Archive for March, 2010

Letter to Annunziata

March 22, 2010

About: http://wp.me/pRr5F-4

Hello,

 I’m writing to challenge and discuss your position on the Science and Technology select committee. The committee assessed the evidence for homeopathy, coming to the conclusion that there is sufficient evidence for homeopathy’s lack of efficacy. Homeopathy produces only broad placebo effects, according to the evidence: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1874503/?tool=pubmed

                                                                    http://www.ncbi.nlm.nih.gov/pubmed/9310601

 I will not assume that you are familiar with meta-analyses or systematic reviews because I do not know in what you have graduated nor where you’ve trained. These methods of assessing data bring together many studies (all that can be found, in fact). Individual trials will vary, especially if they rely on small sample sizes.

 Analogous to this is the notion that you cannot determine sea-level change in the course of a day, nor a year, because the tide nor annual fluctuations tell you the underlying trend you wish to determine.

 In a systematic review, authors examine the methodologies of all trials before viewing any of the rest of the trial. If there are serious methodological flaws with a trial it will not be included in the analysis, and the reasons are thoroughly explained in every detail in the published systematic review. The purposes of these analyses are both to collate a larger and more reliable sample size, and to eliminate confounding bias (in the design, in interpretation of the results, publication bias). This approach is directly counter to the “cherry-picking” that many advocates of homeopathy are accused of.
 Here is an example of “cherry-picking”: http://dcscience.net/Overview-of-positive-research.pdf 

 Furthermore, the committee noted: “We regret that advocates of homeopathy, including in their submissions to our inquiry, choose to rely on, and promulgate, selective approaches to the treatment of the evidence base as this risks confusing or misleading the public, the media and policy-makers.

 You will notice that of the two articles I provided links to, the Lancet meta-analyses stated: “Further research on homeopathy is warranted provided it is rigorous and systematic.” Note that this meta-analysis was published in 1997.

 I put it to you that much research has been conducted since, notably by Edzard Ernst, first professor of CAM, at the CAM research department of Exeter uni (which is under threat, largely to the very public criticisms made by the Prince of Wale’s institute for unproven medicines.) http://www.guardian.co.uk/uk/2010/mar/19/prince-charles-health-charity-complaint

 It is therefore reliably certain that homeopathy is a system of prescribing placebo pills. This has ethical implications, summarised by Ernst, cited in the STC’s evidence check:

 36. Professor Ernst summarised the problem with prescribing placebos in the NHS:

 “I would argue it is unnecessary, unreliable and unethical to prescribe placebos through the NHS; unnecessary because if you do it well then an active treatment will also generate a placebo effect. If I give my patient an aspirin for his or her headache and I do it with empathy, time and understanding this patient will benefit from the pharmacological effect of the aspirin and she will also benefit from the placebo effect through the encounter with her clinician. It is unreliable and there is lots of data to show that placebo effects are notoriously unreliable; somebody who responds today may not respond tomorrow; responses are not large in effect size and they are not usually long-lasting. Foremost, it is unethical.”

 In your news piece http://annunziata.co.uk/ANewsHomeopathy26Feb2010.htm, you say: “Their findings would prevent our doctors from using homeopathy as an option for NHS patients, making it only available to those who can afford to pay.”

Your concern is more than adequately addressed by the before extract. A treatment with no specific medical efficacy is by all means a luxury. Those with the means may pay for a non-specific treatment, I can reasonably imagine that the consultation at a homeopathic clinic is superior to that afforded by time-constrained GPs. Those who can not afford private healthcare should be offered efficacious treatments that have a positive effect on specific illnesses, only. The losses to the NHS and thus to sick individuals created by money spent on homeopathy is a reason for concern. The misleading of patients is also reason for concern. It has been observed that patients will return to demand treatments they have already been offered, regardless of its effectiveness.

 Prescribing any intervention for conditions are short-lived and minor, that will become better by themselves, results in patients perceiving causality. http://www.bmj.com/cgi/content/full/315/7104/350?view=long&pmid=9270458

 This increases the workload on GPs. As we are able to establish that homeopathy is a system of prescribing placebos, usually for these minor self-correcting conditions; offering homeopathy on the NHS can be predicted, with evidence, to increase the NHS’s workload for minor conditions (often not requiring an intervention) and to increase patients’ confidence in (thus reliance on) an unproven (or proven non-efficacious) system of treatment.

 You say “we should trust doctors to make decisions on the best medical treatment for each patient“. I would like to take the chance to point out that the vast majority of medicine works near-identically for anyone. Human biology is not idiosyncratic on the whole.

 An example of false idiosyncrasy. The mechanism for allergies is not idiosyncratic, despite the resultant combination of allergies being unique; allergic reactions are manifest by the interactions of antigens (signalling proteins) on foreign bodies, and our leukocytes (cells of the immune system). Homeopathy has not been shown to benefit allergies anyway. In cases where an idiosyncratic appearance or fluctuation of symptoms is claimed (“unexplained pain”), this is plausibly due to psychological processes, not a person’s uniform biochemistry & physiology, nor the (lack of) pharmacological effect of homeopathy.

 CAM practitioners often claim benefit for such supposedly idiosyncratic conditions, and make a big deal of treatments being individualised. Frankly their treatments’ uniqueness is not plausibly of any benefit to patients in itself (herbalists and TCM-ers may be ignorant of drug interactions, and these groups have made no effort to compile evidence to inform their combinations of herbs), but rather may enhance the placebo effect by producing a more caring consultation.

 You go on to say “It is doctors who are the experts, which is precisely why they go through so many years of intensive training.” Our doctors are reliant on evidence to inform their treatment of patients. They are not able to stand completely alone, with their expertese, and continue to provide the best healthcare as new medicines are developed and new evidence is gained or synthesised critically.

 There are many academics involved in progressing our understanding of human biology, understanding pharmacology and producing evidence that accurately allows us to determine what is true and what is not. They have all been educated, and continue to educate themselves and the rest of us in their work; they are experts too.

 The STC’s evidence check takes good note of the valuable work done by people like professor Ernst, and comes to a reasonable conclusion. I must ask you if you lack trust in the expert scientists whose particular expertese is (or should be) in critically evaluating evidence, and determining truthood and causality.

 Why is it that you feel one person’s idea of what is an effective medicine is equal to any other person, regardless of how they are informed? 

 “I saw a practitioner in Frome for eczema, which conventional medicine had failed to cure. Ten years on and it has never recurred.” You of course realise that anecdotes are too weak evidence to determine causality. I believe that your eczema did clear up after seeing a homeopath, after your GP’s reccommendations did not “cure” it. And I believe it has never recurred.

 According to the national eczema society  “60-70% of children are virtually clear of the condition by the time they reach their mid-teens”. I’m afraid it is very unlikely that homeopathy caused the subsiding of your eczema symptoms. 

 I do hope that I have not been insensitive, and that you may find some of this letter and the accompanying links helpful in understanding this issue. Whilst you may have had a good experience of homeopthy, that does not mean it is good policy to provide unproven and implausible treatments on the NHS, which is supposed to provide healthcare.

 Patient choice is important, but homeopathy is basically irrelevant to healthcare because of its fundamental lack of efficacy. Patients should be offered and accurately informed about the range of efficacious treatments so rightly available free on the NHS. Prescribing placebos as primary care is highly unethical when the patient has a serious illness that has an effective conventional treatment; and costly in the case of minor self-correcting conditions, not just a financial cost but an idealogical cost: patients are mislead to have false confidence and a distorted idea of medicine and science that may lead to future harm.

 An anecdote to present to you the potetial harms of increasing provision for homeopathy on the NHS: I know a woman who died from cancer after seeing her homeopath rather than her GP. It was a painful and possibly unnecessary death no doubt. Qualified NHS homeopaths may not condone such conduct, but an increased confidence in homeopathy will confer to the poorly regulated and often law-breaking non-medical homeopaths.

 Thankyou for taking the time to read this.

    I wish you all the best,

 Teige Matthews-Palmer (a student who is concerned about antiscience.)