Last year a review into pharmacy in Australia recommended homeopathic products be banned from sale in chemist shops across the country. This was a sensible recommendation, given pharmacists are trusted scientists in the community and science tells us homeopathic products simply don’t work.
In the government’s recent response to this review they “noted” the concerns of the reviewer, and have chosen not to adopt it. Here’s why that is a mistake.
What is homeopathy?
Homeopathy involves extreme dilution of a compound that is claimed to be therapeutically effective, and uses the concept of “like cures like”. For example a fever might be treated with a compound used to induce fevers, in the belief the diluted active ingredient will have the opposite effect and cure the fever.
Products tend to contain the equivalent active ingredient to a single molecule within an Olympic-size swimming pool. Practitioners of fact-based medicine have understandably indicated that any effect of the product could only be attributable to the placebo effect (it works because you believe it works) or because the product contains alcohol or a similar base.
Most pharmacists probably abhor such treatments lacking evidence, given they go through years of rigorous university training, are heavily regulated and have a strong professional ethic. But it makes the cash registers clang.
These days pharmacies also sell jelly beans, lipstick, energy bars, vitamins, teddy bears and sunglasses – as well as prescription medications. This, unfortunately, is business practice.
Pharmacies have a special status as businesses, along with many actors in the health system. Successive governments have grappled with tensions around service delivery, standards and competition.
They’ve also had to grapple with a very strong industry body, the Pharmacy Guild (stronger than the Pharmaceutical Society). Much of the review reflects agreement between them. In responding to the review the government has flicked the homeopathic hot potato to pharmacy owners:
Professional standards have been designed for use by individual pharmacists to assess their own professional practice. They are intended to serve as guidance for desired standards of practice. However, it is the sole responsibility of the individual pharmacist to determine, in all circumstances, whether a higher standard is required. It is equally their responsibility to meet that standard and ensure that consumers are provided with the best available information about the current evidence for, or lack-of efficacy in, offered treatments and therapies.
So given the government has not banned homeopathic products from pharmacies, we could hope for restriction under Australian Consumer Law. They can, for example, prohibit sale of products that lack the purported constituents or qualities. But this has yet to happen with homeopathy, as it’s considered misleading but harmless.
The government is putting the onus on consumers to ask the pharmacist “does this work?”, and only the exceptional customer will ask.
If consumers wish to purchase therapies without a proven effect, they should be able to do so from venues that sell incense sticks and similar “wellness” paraphernalia.
They should not be available for sale in an industry necessarily regulated by government and trusted by the community.
It’s time for the Guild and Society to take a stand and reject sale by their members of products that by definition do not work. If pharmacies want status, they have to skip the junk products dollar. The government should help.
Calling something a “scientific truth” is a double-edged sword. On the one hand it carries a kind of epistemic (how we know) credibility, a quality assurance that a truth has been arrived at in an understandable and verifiable way.
On the other, it seems to suggest science provides one of many possible categories of truth, all of which must be equal or, at least, non-comparable. Simply put, if there’s a “scientific truth” there must be other truths out there. Right?
Let me answer this by reference to the fingernail-on-the-chalkboard phrase I’ve heard a little too often:
“But whose truth?”
If somebody uses this phrase in the context of scientific knowledge, it shows me they’ve conflated several incompatible uses of “truth” with little understanding of any of them.
As is almost always the case, clarity must come before anything else. So here is the way I see truth, shot from the hip.
While philosophers talk about the coherence or correspondence theories of truth, the rest of us have to deal with another, more immediate, division: subjective, deductive (logical) and inductive (in this case, scientific) truth.
This has to do with how we use the word and is a very practical consideration. Just about every problem a scientist or science communicator comes across in the public understanding of “truth” is a function of mixing up these three things.
Subjective truth is what is true about your experience of the world. How you feel when you see the colour red, what ice-cream tastes like to you, what it’s like being with your family, all these are your experiences and yours alone.
In 1974 the philosopher Thomas Nagel published a now-famous paper about what it might be like to be a bat. He points out that even the best chiropterologist in the world, knowledgeable about the mating, eating, breeding, feeding and physiology of bats, has no more idea of what it is like to be a bat than you or me.
Similarly, I have no idea what a banana tastes like to you, because I am not you and cannot ever be in your head to feel what you feel (there are arguments regarding common physiology and hence psychology that could suggest similarities in subjective experiences, but these are presently beyond verification).
What’s more, if you tell me your favourite colour is orange, there are absolutely no grounds on which I can argue against this – even if I felt inclined. Why would I want to argue, and what would I hope to gain? What you experience is true for you, end of story.
Deductive truth, on the other hand, is that contained within and defined by deductive logic. Here’s an example:
Premise 1: All Gronks are green. Premise 2: Fred is a Gronk. Conclusion: Fred is green.
Even if we have no idea what a Gronk is, the conclusion of this argument is true if the premises are true. If you think this isn’t the case, you’re wrong. It’s not a matter of opinion or personal taste.
If you want to argue the case, you have to step out of the logical framework in which deductive logic operates, and this invalidates rational discussion. We might be better placed using the language of deduction and just call it “valid”, but “true” will do for now.
In my classes on deductive logic we talk about truth tables, truth trees, and use “true” and “false” in every second sentence and no one bats (cough) an eyelid, because we know what we mean when we use the word.
Using “true” in science, however, is problematic for much the same reason that using “prove” is problematic (and I have written about that on The Conversation before). This is a function of the nature of inductive reasoning.
Induction works mostly through analogy and generalisation. Unlike deduction, it allows us to draw justified conclusions that go beyond the information contained in the premise. It is induction’s reliance on empirical observation that separates science from mathematics.
In observing one phenomenon occurring in conjunction with another – an electric current and an induced magnetic field, for instance – I generalise that this will always be so. I might even create a model, an analogy of the workings of the real world, to explain it – in this case that of particles and fields.
This then allows me to predict what future events might occur or to draw implications and create technologies, such as developing an electric motor.
And so I inductively scaffold my knowledge, using information I rely upon as a resource for further enquiry. At no stage do I arrive at deductive certainty, but I do enjoy greater degrees of confidence.
I might even speak about things being “true”, but, apart from simple observational statements about the world, I use the term as a manner of speech only to indicate my high level of confidence.
Now, there are some philosophical hairs to split here, but my point is not to define exactly what truth is, but rather to say there are differences in how the word can be used, and that ignoring or conflating these uses leads to a misunderstanding of what science is and how it works.
For instance, the lady that said to me it was true for her that ghosts exist was conflating a subjective truth with a truth about the external world.
I asked her if what she really meant was “it is true that I believe ghosts exist”. At first she was resistant, but when I asked her if it could be true for her that gravity is repulsive, she was obliging enough to accept my suggestion.
Such is the nature of many “it’s true for me” statements, in which the epistemic validity of a subjective experience is misleadingly extended to facts about the world.
Put simply, it smears the meaning of truth so much that the distinctions I have outlined above disappear, as if “truth” only means one thing.
This is generally done with the intent of presenting the unassailable validity of said subject experiences as a shield for dubious claims about the external world – claiming that homeopathy works “for me”, for instance. Attacking the truth claim is then, if you accept this deceit, equivalent to questioning the genuine subject experience.
Checkmate … unless you see how the rules have been changed.
It has been a long and painful struggle for science to rise from this cognitive quagmire, separating out subjective experience from inductive methodology. Any attempt to reunite them in the public understanding of science needs immediate attention.
Operating as it should, science doesn’t spend its time just making truth claims about the world, nor does it question the validity of subject experience – it simply says it’s not enough to make object claims that anyone else should believe.
Subjective truths and scientific truths are different creatures, and while they sometimes play nicely together, their offspring are not always fertile.
So next time you are talking about truth in a deductive or scientifically inductive way and someone says “but whose truths”, tell them a hard one: it’s not all about them.
Obviously we need to turn over the D to check that there is a 3 on the back (everybody gets this one right). And equally obviously, there’s no need to turn over the K (and again, everybody realises this). The 3 card is a tricky one. Most people think that you need to turn this card over to see whether there is a D on the other side. This would be necessary had the claim been that “Every card that has a D on one side has a 3 on the other, and vice versa”. But it wasn’t. The 7 is the other tricky one. It doesn’t occur to most people that we need to turn this card over to check that the letter on the back is not D. If it is D, then the claim is false.
This trick illustrates the phenomenon of confirmation bias. Most people, being fairly charitable sorts, want to turn over the 3, find a D on the back and confirm the claim (“Well done, you’re right!”). And so it is with homeopathy (or conspiracy theories). People who want to believe that the treatment works actively search for opportunities to confirm this belief, focusing on homeopathy patients who seem to have got better (“3 cards”) and reject opportunities to disconfirm it, by ignoring research studies (“7 cards”).
The NHMRC has released its final statement on homeopathy. To no ones great surprise, the report concluded that there was no evidence that homeopathy was effective in treating any of 63 separate medical conditions.
I have already dealt with aspects of the interim report, and articles in The Conversation have already dealt with the report in general (see here and here), so I would like to look at it from a different angle; how do we effectively communicate the science behind the report?
After all, the target audience for this information is not the people who have been following the evidence, and are well aware that homeopathy is ineffective. To some degree the people who want to treat mild or self limiting conditions, for example insomnia, and who think that homeopathy is some form of herbal medicine are also not the target audience.
What we are worried about most is those people with serious conditions who abandon standard therapy for ineffective homeopathy (for example, trying to treat diabetes with homeopathic dilutions of uranium salts). We accept that adults should be able to choose (or reject) their therapies. But we also expect that people choose or reject therapies based on the best available evidence. What happens when people reject that evidence?
A recent paper looked at various ways to communicate with parents to increase vaccination rates. They found that parents accepted that the MMR vaccine did not cause significant side effects after the various communication strategies, but were not inclined to get their children vaccinated. One subset of parents, those who had the least favourable views on vaccination at the beginning of the study, were now LESS likely to vaccinate their children.
This is consistent with other studies (see also here) showing that when people with deeply entrenched beliefs are confronted with facts that disprove those beliefs, paradoxically they become firmer in their beliefs.
So how do we effectively communicate the science in the report? The NHMRC site has meticulous information on what they did, summaries and a FAQ, but we have to get people to read them. Most news articles and radio shows do not provide the information to find the report.
From a science communication point of view, most of the information on the NHMRC site is too technical for the general public. As an example of a good way to convey science around a contentious issue, the Australian Academy of Sciences has a great web accessible document that simply and clearly explains the science behind vaccines.
However, if you google “Vaccine Information Australia” you will see 4 of the top 10 results are vaccine denialist sites (and 3 of the top 5), and the AAS report is nowhere to be found.
As well as finding information in a format accessible to the general public, we need to consider that those most at risk of ignoring conventional medicine for homeopathy are also very likely to be in that 20% that the CSIRO found to be disengaged from or distrustful of science. As well, peoples perception of health and their health philosophy can make this a very emotionally charged issue.
We need to carefully consider how to approach this audience. In the light of the pediatrics paper, referenced above, where factual information led people to be less likely to vaccinate, merely giving people the facts is unlikely to be enough.
However, there are a variety of approaches that can be tried. Most of these have been developed in relation to politics or global warming, but the processes that are involved are similar.
In view of how homeopathy may be deeply linked with peoples world views, and showing homeopathy is no more than placebo may leave a gap in peoples beliefs (accounting for their reluctance to accept the facts), an approach such as replacing the gap with an alternative narrative may be the best approach.
Whatever the approach we use, the publication of the NHMRC report on homeopathy is the beginning of a long process of engagement, not the end of the matter.
The release today of the long-awaited NHMRC Statement and Advice on Homeopathy is just the latest in a series of pointless and ideologically motivated exercises that this peak scientific body has been tasked to undertake.
We have seen this group of professional scientists sent on wild goose chases after Wind Turbine Syndrome, water fluoridation and now homeopathy on behalf of a government that clearly wants science to be done to order for its political agenda. At a time when they are holding valuable, productive and world-class research infrastructure hostage to their unpopular higher education legislation, it is simply impossible to believe that the federal government takes science seriously at all.
Thankfully, the scientists continue to do their job well even when sent on a fool’s errand. The report on homeopathy is a model of science-based enquiry. It really should put to bed the case for supporting this entirely fantastical enterprise with science or higher education dollars. The analysis of the literature was comprehensive, covering some 1800 articles published. The majority of these were of such poor quality that only a couple of hundred even met the most basic criteria for further analysis. The consensus of these acceptable studies was that there was nothing to see here, and science should move on.
If some good is to come out of such a whimsical use of public funds, it should lead to the removal of public subsidies for private health insurance to cover homeopathy services. It should be wielded mercilessly in support of a crackdown by TGA and ACCC on the spivs and hucksters who sell complete moonshine to vulnerable patients. After all, as the Prime Minister reminded us yesterday in another context,
“ what we can’t do is endlessly subsidise lifestyle choices”
This Statement of Advice on homeopathy is reported to have cost around $800,000 to produce, and followed a similar document having been produced in the UK which arrived at the same conclusion just a couple of years earlier. I’m sure a few of Australia’s newly unemployed research scientists could have put that money to good use. The fluoridation and wind turbine fiascos add insult to injury by wasting precious science dollars on fatuous ideological stunts. One wonders whether NHMRC reports on the health effects of “superfoods” or dangers of immunisation will be next. Perhaps Senator McFarlane should just change his job title to Minister for Industry and Junk Science.
The National Health and Medical Research Council today released a statement concluding that there is no good quality evidence to support the claim that homeopathy is effective in treating health conditions.
Its release follows a thorough review of the evidence, conducted as part of NHMRC’s responsibility to provide advice and support informed health care decisions by the Australian community. This is the final outcome from the draft information paper the NHMRC released last year.
The conclusion is based on the findings of a rigorous assessment of more than 1800 papers. Of these, 225 studies met the criteria to be included in NHMRC’s examination of the effectiveness of homeopathy.
The review found no good quality, well-designed studies with enough participants to support the idea that homeopathy works better than a placebo, or causes health improvements equal to those of another treatment.
Quoting from the ACCC website “…[Homeopathy Plus!] engaged in misleading and deceptive conduct and made false and misleading representations to the effect that there was an adequate foundation in medical science for the statement that homoeopathic treatments are a safe and effective alternative to the whooping cough vaccine, when in fact no such foundation exists..”
Before we examine these claims, let me remind you that homoeopathy is based on two principles “like cures like” and extreme dilution, in most cases to levels so dilute that there is almost no chance of a single remaining molecule of original compound being present in the remedy. Thus caffeine diluted 1 in a hundred 30 times is used to treat insomnia and Uranium nitrate diluted 1 in a hundred 30 times is used to treat diabetes.
In the latter case it is fortunate at no uranium will actually be present, as uranium nitrate causes kidney failure. In uranium nitrate-induced kidney failure some glucose turns up in the urine, as the kidneys ability to reabsorb it is damaged. This is completely unlike what happens in diabetes, where high blood glucose overwhelms the kidneys capacity to reabsorb it (in uranium nitrate toxicity blood glucose is not elevated so it is not “like” diabetes at all). Thus the rationale for homoeopathic treatment is flawed at many levels.
But back to the draft report of the NHMRC’s review of homoeopathy. This represents the largest and most extensive recent review of homoeopathy research. The review looked at both systematic reviews of the use of homoeopathy in 61 heath conditions and submissions on behalf of interested parties, which contained a mix of systematic reviews and individual randomised controlled trials. All submissions and papers were carefully evaluated against strict criteria recognised internationally for this type of review. The Australasian Cochrane Centre independently reviewed the overview report to ensure that it was valid and high quality.
To remind you, the review found there was no good evidence that homeopathy was effective for any of the 61 medical conditions considered. In some cases, there was clear evidence that homoeopathy was ineffective; in others the evidence base was too weak to give a clear result. These findings are in concert with other large reviews of homoeopathy. Let’s look at the claimed “flaws”.
There was no adequate explanation of why randomised controlled trials (RCTs) were excluded.
They were not excluded. The main review focused on systematic reviews, which included randomised controlled trials (and other types of high level evidence). This is the best way to compare multiple studies. Randomised controlled trials are considered the highest level of evidence, but the results of a single randomised controlled trial may be misleading for many reasons.
Chance is one, if a therapy has no actual effect,by chance alone you will find some studies that appear to show an effect.
Thus it is far better to compare as many high quality trials as possible to get a clearer picture. Randomised trials were not excluded, but an integral part of the evidence through systematic reviews. Randomised controlled trials submitted by stakeholders that were not already part of systematic reviews were considered as well.
While there are limitations to this approach (specifically the most recent research may be excluded), it is widely used in making clinical decisions and in no way invalidates the findings of the report. One of the biggest limitations is that negative findings tend to be under-reported, so that systematic reviews tend to overestimate the effectiveness of a therapy. That homoeopathy cannot pass muster under these conditions is telling.
Three academics invited to comment on the review all broadly agreed there was no high quality evidence recommending homoeopathy for any disorder.
The review excluded too many studies.
Of the 1367 publications considered in the main review, only 60 were finally considered. Not because of anything sinister, but because only those met the review criteria. 374 were duplicate citations, 729 were the wrong study type (not peer-reveiwed, not systematic reviews or metaanalyses, or not looking at controlled trials or high level evidence) or were not looking at the conditions considered in the review or did not report the outcomes (etc. etc.) (see the main review for details).
Of the reports submitted by stakeholders, only a few passed the inclusion criteria or were not already included. Pro tip, if the NHMRC asks you for peer-reviewed systematic reviews and randomised controlled trials in humans, don’t submit books on the life of Hahneman and studies of frogs exposed to thyroxine (yes, I went through the papers).
The review did not consider any publication not in English.
While this excludes some studies, most high quality studies are published in the English language press. As well, the practicalities of translating foreign language papers to ensure there are no complicating errors in translation are avoided. Overall, the impact of this decision on the reliability of the report is marginal at best.
The NHMRC had not appointed a homeopathic expert to the panel.
These homoeopathic preparations are already in use in humans, so the appropriate studies are ones in humans in the first place. As well, the studies in animals suffer the same flaws as those in humans, too many are of poor quality and many are unable to be interpreted or make claims that cannot be supported. For example, one study submitted to the review that claimed to demonstrate that homoeopathic treatments kill breast cancer cells actually shows that the ethanol diluent is the lethal factor.
Overall, while there are some limitations to the study, this is a wide ranging, carefully interpreted study. While overall the broad conclusion is that there is no good evidence the homoeopathy being effective in the 61 studied conditions, in at least 13 studies there was good evidence that homoeopathy was ineffective (asthma for example). The results of this study are in broad agreement with previous studies of homoeopathy (see also this, and before you bring up the “Swiss Report” see here and here).
The NHMRC study conclusion that “…the assessment of the evidence from research in humans does not show that homeopathy is effective for treating the range of health conditions considered” cannot be ignored or dismissed.
In 1800, conventional medicine was a disaster. Doctors weakened patients with bloodletting and purging, they poisoned them with mercury and other harmful substances, and they often killed more patients than they cured. Dr. Samuel Hahnemann was looking for safer, more effective ways to help his patients. He had an epiphany after he took a dose of cinchona bark and developed symptoms similar to those of malaria, the disease cinchona was supposed to treat. He extrapolated from this one observation to conclude that if any substance causes a symptom in healthy people it can be used to treat the same symptom in sick people. He formulated this as the first law of homeopathy, similia similibus curentur, usually translated as “like cures like.” He diluted his remedies so that they would no longer cause symptoms; this led to his second law of homeopathy, the law of infinitesimals, which states that dilution increases the potency of a remedy. When he observed that his remedies worked better during house calls than in his office, he attributed it to jostling in his saddle bags, so he added the requirement of “succussion,” specifying that remedies must be vigorously shaken (not stirred) by striking them against a leather surface at every step of dilution.
Homeopathic remedies are usually labeled with the notation X or C, corresponding to ten and one hundred. 15C would mean that one part of remedy was diluted in 100 parts of water, one part of the resulting solution was again diluted in 100 parts of water, and the process was repeated fifteen times. Hahnemann died before Avogadro’s number was available to calculate how many molecules are present in a volume of a chemical substance. Today we can calculate that by the thirteenth 1:100 dilution (13C), no molecules of the original substance remain. Hahnemann typically used 30C remedies. At 30C, it would take a container thirty million times the size of Earth to hold enough of the remedy to make it likely that it would contain a single molecule of the original substance. The most popular homeopathic cold and flu remedy is sold as a 200C dilution, and there are even higher dilutions. Above the 1,000C level there are remedies designated as multiples of M, where 1M=1,000C.
An example will clarify the mind- boggling implausibility of homeopathy. If coffee keeps you awake, according to homeopathy dilute coffee will put you to sleep. The more dilute, the stronger the effect. If you keep diluting it until there isn’t a single molecule of coffee left, it will be even stronger. The water will somehow remember the coffee. If you drip that water onto a sugar pill and let the water evaporate, the water’s memory will somehow be transferred to the sugar pill, and that memory of coffee will somehow enable it to function as a sleeping pill.
1857 painting by Alexander Beydeman showing historical figures and personifications of homeopathy observing the brutality of medicine of the ninetenth century.