Clothing naked quackery and legitimising pseudoscience
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5960 (Published 21 September 2011) Cite this as: BMJ 2011;343:d5960
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In view of this thoroughly unbalanced approach would Bewley et al now please consider retracting the inappropriate 'Daily Mail' unscientific statement in their original letter with their misleading interpretation of the available and currently inconclusive clinical science? Their lack of proper scientific balance demeans all those of us who take clinical science seriously. Even Ernst has co-authored material that suggests the clinical effects of homeopathy may be promising in some situations so his co-authorship of this BMJ letter is confusing (4).
References:
1. Bewley S et al. Clothing naked quackery and legitimising pseudoscience. BMJ 2011; 343:d5960
2. (1) Shang A; Huwiler-Muntener K; Nartey L; Juni P; Dorig S; Sterne JA; et al. Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy. Lancet. 2005; 366: 726-732.
3. Ludtke R, Rutten ALB. The conclusions on the effectiveness of homeopathy highly depend on the set of analyzed trials. J Clin Epidemiology. 2008; doi: 10.1016/j.jclinepi.2008.06.015.
4. Complementary and alternative medicines for the treatment of rheumatoid arthritis, osteoarthritis and fibromyalgia. ARC Report.2009. ISBN 978-1-901815-13-9
Competing interests: No competing interests
Sir,
I am grateful to Professor Ernst for confirming a point that was
actually addressed to a colleague of his, Dr Ray Noble. Namely, that there
is no evidence for Dr Noble's suggestion that medical homeopaths dissuade
people from taking standard treatments, if given homeopathic remedies.
Professor Ernst mentions immunisation. The UK Faculty of Homeopathy (
which regulates medical homeopaths ) is emphatically in support of the
immunisation advice given by the UK Ministry of Health.
Nevertheless, it is interesting to note the recent experience in
Cuba, where serious epidemics of Leptospirosis follow flooding from
hurricanes. In 2007 there was insufficient vaccine as the hurricane
season approached.
It was decided to give a homeopathically prepared extract of the
Leptospirochaete to 2.3 million people. A dramatic reduction in the
number of expected cases of Leptospirosis was observed in those people.
The 8.8 million people in adjoining provinces who had not received the
preparation, suffered the expected number of cases. (1)
Professor Ernst remarks , " Homeopathic remedies are placebos and
those who prescribe them may do harm. Thus homeopathy cannot be considered
an ethical approach and does not have a place in EBM."
Two years ago Professor Ernst wrote , " Placebo- effects are real and
they can help many patients. So why do we not make better use of them ? "
(2)
Could this be encouraging evidence that Professor Ernst changes his
mind ?
What next ?
1 Bracho G, Varela E, Fernandez R, et al. Large-scale application of
highly-diluted bacteria for Leptospirosis epidemic control. Homeopathy
2010; 99: 156-166.
2 Pulse. 11 August 2009.
Competing interests: NHS GP. Occasional homeopath, unpaid.
Susan Bewley and others attack the UK MHRA for advertising for new
members for its Advisory Board on Registration of Homeopathic Products
(ABRHP) and imply that anyone who practices or researches homeopathy is a
quack or pseudoscientist. This is based on the unreferenced claim that
'Homeopathy has definitively and repeatedly been proved to work no better
than placebo or nocebo'.(1) This claim is not based on evidence. On the
contrary, evidence from meta-analyses and systematic reviews consistently
shows that Homeopathy is effective in certain conditions, such as seasonal
allergic rhinitis and upper respiratory tract infections.(2,3,4,5) Another
systematic review has demonstrated there are a number of in vitro studies
that show effects attributable to very high diluted substances.(6)
The evidence around Homeopathy is challenging. It is high time that
the medical and scientific community rose to the challenge instead of
sinking to unfounded ad hominem insults.
References
1) BMJ 2011; 343:d5960
2) Wiesenauer M, Luedtke R (1996). A meta-analysis of the homeopathic
treatment of pollinosis with Galphimia glauca.Forschende
Komplementaermedizin und Klassische Naturheilkunde, 3:230-236.
3) Taylor MA, Reilly D, Llewellyn-Jones RH, McSharry C, Aitchison TC
(2000). Randomised controlled trials of homoeopathy versus placebo in
perennial allergic rhinitis with overview of four trial series. British
Medical Journal, 321:471-476.
4) Bornhoeft G, Wolf U, Ammon K, Righetti M, Maxion-Bergemann S,
Baumgartner S, Thurneysen AE, Matthiessen PF (2006). Effectiveness, safety
and cost-effectiveness of homeopathy in general practice - summarized
health technology assessment. Forschende Komplementarmedizin, 13 Suppl 2:
19-29.
5) Bellavite P, Ortolani R, Pontarollo F, Piasere V, Benato G, Conforti
A (2006). Immunology and homeopathy. 4. Clinical studies - Part 2.
Evidence-based Complementary and Alternative Medicine: eCAM, 3:397-409.
6) Witt CM, Bluth M, Albrecht H, Weisshuhn TER, Baumgartner S, Willich
SN (2007). The in vitro evidence for an effect of high homeopathic
potencies - a systematic review of the literature. Complementary Therapies
in Medicine, 15:128-138.
Signatories:
Peter Fisher Royal London Hospital for Integrated Medicine;
Ubiratan Adler University of Sao Paulo;
Paolo Bellavite University of Verona
Philippe Belon CRDT, Paris;
Brian Berman University of Maryland;
Simonetta Bernardini Centro Ospedaliero di Medicina Integrata, Ospedale F.
Petruccioli;
Leoni Bonamin Universidad Paulista;
Marie France Bordet International Foundation for Clinical Homeopathy;
Irene Camerlink Wageningen University;
Flavio Dantas University of Sao Paulo;
Jonathan Davidson Duke University;
Peter Davis University of Westminster;
Robert Dumont Northwestern University;
Jose Eizyaga Universidad Maimonides;
Francisco Eizyaga Universidad Maimonides;
Michael Frass University of Vienna;
Joyce Frye University of Maryland;
Carla Holandino University of Rio de Janeiro;
John Hughes University of Liverpool;
John Ives Samueli Insitute;
Jennifer Jacobs University of Washington;
Kim Jobst Journal of Alternative and Complementary Therapy;
Wayne Jonas Samueli Institute;
Anisur Khuda Bukhsh Kalyani University;
Christein Klein Louis Bolk Institute;
Rainer L?dtke Carstens Foundation;
Anne Majumdar University of Liverpool;
Rajkumar Manchanda Health & Family Welfare Department, Government of
Delhi;
Robert Mathie Faculty of Homeopathy;
Lionel Milgrom Program for Advanced Homeopathic Studies;
Marcin Molski Adam Mickiewicz University Poznan;
Chaturbhuja Nayak Central Council for Research in Homeopathy, Delhi;
Ton Nicolai European Committee for Homeopathy;
Menahem Oberbaum Sha'are Zedek Medical Center;
Chandragouda Patil R C Patel College of Pharmacy;
Bernard Poitevin Faculty of Medicine, Marseille;
David Reilly Glasgow Homeopathic Hospital;
David Riley University of New Mexico;
Helmut Roniger Royal London Hospital for Integrated Medicine;
Elio Rossi Centro di riferimento regionale toscano;
Lex Rutten VHAN;
Jean Sainte Laudy CERBA, Paris;
Marcus Zulian Teixera University of Sao Paulo;
Trevor Thompson University of Bristol;
Elizabeth Thompson Bristol Homoeopathic Hospital;
Alexander Tournier Homeopathy Research Institute;
Michel Van Wassenhoven Chair, homeopathic medicines registration
committee, Belgian Medicines Agency;
Carlos Zacharias University of Sao Paulo.
Competing interests: No competing interests
Sir
It remains misleading to baldly state Homeopathy is 'ineffective'
and quite easy for the authors to ignore opposition, disagreement and
debate regarding their own beliefs.
Personally I have neither belief in Homeopathy nor in antibiotics yet
see patients respond to both.
With regard to exposing falsehood please consider Medical Fundamentalism: An Unscientific Attitude, which can be read in its full context with references at the following web address: http://www.huffingtonpost.com/dana-ullman/disinformation-
homeopathy_b_969627.html
Competing interests: No competing interests
This rapid response debate seems to have moved on from the efficacy
(or rather lack of it) of homeopathy compared to placebo in well-conducted trials. It is about professionalism. And Dr Andrew Sikorski
makes me despair. Over 20 years ago as a lay member of a consensus
conference on breast cancer I learned how dangerous it is to rely on the
"personal opinions and clinical experience" of practitioners or patients.
It was such firmly-held opinion and experience that for decades had
British women unnecessarily mutilated; and for two millennia before that
had physicians bleeding their poor patients to readjust their "humours".
It is a sad reflection on the medical profession that there are still a
few qualified doctors who still haven't quite reached the scientific age
of enlightenment, and who, when they do consider scientific trials,
selectively cite evidence that reinforces their prejudices rather than
that which confounds them. Finally, quite contrary to Dr Sikorski's view,
Prof Ernst is one of the scientists best placed to judge the efficacy of
homeopathy. He once was a homeopath himself and it is a tribute to his own
professionalism that he changed his view when the evidence went against
it.
Competing interests: No competing interests
Sikorski makes an unjustifiable and untrue ad hominem attack (which
has no place in the BMJ) on Professor Ernst who still holds the chair at
Exeter. Sikorski makes a point of challenging Ernst's citations, before
contradicting himself in the next sentence by saying he makes no
citations. He then refers to the 'personal opinions and clinical
experience' of practitioners without himself making a citation!
Competing interests: No competing interests
We thank the authors of rapid responses for their comments. Our
letter chiefly concerned the advertisement for experts to advise the MRHA
on the safety and quality of Homeopathy ignoring the fact that it is
ineffective. Whilst we might wish to respect one another's beliefs,
expertise in belief has nothing to do with the MHRA. Even if homeopathy
was shown to be marginally effective in unbiased trials (which it hasn't),
such a cost-ineffectual approach should have no place in the NHS. This is
tantamount to throwing good money after bad and demonstrates the absurdity
of the government's position - which is clearly stated as "Homeopathy
works no better than placebo".(1)
With respect to the large body of evidence, we refer readers to the
details of the 2010 House of Commons Science and Technology Committee
report.(2) Those with interest in the wider field of complementary
therapies might start with the 721 Cochrane reviews.(3) The implication
that positive and inconclusive trials of homeopathy are equally divided is
not true, especially when taking trial quality into account, and is a
persistent bugbear of these discussions. Cherry-picking a 'positive' study
does not overturn the conclusions of the subsequent rigorous
methodological analysis which concluded: "Biases are present in placebo-
controlled trials of both homoeopathy and conventional medicine. When
account was taken for these biases in the analysis, there was weak
evidence for a specific effect of homoeopathic remedies, but strong
evidence for specific effects of conventional interventions. This finding
is compatible with the notion that the clinical effects of homoeopathy are
placebo effects".(4)
The adjective 'naked' attached to the concept 'quackery' did not mean
'nude' (as in a person), but "bare of any overlying matter; stripped, or
destitute without the customary covering, container, or protection" in the
sense of an exposed falsehood.
1)http://www.parliament.uk/business/news/2010/02/mps-urge-government-
to-withdraw-nhs-funding-of-homeopathy/ accessed 2nd October 2011
2)
http://www.publications.parliament.uk/pa/cm200910/cmselect/cmsctech/45/4...
accessed 2nd October 2011
3)http://www2.cochrane.org/reviews/en/subtopics/22.html accessed 2nd
October 2011
4)Shang A, Huwiler-Muntener K, Nartey L, Juni P, Dorig S, Sterne JA,
Pewsner D, Egger M. Are the clinical effects of homoeopathy placebo
effects? Comparative study of placebo-controlled trials of homoeopathy and
allopathy. Lancet 2005;366:726-32
Competing interests: As previously described
Sir
Ernst no longer holds a Professorial chair at Exeter.
Ernst cites himself and the discredited Shang metanalysis to back up
his personal opinion on a topic he holds no qualifications and has only
minimal training in.
Ernst provides no citation for his bald opinion of Homeopathy being
purely a placebo.
Ernst's personal opinion is outmatched by the personal opinions and
clinical experience of thousands of practitioners and many millions of
pateints.
Ernst's vigour in debate would better serve global healthcare were it
aimed at therapeutic interventions identified by the BMJ clinical evidence
website I previously refered to which cause harm rather than attacking a
safe intervention giving benefit to suffering patients whilst causing
minimal iatrogenesis.
Competing interests: Clinician with scientific training
George Lewith asked us about the evidence showing homeopathic
remedies to be ineffective. Of course, proving a negative can be tricky.
But, if for a given therapeutic approach, well over a dozen systematic
reviews e.g.[1-3] conclude that the evidence is insufficient or negative,
perhaps even evangelic believers in homeopathy should concede that their
remedies do not work. If something looks like a placebo, behaves like a
placebo, perhaps it is a placebo!
Noel Thomas asked us to provide evidence that homeopaths encourage
patients to dismiss demonstrably effective treatments in favour of
homeopathic placebos. I do admit that this area is under-researched. But
there is plenty of evidence to show that homeopaths do exactly that in the
realm of immunization [4].
Homeopathic remedies are placebos and those who prescribe them may do
harm. Thus homeopathy cannot be considered an ethical approach [5] and
does not have a place in EBM.
Reference List
(1) Ernst E. A systematic review of systematic reviews of homeopathy.
Br J Clin Pharmacol 2002; 54:577-582.
(2) Altunc U, Pittler MH, Ernst E. Homeopathy for Childhood and
Adolescence Ailments: Systematic Review of Randomized Clinical Trials.
Mayo Clin Proc 2007; 82(1):69-75.
(3) Shang A, Huwiler-Muntener K, Nartey L, Juni P, Dorig S, Sterne JA
et al. Are the clinical effects of homoeopathy placebo effects?
Comparative study of placebo-controlled trials of homoeopathy and
allopathy. Lancet 2005; 366:726-732.
(4) Schmidt K, Ernst E. Welcome to the lion's den - CAM therapists
and immunisations. Focus Altern Complement Ther 2005; 10:98-100.
(5) Smith KR. Why homeopathy is unethical. Focus Altern Complement
Ther 2011; 16(3):208-211.
Competing interests: No competing interests
Re:The clinical evidence for the specific effects of homeopathy: 3
George Lewith balances negative research findings regarding
homeopathy, with the findings of Shang et al that homeopathy trials are
compatible with homeopathy being a placebo. Lewith seems to follow a
policy of endless open-mindedness. He is right that we know nothing for
certain, but if we follow his lead we will simply end up knowing nothing.
As a clinician I have to act on the basis of what I know. If something has
no plausible mechanism of action, and the best that can be said for it is
that it is compatible with being a placebo, then I know I should not be
raising the expectations of my patients or wasting tax-payers money by
using it. Do I know that homeopathy doesn't work beyond a shadow of a
doubt? No. Do I know that there is a real world out there beyond a shadow
of a doubt? No. Maybe homeopathy doesn't even exist. I'll keep my mind
open on that.
Competing interests: No competing interests