that demonstrate harm, there are
also no trials that demonstrate benefit and no trials that demonstrate
lack of harm. If you use science to determine oscillococcinum presents
with zero risk (because it is nothing but water), you have to also
conclude it has zero benefit (because it is nothing but water).
With zero expected benefit, other harms, although small, become
important. In the US there is about 1 traffic fatality per 100,000,000 km
driven. If 20 million customers each drive 5 km to obtain their
oscillococcinum, then likely one person will be killed. At $15 per
treatment, 20 million customers will spend $300 million. At $20/hr that
is ~94 lifetimes of work at 2,000 hours per year and 80 years of work.
On the other hand, $300 million could purchase enough gasoline to drive
several billion km, so ~40 drivers who purchase oscillococcinum instead
of gasoline will be saved from highway fatalities through impoverishment.
Since reading about oscillococcinum will deliver exactly the same
dose of duck heart/liver as ingesting it (that would be zero), people who
wish to get equivalent benefit from oscillococcinum with even less risk,
could simply purchase a subscription to BMJ and read this story online.
Since a subscription to BMJ costs $158, purchasing a single BMJ
subscription instead of oscillococcinum will save ~10 times more lives
through reduced highway fatalities. Some might consider it unseemly for
BMJ to promote subscriptions this way (Saves 10x more lives than
Oscillococcinum!!!), even though it is completely accurate. But surely
saving 10x more lives is more important than such sensibilities.
The major benefit from reading BMJ is lives saved through better
medical practices. The 'M' in BMJ does not stand for "Magic", it stands
1. Nichol KL, Nordin JD, Nelson DB, Mullooly JP, Hak E.
Effectiveness of influenza vaccine in the community-dwelling elderly. N
Engl J Med. 2007 Oct 4;357(14):1373-81.
2. Jefferson T, Di Pietrantonj C, Al-Ansary LA, Ferroni E, Thorning
S, Thomas RE. Vaccines for preventing influenza in the elderly. Cochrane
Database Syst Rev. 2010 Feb 17;(2):CD004876.
3. Simonsen L, Taylor RJ, Viboud C, Miller MA, Jackson LA.
Mortality benefits of influenza vaccination in elderly people: an ongoing
controversy. Lancet Infect Dis. 2007 Oct;7(10):658-66.
4. Jefferson T, Rivetti A, Harnden A, Di Pietrantonj C, Demicheli V.
Vaccines for preventing influenza in healthy children. Cochrane Database
Syst Rev. 2008 Apr 16;(2):CD004879.
and-other-flu-bits/ (accessed 083111)
6. IOM (Institute of Medicine). 2011. Adverse Effects of Vaccines:
Evidence and Causality. Washington, DC: The National Academies Press.
http://www.nap.edu/catalog.php?record_id=13164 (accessed 082611)
Competing interests: None, but hope to get a commission on sales of BMJ subscriptions to prevent flu. ;)
In the midst of this tedious exchange it is interesting that Dr Paul
Morgan's first paragraph expresses the same belief that Professor Ernst
demonstrated in his recent retirement interview: " It works because of a
very long empathetic consultation " (1)
Where is the evidence for this statement ?
Generations of practitioners, using every form of psychotherapy from
Freudian analysis to contemporary CBT would have been overjoyed if "a long
empathetic consultation" produced any more than transient relief in the
vast majority of subjects.
Medical homeopaths working in the NHS are obliged to see and treat
nearly all those to whom they offer homeopathy, in the same brief slots
that are the norm. Occasional people may be seen for extended
consultations, by mutual agreement, and at no charge of course. (2)
Where does the evidence about these " long empathetic consultations "
Could it be that the suspicion that has grown among medical
homeopaths, that the outspokenness of our critics is inversely
proportional to their knowledge of what they choose to dismiss, is correct
Maybe this talk of " a long empathetic consultation " is an
extrapolation from anecdotes about private consultations with
practitioners out with the NHS, without medical degrees and not subject to
If it is an opinion, based on misinformation, that critics are
comfortable with, we can all draw our own conclusions, without needing to
Perhaps critics will extend the same simple courtesy to us, as we
beaver away in our NHS practices, giving homeopathic remedies where
appropriate, saving the taxpayers' money, and often getting results that
defy our scepticism and powers of scientific explanation.
We seek no fame nor reward,( positive feedback from patients is more
than sufficient ), but would be pleased to be treated with less derision
by those few colleagues who see us as a threat to their world view.
(1)BMJ 2011; 343:d4937
(2) Personal experience, and anecdotal reports from many colleagues,
journals and meetings over 30 years.
Competing interests: Contented GP, occasional unpaid homeopath, never used Oscillococcinum, no knowledge of Boiron.
Jennifer Keane provides a sensible balanced opinion of the Boiron vs
Reva case. It is incumbent on bloggers to 'stay nice within the law' as
Keane suggests and in this case the blogger may with hindsight have
published his viewpoints more carefully.
However, I think large companies or organisations shoot themselves in
the foot when it comes to prosecuting bloggers. They make what should be a
small semi-private spat hugely public, making themselves look like bullies
and bringing their products or services into dispute. Its akin to washing
your undies in public.
I am sure the public as a whole dismiss alternative medicine services
or products as harmless and not worthy of making a fuss over. However when
a high profile lawsuit arrives the man or woman in the street may take a
more active interest and may view the litigious Goliath as a bit of a bad
egg. Not good for sales or reputation surely?
Competing interests: No competing interests
David R. Whitlock appears to indicate that there is a robust evidence
base for vaccines in influenza prevention. In fact, last year's Cochrane
review was distinctly underwhelming in its praise for the preventative
effect of the seasonal flu-vaccine.
The authors concluded,
"Influenza vaccines have a modest effect in reducing influenza
symptoms and working days lost. There is no evidence that they affect
complications, such as pneumonia, or transmission." 
And then the authors summarised in plain language,
"Over 200 viruses cause influenza and influenza-like illness which
produce the same symptoms (fever, headache, aches and pains, cough and
runny noses). Without laboratory tests, doctors cannot tell the two
illnesses apart. Both last for days and rarely lead to death or serious
illness. At best, vaccines might be effective against only influenza A and
B, which represent about 10% of all circulating viruses. Each year, the
World Health Organization recommends which viral strains should be
included in vaccinations for the forthcoming season. Authors of this
review assessed all trials that compared vaccinated people with
unvaccinated people. The combined results of these trials showed that
under ideal conditions (vaccine completely matching circulating viral
configuration) 33 healthy adults need to be vaccinated to avoid one set of
influenza symptoms. In average conditions (partially matching vaccine) 100
people need to be vaccinated to avoid one set of influenza symptoms.
Vaccine use did not affect the number of people hospitalised or working
days lost but caused one case of Guillian-Barre syndrome (a major
neurological condition leading to paralysis) for every one million
vaccinations. Fifteen of the 36 trials were funded by vaccine companies
and four had no funding declaration. Our results may be an optimistic
estimate because company-sponsored influenza vaccines trials tend to
produce results favorable to their products and some of the evidence comes
from trials carried out in ideal viral circulation and matching conditions
and because the harms evidence base is limited.."
However, the evidence for the harmlessness of homeopathic
preventative remedies in the field of flu would appear to be extremely
robust. And I would not like to take that one in a million chance:
Guillian-Barre syndrome can be a very serious and frightening condition.
Boiron's blockbuster homoeopathic product Oscillococcinum, would seem a
much better bet. And that's a fact.
 Vaccines for preventing influenza in healthy adults. Tom
Jefferson, Carlo Di Pietrantonj, Alessandro Rivetti, Ghada A Bawazeer,
Lubna A Al-Ansary, Eliana Ferroni. Editorial Group: Cochrane Acute
Respiratory Infections Group. Published Online: 7 JUL 2010. Assessed as up
-to-date: 2 JUN 2010. DOI: 10.1002/14651858.CD001269.pub4
Competing interests: No competing interests
As with many such cases, I think the motto should be "I think you'll find it's a little more complicated than that".
Boiron sue completely innocent blogger because he dared to tell the truth about homoeopathy!!!!!11!!11! Can it possibly be true? Well, no, not exactly, and one thing this case will serve to demonstrate well is the fact that you can't say much without facts, and that it's easy to lose sight of them in all of the fuss.
Already, comparisons between this case, and that of BCA vs. Singh are being bandied about, and the picture of Samuele Riva as David to Boiron's Goliath is forming rapidly, but I think that the whole situation deserves further scrutiny before Riva is painted as a hero of modern science. As the letter is originally in Italian, some of the translations have been a little shaky (several machine translations have been doing the rounds), and as the legal wording is likely to be quite important in such a case, it's difficult to understand the spirit of the letter without being able to read it, fluently, in its original Italian (and in the context of Italian law). As I can do neither, I can only look to the translations, as others have been doing.
A selection of the points Boiron seem to be complaining about are as follows:
- The unauthorised inclusion of a picture of their product
- The caption associated with the picture (the total nothing that according to Boiron is the cure for influenza... diluted 200C does not contain any molecule of active ingredient!)
- A further article, including a picture, and caption associated with the picture (Seriously damages the intelligence (of the person buying it))
The letter also contains some other points, such as demands for removal of internet services, denying Reva's access to his blog, etc. All in all, it's the kind of letter that I'm sure anyone would be intimidated to receive, and I have little doubt that this was the intention, and while I recognise that Reva has a right to state his opinion, there are things he could have done differently that may have prevented this letter arriving in the first place.
As unpalatable as it may be, the simple fact of the matter is that people tend to be rather lax about copyright on the internet. We take images from websites without crediting them or asking the owner, and often use them repeatedly without asking the owner. This is as wrong as it would be to copy a chapter from a book and claim it as your own. Copyright law means that you cannot just take the first image you find and use it with impunity - if that image belongs to someone else, and you haven't asked their permission to use it, and they haven't stated that it's there for the taking, then you are breaking the law by using it. In this respect, Boiron do have the right to request that their image be removed, as I suspect they were not asked for permission to use it, and were certainly unlikely to give permission given the context in which it would be placed.
The next major point is to do with the caption of the image - "the total nothing that according to Boiron is the cure for influenza... diluted 200C does not contain any molecule of active ingredient!" We know that one part of this sentence is fact - a 200C dilution can not include a single molecule of the active ingredient. This has been tested and proven repeatedly, and it is an established fact. In this respect, Boiron really have no complaint, though I would welcome the situation in which they were legally obliged to provide proof that this statement was untrue, should it arise. The first part of the sentence, though, is a bit more tricky. The author states that Boiron say Oscillococcinum is the cure for influenza, and if this were true, it would be both laughable and sad. A thorough scouring of their promotional media, however, has failed to turn up a single instance of Boiron stating that Oscillococcinum is a cure for influenza - the strongest claim they make is that is is used "to reduce the duration and severity of flu-like symptoms". They don't claim to cure the flu, and it's quite likely that this is a conscious decision made as a result of legal advice given to them - quite simply, they're not stupid, and they haven't come to be the largest manufacturer of homoeopathic products in the world without learning a thing or two. Whether or not their employees believe in the efficacy of the product, their literature is carefully crafted to avoid the mention of an outright cure, and instead employs the same terminology as often found advertising other products with questionable scientific background (e.g. may help to improve x, etc.). By putting words in their mouth, Riva left himself open to criticism and sanctions - to say that they claim it's a flu cure is, factually speaking, untrue.
The last point I've highlighted refers to another use of a product picture, and the caption accompanying it - Seriously damages the intelligence (of the person buying it). This is a comment which, I believe, falls into a bit of a gray area. While I make absolutely no pretence at being a lawyer, I'd imagine that Boiron might argue that this is a serious slight against their product and a claim about a side-effect of using the product which doesn't exist. In this, and only this, respect, this is similar to BCA vs. Singh, because it can possibly be argued that this is use of opinion, etc. on the part of Riva. For a better discussion of where this particular argument may go, I suggest you look up the various rulings for the BCA/Singh case, as they explain it far better than I could.
Let me be absolutely clear - I don't like what Boiron are doing, and I think it is a disproportionate response, but to cast them as the big bad wolf without any consideration for the blog itself is neither rational, nor critical, nor sensible. Libel laws are, in many countries, downright punishing, and sadly, open to abuse, but here's the rub - if we want the law to change, to better protect bloggers and authors and anyone else who wishes to share an opinion, then we also have to play nice with the existing laws. Direct criticism of a company or their product is a difficult thing to do, and there is a fine, often poorly defined, line between valid criticism and outright libel. You can be critical of a company or product if you have evidence to back up that criticism. You can share your opinion of a product or company, but you can't put words in their mouth. In short, you can't damn a company simply because you don't believe in their product, and you can't use their copyrighted imagery to help you damn them. I have sympathy for the position that Riva now finds himself in, but I also hope that others take this as a cautionary tale and learn from the mistakes that were made.
Competing interests: No competing interests
Professor Lewith, I agree with you that this article is more about
the business of selling medicines than it is about science, or rather it
is about the selling of sugar pills dotted with magic water while claiming
them to be medicine effective for treating flu; a disease that in a good
year kills only a few hundreds of thousands.
Surely the safety and efficacy of medicines to treat fatal diseases
needs to be based upon science?
The Cochrane review you cite is interesting (but shows as withdrawn
in PubMed). The abstract of the 2000 review found only the exact same
seven studies and cites the exact same two studies, and reaches the exact
"Current evidence does not support a preventative effect of
homeopathy in influenza and influenza-like syndromes."
Damning with faint praise would be too kind, but maybe homeopathic
praise is different?
I completely agree with you, let us focus on the facts. It is now
2011. Several million people have died, world-wide from influenza since
the 2000 Cochrane Review and the makers of homeopathic flu treatments have
published nothing suggesting the products they continue to make and sell
are safe and effective to treat or prevent flu. That is a fact. We may
quibble as to whether it is a scientific fact, a medical fact, a legal
fact, or a marketing fact. I think we are all agreed that it is an
In contrast to homeopathy, flu vaccines have numerous studies showing
robust prevention in trials and meta-trials with tens or hundreds of
thousands of participants. PubMed shows 1996 hits for "flu vaccine
clinical trials". It shows only four for "Oscillococcinum clinical
Surely those of us with scientific knowledge have an obligation to
use that knowledge to ensure that those without scientific knowledge are
not mislead or defrauded. I completely agree with you when you say that
"Complementary medicine must be research led and evidence based".
Perhaps as an investigator involved in homeopathy research you can
provide us with some insight as to why, in the absence of evidence of
effectiveness for homeopathic prevention of flu, homeopaths consider there
to be sufficient justification to continue making and selling sugar pills
dotted with magic water?
You ask what do these facts tell us about the BMJ editorial
practices? What do these facts tell us about those who practice
1. Influenza (Seasonal), World Health Organization, April 2009.
http://www.who.int/mediacentre/factsheets/fs211/en/ (Retrieved 2011-08-17)
2. Vickers AJ, Smith C. Homoeopathic Oscillococcinum for preventing
and treating influenza and influenza-like syndromes. Cochrane Database
Syst Rev. 2000;(2):CD001957.
3. Lewith GT, Ernst E, Mills S, Fisher P, Monckton J, Reilly D,
Peters D, Thomas K. Complementary medicine must be research led and
evidence based. BMJ. 2000 Jan 15;320(7228):188.
4. http://www.cam-research-group.co.uk/homeopathy_res.php (retrieved
Competing interests: Member of the reality based community, advocate of Science Based Medicine, skeptic, developer of treatments for low nitric oxide, amateur blogger.
Homeopathy has no mechanism for any potential beneficial effect
beyond the psychotherapeutic effect of a nice chat in a consultation that
is much longer than a traditional NHS consultation lasts for.
We have no information as to why the authors were unable to update
the review or why they were asked to. The age of the review per se doesn't
seem to be an issue - for example, the Cochrane database lists a review
published in January 2009 on haemodilution for ischaemic stroke,
which was last assessed as up to date on 13th August 2002.
Could it be that re-examination of the plausibility factor and the
data itself may have led to conclusions different from those originally
given? Or could it be that any additional data has contradicted the
original conclusion? The first review of this "remedy" was published in
2000, updated in 2004 and 2006. Each update was less positive than the
previous one, so we have gone from the 2000 conclusion that it "probably
reduces the duration of illness in patients presenting with influenza
symptoms" to "...the data are not strong enough to make a general
recommendation to use Oscillococcinum for first-line treatment of
influenza and influenza-like syndrome." in 2004. They came to the same
conclusion again in 2006, and again at the withdrawal in 2009.
The policies used by the Cochrane Library for withdrawing reviews are
The Cochrane website lists the most recent online publication (the
withdrawal) as 8th June 2009 and it being assessed as being up-to-date as
of 19th May 2006.
The website of the Cochrane Acute Respiratory Infections Group
makes no other mention of an update in progress. I'm sure the reader would
be interested in seeing an update. However, given that proper scientific
scrutiny of homeopathy leads to the conclusion that is no better than
placebo, it will be extremely surprising if any new review comes to a
conclusion suggesting benefit.
The now-withdrawn review at best suggested a benefit in symptom
reduction of 0.28 days - in other words a little over 6 hours. Given that
influenza is mostly a self-limiting illness where regression toward the
mean is the most likely outcome, such a reduction in symptomatology is of
no clinical benefit irrespective of any statistical significance.
Of course, there are significant problems with making any claims of
benefit for "Oscillococcinum" - it's a substance that only existed in the
mind of Joseph Roy the "discoverer" of that entity in 1925. It seems to
either have been a figment of his imagination or a misinterpretation of
Brownian motion of bubbles. It has never been confirmed as a real entity
over 85 years later, during which time we have seen the use of electron
microscopy and other techniques. Even if mashed-up Barbary duck liver and
heart had some strange means of producing flu-like symptoms (other than
pure revulsion!), a dilution of 200C would require a volume of water
greater than all the atoms in the known universe to find a single
"molecule" of active ingredient (not sure which molecule you'd even look
for!). Homeopathy is bunk and "Oscillococcinum" is about as bad as it
Competing interests: No competing interests
Dr Morgan is correct in that the review is out of date as far as the
Cochrane library is concerned. However it is still available on the web
and was withdrawn from the library because the authors were not able to
update it. This is routine for all Cochrane reviews but the 2009 review is
the last extant and widely available data summary about this product which
is why I quoted it. The editor of the Cochrane collaboration states; 'This
review was withdrawn from The Cochrane Library, Issue 3, 2009 as the
authors were unable to update it. The review will be updated by a new team
of authors.' I have been in touch with the new authors who have suggested
to me that their preliminary conclusions seem much the same as Vickers and
Smith but we must of course wait and see the publication before jumping to
conclusions. For the moment it is important to understand that the 2009
review is the best data summary available and was available to the Italian
Competing interests: No competing interests
If we're going to focus on the facts, perhaps Prof. Lewith should
also tell the reader that the Cochrane Collaboration withdrew the article
on Oscillococcinum in 2009.
Competing interests: No competing interests