Tuesday, August 03, 2010

The BMA Homoeopathy (homeopathy) debate

The BMA is calling for homoeopathy to be removed from the NHS.

OK. I'm going to put my head above the parapet, ready for a hail of machine gun products from the anti-homoeopathy activists.

I confess that I have prescribed a few homoeopathic remedies in my in my 30 years as a GP. Just a few - pulsatilla, arnica, rhus tox, aconite. I found aconite especially useful for patient self-management of panic attacks (backed by good information) - very much more useful, and less problematic, than diazepam. I saw no harm from it.

I saw some dramatic recoveries - coincidental, naturally. I saw a particularly impressive coincidence with an adolescent whose problematic asthma disappeared after one dose of a powder prescribed by a proper homoeopathic doctor.

I have huge respect for homoeopathic physicians.  They are old-school. They engage with their patients, get to know them, and form a therapeutic relationship. The patient feels understood, and if the personal physician gives them a powder, they feel confident that they will get better. So they do.

At very least, homoeopath physicians in their natural habitat get an enhanced placebo effect.

Which would explain why published  homoeopathic trials tend to show show positive effect, while randomised double blind trials tend not to show any effect. Or are reported as not showing any effect.

With the notable exception of David Reilly's work.  David did an RCT on homoeopathic preparations in nasal allergy, and got a positive effect. His methods were criticised, so he repeated the work, taking on board the criticisms, and still got a positive effect.

Reilly has a .doc summary of the debate that can be downloaded from this page. It is fairly heavy going, with closely argued statistics so do not waste disc space if you do not do odds ratios and 95% CI's. But it does give another side to the picture about the scientific study of homoeopathy. For instance, the same device is used by H sceptics as has used by detractors of the Spirit Level - discarding unusually positive data.  


He shows a picture of two clusters of placebo controlled trials, one of orthodox drugs, and one of homoeopathic remedies. It is impossible to tell the difference in terms of significance. So the analysts (whose abstract begins with the words "Homoeopathy is widely used, but specific effects of homoeopathic remedies seem implausible." ) proceed to extract 8 homosopathic trials and 6 orthodox trials, and conclude "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 was then reported in an editorial under the headline as The End of Homoeopathy, a report duly amplified in the mainstream media. I confess that I picked up on this. Which just shows that if you want to really know something, you have to trace it right back to source.

I have always asked, when in the right company, that Reilly's work be replicated using two identical ultra-dilute solutions, one prepared by succussion, and one by turbulent mixing. The hypothesis is that the turbulent mix solution will perform less well if succussion is having an effect.As far as I know, this has never been done. It should be.

The response of the objectors is that it just cannot work, because there is no atom present of the original molecule.  Homoeopaths respond that the succussion (passing shock waves through the solution) process creates a "memory" in the water. Objectors ask for evidence of this memory.

Beneveniste thought he had found it, in demonstrating an effect on white cells from antibodies at homoeopathic dilutions. It seems that his effects were not replicated.

However, Louis Rey found this : Ultra-high dilutions of lithium chloride and sodium chloride (10−30 g cm−3) have been irradiated by X- and gamma-rays at 77 K, then progressively rewarmed to room temperature. During that phase, their thermoluminescence has been studied and it was found that, despite their dilution beyond the Avogadro number, the emitted light was specific of the original salts dissolved initially.

The scientific method requires that this work be replicated. It may have been; I don't know. I am coming late to this debate.


Next, this: "We discovered a previously unknown phenomenon in liquid water, which develops over time when water is left to stand undisturbed, and which made precise gravimetric measurement impossible. We term this property autothixotropy (weak gel-like behaviour developing spontaneously over time) and propose a possible explanation. The results of quantitative measurements, performed by two different methods, are presented. We also report the newly discovered phenomenon of autothixotropy-hysteresis and describe the dependence of autothixotropy on the degree of molecular translative freedom. A very important conclusion is that the presence of very low concentration of salt ions, these phenomena do not occur in deionized water. Salt ions may be the determinative condition for the occurrence of the phenomena". Vybíral + Vorácek2007

Reilly quotes Professor Luc Montagnier, a French virologist who co-discovered HIV and who won the Nobel Prize in 2008, made the radical claim ( 2009 ) that some bacterial DNA sequences are able to induce electromagnetic (EM) waves at high aqueous dilutions - if they were 'strongly agitated', a step 'critical for the generation of signals'. 

He also cites "evidence of ultramolecular dilutions of histamine ability to inhibit basophil activation “in a reproducible fashion”" [ Belon P, Cumps J,  Ennis M, Mannaioni PF, Roberfroid M, Ste-Laudy J,  Wiegant FAC. Histamine dilutions modulate basophil activity. Inlfamm Res 2004; 53:181-8]

These are the tip of the iceberg of papers relating to the micro-structure of water. I have a strong suspicion that water is far more sophisticated than the simple image that we have in our textbooks of tiny bouncy balls flying around at random.

Here is a simple starter on the micro structure of water.

The study of the micro-structure of water deserves scientific study. The trouble is that, because it is outside the mainstream, the people who do it tend to work on their own, and sometimes maybe their work leaves a little to be desired in terms of perfection.  But the medical profession should never forget, and never, never repeat, what we did to poor Semmelweiss.

The essence of science is to say dogmatically, not "This is the case", but to ask, "Is this indeed the case?" In this debate, the question is, "Is it indeed the case that water has no nano-structure which is worthy of investigation?"

So there is something to the micro-structure of water that needs scientific investigation. Whether this will have any relevance to homoeopathic medicines we will have to wait and see.

What we do know is that homoeopathic physicians do meet a need. They have high patient satisfaction. Their medicines are not expensive. Above all, their medicines do not (cannot, in the view of the sceptics) cause side effects.

I do not agree with the request from my union, the BMA, to remove homoeopathy from the NHS. It should be allowed to continue, but under conditions of audit, covering all aspects of their practice: what diagnoses they are presented with, the success rates that they achieve, and their cost-effectiveness. When this evidence is collected, we will be able to make an evidence based decision on whether or not it is worthwhile for the NHS to continue to fund homoeopathic physicians.

This would seems a reasonable way to move forward on this issue.

Later blog on this.

6 comments:

weggis said...

Next time we meet I shall buy you a pint of homeopathic bitter.

DocRichard said...

My thanks for that kind offer come to you diluted to 30c.

Anonymous said...

Mitchell and Webb's funny take on it:

http://www.youtube.com/watch?v=HMGIbOGu8q0

and a little more serious but still quite light:
http://www.guardian.co.uk/science/video/2010/feb/05/homeopathy-medicine

and more evidence-based, the excellent Ben Goldacre: http://www.badscience.net/category/complementary-medicine/homeopathy/

The BMA action is long overdue. As for the Green Party, I'd recommend steering well clear of this kind of stuff. Especially when you comment on the quality of science and how it can't be argued with, when it comes to AGW etc.

Glenn Vowles MSc, PGCE, BA said...

Absolutley fascinating. An eye opener for me. Many thanks for your clarity and expertise Richard.

DocRichard said...

I am not arguing with the reviewed science, although I have not read them, just watched the press reports of them pass by in a steady stream over the last 2 years.

What I am calling for is that NHS homoeopathy should be audited for say 12 months, and outcomes measured. That way we will garner some interesting evidence on which to base our decision as to whether H is cost effective or not.

DocRichard said...

Anon,

Well, I've had a look. I like Mitchell and Webb, but the dilution joke is wearing a bit thin (no pun intended) after 150 years.

The "mass overdose" made one point for H : it is safe in overdose. I have an anecdote about that, involving a toddler, a bottle of arnica within reach, and a fall down the stairs next day that... but we don't do anecdotes do we?

In reading Ben's blog, he says that there have been no meta-analyses of H, which is not correct.

I looked at Natural History Museum debate. Dr Peter Fisher, the H advocate, does an interesting review of proper H trials which would be routinely accepted by medics - were it not for the a priori problem that exists with ultra-dilutions. He mentions the negative H results (3%), which is good from the publication bias aspect.

I have the same probs with lay practitioners as Ben. As soon as they know I am a doctor, their hackles rise, and they begin to attack me, before they have time to learn that I have an open mind.

Much of Ben's polemic is against these practitioners.

He leads on placebo, which is fine.

I fully agree with Ben's bit on nocebo effect (negative placebo effect) and agree that the argument that some peeps get worse after H treatment does not show that H has an effect.

His analysis is not as evidence based as Fisher, in the sense that he is not presenting specific trials.

I stress that I am not comfortable with this debate. I am not a homoeopathic practitioner, and am perfectly ready to give way to evidence. But it seems to me that H is not being treated fairly because of the a priori problem.

Summary: The scientific approach to solve the question of whether ultra dilutions can have a clinical effect demands a well-designed RCT on H remedies against equally dilute preparations made without succussion (the knocking that takes place in preparations).

Hope this helps. Thanks for commenting.