Evidence-based medicine is a worthy objective. According to the Oxford-based Centre for Evidence Based Medicine, “Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”
The present campaign against homeopathy and other complementary therapies makes extensive use of these aims to justify calls for these therapies’ exclusion from the NHS on the grounds that there is “no evidence” for their efficacy. I’ve gone into the evidence question in relation to homeopathy in other posts. This one looks at the evidence base for biomedical treatment. After all, if biomedical treatment is to be so clearly preferred over the complementary therapies which presently lack the robust evidence base being demanded, then one would assume that biomedical treatments have a clear advantage here.
One would assume wrongly.
This from BMJ Clinical Evidence:
What proportion of commonly used treatments are supported by good evidence, what proportion should not be used or used only with caution, and how big are the gaps in our knowledge? Of around 2500 treatments covered 13% are rated as beneficial, 23% likely to be beneficial, 8% as trade off between benefits and harms, 6% unlikely to be beneficial, 4% likely to be ineffective or harmful, and 46%, the largest proportion, as unknown effectiveness (see figure 1). Dividing treatments into categories is never easy hence our reliance on our large team of experienced information specialists, editors, peer reviewers and expert authors. Categorisation always involves a degree of subjective judgement and is sometimes controversial. We do it because users tell us it is helpful, but judged by its own rules the categorisation is certainly of unknown effectiveness and may well have trade offs between benefits and harms. However, the figures above suggest that the research community has a large task ahead and that most decisions about treatments still rest on the individual judgements of clinicians and patients.
So let’s get this straight. Just 13% of the 2,500 treatments assessed — around 325 treatments — have been shown to have clear benefit. A further 23% are “likely to be beneficial”. The remainder, a staggering 64%, have either too many harmful side effects to be of clear benefit, are just plain ineffective and/or harmful, or have unknown effectiveness.
Yet so many of these drugs are presently being prescribed to the population of the United Kingdom that not only is the NHS close to bankruptcy, but traces of them are even showing up in rivers and drinking water supplies, including cytotoxic chemotherapy drugs which, according to figures publicised in 2003 by GlaxoSmithKline’s Allen Roses, have a response rate of only 25%. Further, for those that do respond to the therapy, a 2004 study concluded that “the overall contribution of curative and adjuvant cytotoxic chemotherapy to 5-year survival in adults was estimated to be 2.3% in Australia and 2.1% in the USA.” The authors went on to say “it is clear that cytotoxic chemotherapy only makes a minor contribution to cancer survival. To justify the continued funding and availability of drugs used in cytotoxic chemotherapy, a rigorous evaluation of the cost-effectiveness and impact on quality of life is urgently required.”
In the context of these figures, the present campaign against complementary therapies seems completely indefensible. Until biomedical treatments can provide robust evidence that their continued use is justified in terms of the benefit they provide to patients, then they too should be dropped from the NHS. And perhaps some of the enormous savings this would achieve could be spent on funding a better evidence base for complementary therapies …
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February 6, 2008 at 4:12 pm
John R
Regarding your comments about cancer chemotherapy you might want to look at:
http://tinyurl.com/2lhrbt
This illustrates the problems with using a single study as evidence for anything. Something homeopaths in general would do well to bear in mind.
February 6, 2008 at 5:24 pm
gimpy
Yes but you haven’t adressed the awkward fact that there is no convincing evidence that homeopathy works………
Or are you cleverly arguing that because there are problems with the evidence base for some treatments then all treatments with no evidence base should be allowed?
February 6, 2008 at 8:52 pm
John R
Laughing that letter I linked to is behind a pay-wall so as you may not have access here’s the text.
The Contribution of Cytotoxic Chemotherapy to the Management of Cancer
We read with interest the paper by Morgan et al. [1], which claimed to assess the contribution of curative or adjuvant cytotoxic chemotherapy to survival in adults with cancer. We are concerned that their approach underestimates the contribution of chemotherapy to the care of cancer patients. By using all newly diagnosed adult patients as a denominator, despite the fact that chemotherapy is not indicated for many of these patients, the magnitude of the benefit in many sub-groups is obscured.
Furthermore, the authors use a time-point of 5 years to assess effect on survival. This will underestimate the efficacy of chemotherapy because of late relapses. In breast cancer, the leading cause of cancer death in women, survival curves show ongoing relapses beyond 5 years. Adjuvant chemotherapy produces an absolute survival benefit at 10 years in women less than 50 years with node-negative and node-positive disease of 7% and 11%, respectively, whereas the benefit at 5 years is 3% and 6.8% [2]. Quality-adjusted Times Without Symptoms of disease and Toxicity of treatment (Q-TWIST) analysis has shown additional benefits beyond just survival, with adjuvant treatment of breast cancer prolonging quality-adjusted survival, partly by delaying symptomatic disease relapse [3].
The paper also contains several inaccuracies and omissions. The authors omitted leukaemias, which they curiously justify in part by citing the fact that it is usually treated by clinical haematologists rather than medical oncologists. They also wrongly state that only intermediate and high-grade non-Hodgkin’s lymphoma of large-B cell type can be cured with chemotherapy, and ignore T-cell lymphomas and the highly curable Burkitt’s lymphoma. They neglect to mention the significant survival benefit achievable with high-dose chemotherapy and autologous stem-cell transplantation to treat newly-diagnosed multiple myeloma [4]. In ovarian cancer, they quote a survival benefit from chemotherapy of 11% at 5 years, based on a single randomised-controlled trial (RCT), in which chemotherapy was given in both arms [5]; however, subsequent trials have reported higher 5-year survival rates. In cancers such as myeloma and ovarian cancer, in which chemotherapy has been used long before our current era of well-designed RCTs, the lack of RCT comparing chemotherapy to best supportive care should not be misconstrued to dismiss or minimise any survival benefit. In head and neck cancer, the authors erroneously claim the benefit from chemotherapy given concomitantly with radiotherapy in a meta-analysis to be 4%, when 8% was in fact reported [6].
The authors do not address the important benefits from chemotherapy to treat advanced cancer. Many patients with cancers such as lung and colon present or relapse with advanced incurable disease. For these conditions, chemotherapy significantly improves median survival rates, and may also improve quality of life by reducing symptoms and complications of cancer. Advanced cancer consumes a significant component of the healthcare dollar, and chemotherapy can be a cost-effective treatment. For example, lung cancer with more than two-thirds of patients presenting with advanced disease, accounted for 5.6% of total healthcare system costs in Australia in 1993–1994 [7]. The use of chemotherapy rather than best-supportive care alone is cost-effective, as it reduces costs of treatment of complications of lung cancer and requirement for palliative radiotherapy to control pain 8 and 9.
Although we fully agree that there is a need for evidence-based assessment of all treatments, the contribution of this type of analysis, with pooling of all cancer patients, is questionable and potentially misleading. It is time to focus on future improvement by providing optimal evidence-based multi-disciplinary care to our patients.
References
1 G. Morgan, R. Ward and M. Barton, The contribution of cytotoxic chemotherapy to 5-year survival in adult malignancies, Clin Oncol 16 (2004), pp. 549–560. SummaryPlus | Full Text + Links | PDF (189 K) | View Record in Scopus | Cited By in Scopus (8)
2 Early Breast Cancer Trialists’ Collaborative Group, Polychemotherapy for early breast cancer: an overview of the randomised trials, Lancet 352 (1998), pp. 930–942.
3 B.F. Cole, R.D. Gelber, S. Gelber, A.S. Coates and A. Goldhirsch, Polychemotherapy for early breast cancer: an overview of the randomised clinical trials with quality-adjusted survival analysis, Lancet 358 (2001), pp. 277–286. SummaryPlus | Full Text + Links | PDF (264 K) | View Record in Scopus | Cited By in Scopus (52)
4 J.L. Harousseau, J. Shaughnessy Jr. and P. Richardson, Multiple myeloma, Hematology (Am Soc Hematol Educ Program) (2004), pp. 237–256. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (33)
5 M.H. Tattersall, C.E. Swanson and H.J. Solomon, Long-term survival with advanced ovarian cancer: analysis of 5-year survivors in the Australian trial comparing combination versus sequential chlorambucil and cisplatin therapy, Gynaecol Oncol 47 (1992), pp. 292–297. SummaryPlus | Full Text + Links | PDF (596 K) | View Record in Scopus | Cited By in Scopus (5)
6 J.P. Pignon, Chemotherapy added to locoregional treatment for head and neck squamous-cell carcinoma: three meta-analyses of updated individual data. MACH-HC Collaborative Group. Meta-analysis of chemotherapy on head and neck cancer, Lancet 355 (2000), pp. 949–955. SummaryPlus | Full Text + Links | PDF (118 K) | View Record in Scopus | Cited By in Scopus (737)
7 The Cancer Council Australia, Clinical practice guidelines for the prevention, diagnosis and management of lung cancer, National Health and Medical Research Council (2004).
8 J.M. Berthelot, B.P. Will, W.K. Evans, D. Coyle, C.C. Earle and L. Bordeleau, Decision framework for chemotherapeutic interventions for metastatic non-small-cell lung cancer, J Natl Cancer Inst 92 (2000), pp. 1321–1329. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (44)
9 A. Szczepura, Healthcare outcomes: gemcitabine cost-effectiveness in the treatment of non-small cell lung cancer, Lung Cancer 38 (2002) (Suppl 2), pp. 21–28. SummaryPlus | Full Text + Links | PDF (455 K)
February 6, 2008 at 9:28 pm
yeshomeopathy
Its always interesting when a resoundingly positive-for-homeopathy and negative-for- conventional medicine fact based choice comes out the Randini tricks start to multiply. IT TRIGGERS A MASSIVE DENIAL COMPLEX. Like discredit a study, even though it may be only part of the picture etc. The point is that the evidence and personal experience is overwhelming that there is something wrong with the evidence it works overall or is SAFE overall IS SIMPLY MISLEADING. It has lead to a misplaced faith-based opinion by science skeptics that defend any negative report and have little or no clinical understanding of the implications.
Why not allow the public to choose wisely between homeopathy and conventional medicine? And we don’t need the danger rhetoric here since this study shows that in the treatment of chronic disease by conventional medicine there are some serious problems and even some environmental damage that medications are causing.
Skeptics- its time to spend your time dealing with these toxic environmental hazards caused by drugs instead of beating the drum against “water”.
February 7, 2008 at 2:35 am
woodchopper
“The 46% of treatments which are not proven to be effective is 46% of all treatments for 240 common conditions – and very few are used in the NHS. The great majority are treatments used by alternative practitioners.”
Source here http://www.guardian.co.uk/letters/story/0,,2238067,00.html
I applaud your stance in favour of evidence based medicine, and eagerly await your call for these alternative practitioners to adopt scientifically proven procedures.
February 7, 2008 at 9:56 pm
openmind
So? They use all use active compounds. A homeopathic remedy is just water. To make the case for homeopathy it’s not enough to complain about the evidence base for other treatments, you have to demonstrate to the same standards as any other medicine that it can have an effect over and above placebo. Heck, it doesn’t even have to be a beneficial effect.
Remind me again why this isn’t possible, don’t some quantums get entangled or something?
February 8, 2008 at 7:54 pm
Humber
Lmso,
I don’t see any double standards here. I look forward to seeing SoH’s pie-chart of homeopathy’s performance, so that we may make a more legitimate comparison.
February 10, 2008 at 11:16 pm
laughingmysocksoff
Doesn’t it just.
I’ve 3 words to say in response to that John R: Shang et al.
The campaign against homeopathy that’s been gaining in momentum since 2005 is based almost entirely on the claims of that one severely flawed study. All the assertions that homeopathy “is no more effective than placebo” are based on the conclusion of that one study. The 5 preceding meta-analyses of homeopathic clinical trials all concluded that homeopathy exhibited an effect greater than placebo.
Funny how you’re so quick off the mark to cry “foul” when the same standards that are being used to judge the efficacy of homeopathy are used on conventional treatments …
February 10, 2008 at 11:51 pm
laughingmysocksoff
That’s subjective opinion Gimpy, not fact. The fact that you personally happen to be convinced only by clinical trial data doesn’t mean there’s no convincing evidence that homeopathy works. Even clinical trial data supports an effect beyond placebo for homeopathic remedies. The lack of consistency and replicability would seem to indicate inadequate control of variables more than anything. Until that possibility has been adequately explored, you can’t say the data support any other conclusion.
No. I’m simply pointing out the glaring hypocrisy prevalent in arguments that homeopathy should not be available on the NHS because its efficacy isn’t rigorously proven.
You seem to have a highly idealised view of medicine, Gimpy. I’d seriously suggest spending some time in a clinical setting to evaluate just how well your principles about “evidence” translate into practice.
February 10, 2008 at 11:58 pm
laughingmysocksoff
Different study woodchopper. I’m quoting the BMJ, not The Lancet. I suggest you check out the original reference.
February 11, 2008 at 12:22 am
le canard noir
I am not sure where the hypocrisy lies here. If we assume that all treatments used in NHS hospitals were included here, then homeopathy must have been included. Where would it lie in the pie chart? In the white area, “unlikely to be beneficial’. That much we know.
February 11, 2008 at 12:39 am
laughingmysocksoff
So let me get this straight, open?mind. You’re saying that active compounds are the only possible plausible means conceivable in the entire universe for all time to cure someone of their illness? And you’re saying that in the context of GSK’s worldwide VP of genetics admitting “The vast majority of drugs – more than 90 per cent – only work in 30 or 50 per cent of the people”. And every single one of those drugs passed clinical trials which supposedly proved their efficacy …
I see no evidence at all here that justifies biomedicine claiming either the moral high ground, the efficacy high ground, or the “proven” argument. Statistics like these comprehensively undermine the notion of the DBRCT as some kind of evidence “gold standard”. It seems a more pragmatic and comprehensive attitude to evidence gathering is called for, along the lines of the “evidence mosaic” I’ve quoted Reilly elsewhere as suggesting.
Homeopathy has good evidence for its efficacy in 200 years’ worth of cured cases. It also has clinical study data that lend support to that case history that, in terms of evidence, is to many people a lot more convincing than clinical trial data.
February 11, 2008 at 12:43 am
laughingmysocksoff
Humber, the SoH is a registration body, roughly equivalent to the BMA. The BMA isn’t a research organisation and neither is the SoH.
February 11, 2008 at 12:54 am
laughingmysocksoff
There is no evidence that any alternative therapies were included in the BMJ’s study. They evaluated 2,500 “commonly used” treatments in an attempt to answer the question “how much do we know”? Since the focus of the journal is on conventional treatment, it would be reasonable to assume the focus of the study was on conventional treatment.
As for your assumption that homeopathy would appear in the “unlikely to be beneficial” area, then perhaps you should check out how many clinicians agree with you. All the clinical study data so far suggests “likely to be beneficial” and “beneficial” would be far more likely. The number of primary care physicians wanting to study homeopathy kind of lends support to that idea too.
February 11, 2008 at 1:27 am
bewaiwai
It is totally appropriate to compare this to unfounded CAM criticisms. Especially considering the nil side effects of homeopathy. It is also totally appropriate to not ask homeopathy for this burden of proof. As soon as homeopathy reaches the billions and billions of dollars of outlay on medicines that individuals and governments spend then it may be an appropriate study. It might also be when homeopathy reaches the level of toxicity which it never will.
On the other hand, these type of studies concerning homeopathy have already been done by Iris Bell MD.(Find them yourself if you are interested- do your own research in between your Organon studies).
In the meantime, 4 per cent having been harmed and likely to be harmed is way too much. Four per cent is about the percentage of total hospital beds that are taken up with ill patients from pharmaceutical drugs and iatrogenesis.
And listen, don’t bring out the “homeopathy is dangerous” canard hearsay in response to that. Modern drugs are toxic- some help and are very important in certain situations particularly acute illness but the benefits and the injured and dead are all too many.
Rather than chasing after homeopaths because they are easy to bully I would say some of you here would be better off dealing with the serious crisis that is being caused by pharmaceutical company driven medicine.
February 11, 2008 at 10:58 am
le canard noir
This statement shows you fundamentally misunderstand or misrepresent the evidence-based medicine movement. The whole purpose of sites like the BMJ Clinical Evidence site is to help medicine move away from using treatments based on ‘how many clinicians agree with you’ and to where treatments are used that have objective evidence to back up their efficacy. EBM is as much as a threat and a challenge to many within the medical profession as it is to homeopaths and other CAM practitioners.
So, homeopathy would undoubtedly be relegated to the “unlikely to be beneficial” basket because a) the clinical evidence for it is woefully poor despite the grand claims of homeopaths and b) it is totally scientifically implausible and so does not merit further consideration.
February 11, 2008 at 4:57 pm
John R
Laughing Woodchopper is referring to the same study. Here’s John Garrow author of that letter writing in a letter to the bmj:
http://www.bmj.com/cgi/content/full/335/7627/951-a
Final paragraph:
Lewith’s interpretation of the pie chart is highly misleading. The research community has been commendably diligent, but of course RCTs often fail to find that certain treatments are effective. Euphemisms such as “unknown” or “needs more study” for the inefficacy of such treatments may soothe the feelings of proponents of those treatments that have so far failed to show efficacy, but it does an injustice to the researchers who obtained these data, and misleads both practitioners and patients about the extent to which orthodox medicine is evidence based. It is particularly ironic that CAM therapies are over-represented in the ‘‘not shown to be effective” category, so if anyone should be concerned about lack of evidence it should be CAM practitioners rather than conventional medics.
I don’t have access to the clinical evidence site so I can’t comment directly on the proportion of CAM therapies used in their work, but I’m guessing that neither can you.
February 11, 2008 at 5:01 pm
John R
Also in the health watch newsletter:
http://www.healthwatch-uk.org/newsletterarchive/hw68.htm#Cibet
Perhaps the nearest we can get to an EE is Dr David I Tovey, editorial director for the British Medical Journal’s Knowledge department, which produces evidence-based products for clinicians and the public. It is therefore worrying that on the BMJ Clinical Evidence website [1] a statement on the current knowledge about effectiveness of treatments suggests the meticulous rules for meta-analyses are not being obeyed:
“Of around 2500 treatments covered 13% are rated as beneficial, 23% likely to be beneficial, 8% as trade off between benefits and harms, 6% unlikely to be beneficial, 4% likely to be ineffective or harmful, and 46%, the largest proportion, of unknown effectiveness.”
Can it be true? The selection of 240 common conditions is arbitrary, but they are listed, so I can replicate that. But when I try to replicate the list of treatments I am baffled [2]. To claim that “46% of around 2500 treatments are of unknown effectiveness” (my italics) makes no sense unless the criteria for selecting which treatments to include and which to leave out are clearly stated. Some people may treat their wrinkles by washing their faces in the dew on May mornings. If the treatment list included that, and all the other innumerable evidence-free folk remedies for every common condition, the treatment list would have thousands of entries of which the percentage “unknown” would approach 100%.
On the other hand the list of treatments analysed could have been limited to those which had been tested by good randomised trials, in which case the “unknown effectiveness” category would shrink to nearly 0%. Without the selection criteria specified, the figure of “46%” is meaningless. Worse, it is even snatched up with glee by the alternative health lobby, who have used it to claim that nearly half of orthodox treatments are of unknown effectiveness [3], when in reality many of the treatments analysed are themselves alternative remedies (and are, not surprisingly, over-represented in the “unknown effectiveness” category).
February 11, 2008 at 5:10 pm
John R
At the risk of being awarded loser status for three posts in a row, can anyone find the Lancet paper Garrow refers to in the letter Woodchopper linked to? I can’t find it.
February 11, 2008 at 6:59 pm
bewaiwai
Well, some rather bizarre thinking and activity here. Even magical thinking about pharmaceuticals and the pharmaceutical industry. It similar to the skeptics bizarre approach to the AIDS epidemic as in “Blame the homeopaths!” “Homeopaths cause AIDS”.
There are over 50 million individuals with AIDS and a small percentage treated by pharmaceutical intervention. (Why that is, is a whole other topic). Many who take retrovirals die of Tuberculosis, so it doesn’t do much for the total immune system anyways. But in any case, this tragedy in Africa is somehow being blamed on a few homeopaths who want to treat a few hundred individuals out of the 50 million! This is spreading AIDS! How convenient.
Now, there is evidence that pharmaceuticals do not live up to expectations, and even cause serious side effects. So how do you deal with that? Blame the alternative health crowd! They messed the study up. How totally bizarre. How totally bizarre, zealous and bigot like! Blame a small group of people that are easily bullied. What a solution!
February 11, 2008 at 9:06 pm
John R
Now, there is evidence that pharmaceuticals do not live up to expectations, and even cause serious side effects. So how do you deal with that? Blame the alternative health crowd! They messed the study up. How totally bizarre. How totally bizarre, zealous and bigot like! Blame a small group of people that are easily bullied. What a solution!
WHAT WHAT WHAT!!!
I assume that was in response to my post. If so could you explain where I was being bigoted? I wasn’t blaming anyone for anything. I was just pointing out that the percentage of ineffective interventions Laughing mentioned in his original post is not made up completely by conventional medicine. As Garrow pointed out in his letters, using that figure to measure the effectiveness of conventional medicine is useless. In what way is this ‘magical thinking’.
February 11, 2008 at 9:13 pm
Humber
bewaiwai,
Do you really think that skeptics blame homeopaths for AIDS?
They are certainly critical of homeopathy’s claims, and are concerned that unproven medicines will be administered in the place of ARV’s.
Peter Chappell avows that is not his intention to supplant AVR’s but he is an iconoclast and has his own interpretation of ‘not’ and ‘intention’.
I cannot take the word of a man who sells medicine by MP3.
Pharmacology’s failures are not homeopathy’s gains, though they seem to think they are.
If I dig up some figures that accurately represent the efficacy of ARV’s (no matter how limited) that would be the current level of medicine’s ability. If the results do not meet your expectations, the error is yours.
If you think that homeopathy can do better, then please present the evidence.
February 11, 2008 at 9:35 pm
laughingmysocksoff
Well I think I’m going to have to disagree with you there, Andy. As David Sackett writes (in How to Practice and Teach EBM) “Evidence based medicine is the integration of best research evidence with clinical expertise and patient values.”
By your way of it, it seems you would hold all clinicians to the results of clinical trials and little else. That would be all well and good if human beings all behaved like dutiful little clones, but unfortunately life just isn’t like that and despite sharing broadly similar physiology, we all react idiosyncratically to life’s challenges. By the pharmaceutical industry’s own admission, 90% of treatments exhibit efficacy rates of just 30-50%. Not only that, but 20% of all drugs which pass clinical trials have to be recalled on safety grounds so that doesn’t say much for the reliability of trial data, even before you get into issues like the widespread skewing of results by the pharmaceutical industry. EBM consequently requires a more pragmatic and multi-faceted approach than the one you seem to favour.
People are deserting biomedicine in droves because they are experiencing it as ineffective or harmful or both. They’ve been turning to alternative medicine in droves and experiencing it as effective. However hard you try to argue that this doesn’t constitute “evidence”, the proof of the pudding is in the eating. All you succeed in doing by insisting that homeopathy doesn’t work “because it can’t” and that there’s “no evidence” that it works is turning “science” into even more of a joke among the general population than it is already. This is just plain self-defeating and an enormous shame because the scientific method has so much to offer, even if it’s not the be-all and end-all of existence. But this is what you get for adhering to the theory at the expense of the reality, and trying to tell people that the evidence of their own experience doesn’t count for anything.
February 11, 2008 at 9:45 pm
bewaiwai
Denial. Denial. Denial.
You all fawn over conventional pharmaceuticals and ignore the reports of disasterous effects and perseverate about homeopathy. Just like your above posts. The scale of disaster or injury from pharmceuticals is so much LARGER that it deserves much more of your attention than the scale which homeopathy is at. But bullies like to pick on the little guy.
And unfortunately these disasters from conventional medicine and pharmaceuticals doesn’t make homeopathy any better; it just means that there is a lot of human suffering out there in the name of “science” and the gold standard double blind that you so glorify. Thats a fact, a big fact.
It would be nice to make room in your drug besotted minds that alternatives to these medical interventions are appropriate options for some people, particularly those not clouded by bigotry, bullying and drugs.
February 11, 2008 at 10:08 pm
laughingmysocksoff
Garrow appears to be speculating about included treatments every bit as much as we are. Personally, I’d guess that CAM treatments represent only a tiny proportion of those figures for the simple reason that CAM treatments are still minority treatments and are not used extensively in the NHS, so it looks to me as if Garrow is overstating the case.
But until someone can come up with the original study, there’s no point in discussing these statistics further. I can’t even get onto The Lancet site just now, let alone track anything down.
February 12, 2008 at 3:02 am
Humber
The BJM defines unknown effectiveness as:
‘For which there are currently insufficient data or data of inadequate quality’
As fitting description of CAM, I think.
If the treatments in the 46% category are allopathic and are being dispensed as being proven, then this is obviously wrong.
You could then claim, for what its worth, some moral ground, but nothing in terms of homeopathy’s effectiveness.
February 12, 2008 at 7:51 pm
Humber
I’m a bit confused, nth time loser. Where is the original data? This is Garrow’s “full” letter at BJM ( for me it was behind a paywall, so sorry if it is redundant)
Scientific heavyweights deplore the NHS money wasted on unproved and disproved treatments used by practitioners of complementary and alternative medicine (CAM),1 2 but Lewith, a CAM proponent [see previous letter], is cited elsewhere as saying that the BMJ reckons that 50% of the treatments used in general practice aren’t proved, and 5% are pretty harmful but still being used.3 His data were taken from the BMJ Clinical Evidence website (http://clinicalevidence.com/ceweb/about/knowledge/jsp, viewed 6 May 2007). A pie chart indicates that, of about 2500 treatments supported by good evidence, only 15% of treatments were rated as beneficial, 22% as likely to be beneficial, 7% part beneficial and part harmful, 5% unlikely to be beneficial, 4% likely to be ineffective or harmful, and in the remaining 47% the effect of the treatment was “unknown.” The text says, “The figures suggest that the research community has a large task ahead and that most decisions about treatments still rest on the individual judgements of clinicians and patients.” On 9 October 2007 the situation had changed—but not for the better. Treatments rated “beneficial” had decreased from 15% to 13%. The associated text is unchanged.
Acute low back pain is a common and well investigated condition. BMJ Best Treatments reports that back pain affects 70-85% of all adults, and each year almost half of us get back pain that lasts at least a day (http://besttreatments.bmj.com/btuk/conditions/1559.html). There are 18 treatments for acute low back pain which have been tested by randomised controlled trials (RCTs), of which two (11%) were graded “beneficial” and 13 (72%) “unknown.” The accompanying table shows all of the 18 treatments for acute low back pain and their rated effect. According to this table, a condition that is extremely common, and for which many treatments have been intensively researched, has an even higher than average proportion of treatments that are labelled “unknown” efficacy, or in other places “need further study.” There must be some mistake.
The solution to the mystery is that the label “unknown” does not mean, “We have no knowledge of the effect of this treatment because it has not been tested in an RCT.” Astonishingly, it means, “We have tested this treatment in several RCTs, but on balance there is currently no convincing evidence that it is effective for this condition.” So really the efficacy of these 13 treatments for acute back pain is not “unknown” but “not demonstrated.”
Lewith’s interpretation of the pie chart is highly misleading. The research community has been commendably diligent, but of course RCTs often fail to find that certain treatments are effective. Euphemisms such as “unknown” or “needs more study” for the inefficacy of such treatments may soothe the feelings of proponents of those treatments that have so far failed to show efficacy, but it does an injustice to the researchers who obtained these data, and misleads both practitioners and patients about the extent to which orthodox medicine is evidence based. It is particularly ironic that CAM therapies are over-represented in the ‘‘not shown to be effective” category, so if anyone should be concerned about lack of evidence it should be CAM practitioners rather than conventional medics.
John S Garrow, vice chairman, HealthWatch
Here is the same letter, but with the following appended data.
thttp://www.bmj.com/cgi/eletters/335/7623/736-a
Grading of the efficacy of treatments for acute low back pain
Treatments that work n=2 (11%)
Non-steroidal anti-inflammatory drugs (NSAID)
Keeping active
…that are likely to work n=2 (11%)
Multi-disciplinary treatment programmes (Drs, psychologists, physiotherapy)
Spinal manipulation … that work, but harm may outweigh benefit n=1 (6%)
Muscle relaxants … that “need further study” (aka “unknown”) n=13 (72%)
Acupuncture Massage
Back schools Painkillers
Behaviour therapy Temperature treatments
Biofeedback Traction
Epidural steroid injections Transcutaneous electrical nerve stimulation (TENS)
Back supports … that are unlikely to work n=1 (6%)
Exercise, including back exercises. … that are likely to be ineffective or harmful n=1 (6%)
Bed rest
References
1. Kamerow D. Wham, bang, thank you CAM. BMJ 2007;335:647 (29 September)
2. Calquhoun D. What to do about CAM. BMJ 2007; 335:736 (13 October)
3. Lewith G. (cited by Cope J) Healthwriter. April 2007, p 2.
4. http://clinicalevidence.com/ceweb/about/ knowledge/jsp visited 06-05- 07. Competing interests: None declared
The link provided in the first letter = page not found, but I think this is a typo, that when corrected links to the pie chart article. ?
February 13, 2008 at 12:13 am
laughingmysocksoff
Of course treatments in the 46% category are allopathic!! You’re not seriously suggesting that the majority of around 1,150 of the “commonly used” treatments evaluated by BMJ Clinical Evidence were CAM treatments, are you?!! Holey socks!
And in case you hadn’t noticed, this particular blog entry has nothing to do with demonstrating homeopathy’s effectiveness. It’s purpose is to highlight the hypocrisy and double-standards being applied to sceptical “critiques” of homeopathy’s evidence base.
February 13, 2008 at 12:28 am
laughingmysocksoff
I really don’t see what Garrow is trying to make such a ‘mystery’ and song and dance about here. My presumption on reading the BMJ stats was certainly not his, so his astonishment seems rather incomprehensible. Unknown efficacy is unknown efficacy, whether RCTs are involved or not.
He appears to be trying to make a similar suggestion to your’s, Humber. That somehow this vast number of treatments with unproven efficacy are mostly to do with CAM therapies. Thank heavens I still had a Christmas voucher to exchange at my local sock suppliers today or it would have been frostbite for sure in this weather …
February 13, 2008 at 4:59 am
bewaiwai
“Of course treatments in the 46% category are allopathic!! You’re not seriously suggesting that the majority of around 1,150 of the “commonly used” treatments evaluated by BMJ Clinical Evidence were CAM treatments, are you?!! Holey socks!”
“I really don’t see what Garrow is trying to make such a ‘mystery’ and song and dance about here…so his astonishment seems rather incomprehensible”
Laughingmysocksoff- Very good points you make above but they smack too much of common sense and the obvious so it won’t have much effect on the skeptics here.
Its the convoluted ability of a skeptic to make up look like down if it serves their purpose and to attempt to spoil anything that a reasonable person would draw a conclusion from. It’s impossible to have a reasonable argument with a bigot who presents opinions as fact.
The rigid belief is that conventional medicine isn’t really bad, its bad because there is a conspiracy by CAM and homeopaths to make it look bad.
The truth of conventional medicine and its shortcomings and even danger is just too much to look at. So either obscure it or go blame a homeopath!
February 13, 2008 at 11:15 am
John R
Bewaiwai nobody is suggesting that conventional medicine has reached perfection, can cure all ills and is free from side effects, hence the ongoing research to provide newer, more effective and safer drugs. The point I was making is that making a statement like 74% of treatments are useless, and using this as an argument against conventional medicine, is meaningless, without knowing how many of these treatments are use routinely by doctors. That figure will be made up from current treatments, former treatments that are no longer used and CAM treatments. Without knowing the stats no firm conclusions can be made.
Humber made a sarcastic comment earlier about what a similar pie chart would look like for homeopathy. Despite being sarcastic this does illustrate the differences between medicine and homeopathy. Remember that the Clinical Evidence site is run by the BMJ. Conventional medicine is well aware of its shortcomings, hence research such as this and the wealth of other ongoing research and internal critical appraisal attempting to improve medicine.
Compare and contrast this with homeopathy. The only time I’ve seen any sign of critical appraisal within homeopathy was when Peter Fisher said that homeopaths proscribing homeoprophylaxis for malaria were irresponsible. I’m not saying this is the only case, only that it’s the only case I am aware of, I’d welcome and evidence of other occasions
February 13, 2008 at 12:23 pm
John R
**^^any evidence of other occasions.^^**
February 13, 2008 at 4:02 pm
Humber
Lmso,
I realise this article was to show the shortcomings of conventional medicine; though behind it lies the tacit assumption that homeopathy could do better.
The source of the BMJ’s definition accompanies the pie chart. Whatever the case, medicine has identified a possible source of failure. That too is part of EBM.
The NHS does use CAM, and should be represented in the chart. With the given data, it is not possible to assign the 46% slice to conventional medicine, or any CAM treatments to the effective group.
Unless there is a one-to-one correspondence, the number of treatments will not be the same as the number of material remedies. As JohnR wrote, it is the efficacy of the most commonly prescribed drugs that is important. In the real world, utility is a valued commodity.
In this article you are trumpeting medicine’s failure, yet you are not sure that this is the case, because supporting data is not supplied, or it seems, available. I don’t know why Garrow mentions back pain, and in the second provides only some partial data. I have e-mailed Garrow, if he replies, I will let you know. Furthermore;
Waste Disposal
There are no regulations covering homeopathic waste. Production of the remedies is controlled by food and packaging standards, or not at all. Helios report that their effluent is considered as “bulk waste water”. Medicine and pharmacology are mass-market engineering projects, and share many of the technical and social burdens that accompany such endeavors.
Recalls.
Remedies have no means of direct assay, meaning that errors further down the production line will not be detected. Food manufactures constantly monitor their final product to minimise error, yet it still happens, and many more are caught before recall.
Homeopathy’s open-ended production will certainly lead to many errors, yet I can find not one recall.
How could you know without using the patient as a guinea pig?
Monitoring of Performance
No pie chart available from any homeopathic authority.
February 13, 2008 at 5:40 pm
bewaiwai
“Bewaiwai nobody is suggesting that conventional medicine has reached perfection, can cure all ills and is free from side effects, hence the ongoing research to provide newer, more effective and safer drugs”
Oh this sounds so beautific! Just a few minor adjustments and we are all safe and cozy. If it were only so!
Humber-you sound like someone involved in the pharmaceutical industry?
Toxic chemicals are toxic chemicals as in pharmaceutical drugs and radiation by products etc. that are used in medicine and dentistry, (mercury!).
Homeopathic remedies are not toxic. Your bleatings do not apply to homeopathy.
All the what ifs, danger conjectures and other bleatings by the skeptics are just that- opinions and hear say bleatings. You try to dig up whatever dirt you can on homeopathy and ignore the tragic consequences of so called “well” manufactured, “well” tested drugs like Vioxx etc., etc. And then diminish any disasterous negative effects (which is not an opinion or conjecture but fact) by beautifying the whole business and claiming its just the perspective of homeopaths that is the problem.
February 13, 2008 at 7:24 pm
Humber
Bewaiwai,
No connection with big pharma.
If you believe homeopathic remedies are benign, then how do you explain
the many challenges made to skeptics to consume them and the forecast of pain or discomfort ?
Of course, you have ignored what happens to the poisonous process waste, such as that from nux vomica. Are you sure of their disposal?
The evidence that dental mercury is poisonous is weak at best. Generally, the choice is not between amalgam or something else, but between unfilled cavities or extraction. There are replacements for amalgams – I know because I was involved in the development of the tools – but there is much testing to be done and durability is still an issue. Bad teeth are not only painful, but the toxins produced by the inhabiting bacteria can be fatal. Very bad teeth can also led to malnutrition.
Medicine is not perfect. It is only the 21st Century. As with tooth amalgam, there is a trade off between doing nothing and doing something. Side effects are expected and monitored. I should remind you that lack of toxicity may correlate with lack of effect.
No comment on the last point, then?
February 13, 2008 at 9:44 pm
bewaiwai
Are you equating the 300 metric tonnes of mercury used for amalgam per year to the few grams of nux vomica used to make a homeopathic remedy? Wow- I’m flabbergasted by your weird perseverations and your nasty implications and gossip about homeopathy.
And then are you suggesting there is no such thing as a composite filling as an alternative to amalgam?
February 13, 2008 at 11:23 pm
bewaiwai
Humber says: “Medicine is not perfect. It is only the 21st Century. As with tooth amalgam, there is a trade off between doing nothing and doing something. Side effects are expected and monitored. “
Oh my gosh, here we go again- what drugs are you being monitored for? what “medicine” are you referring to?
Perhaps I should be asking how old you are- You are rambling and self contradictory as well as all over the place in your attempt to malign homeopathy and elevate conventional medicine to the level of mythical status.
February 14, 2008 at 1:16 am
laughingmysocksoff
Humber, we can all always do better. I don’t think you would find a serious homeopath who would say otherwise. We’re human. We’re fallible. We act on the best judgement we can apply at any time, and at the end of the day any prescription is an individual subjective decision for every clinician, homeopathic or conventional. With the best will in the world, no clinician has access to all the necessary relevant information at the time of a first prescription. Some degree of trial and error is inevitable, and frankly anyone who believes otherwise is living in cloud cuckoo land.
This isn’t the point though. Homeopaths are more than happy to allow conventional clinicians their trial and error for the simple reason that we follow a broadly similar process. The point here is that sceptics appear to be attempting to hold homeopathy to standards that are not being applied to conventional interventions. That’s hypocrisy and double standards.
Yes indeed. Which is precisely why homeopathy has the kind of support it does, and why David Tovey, editorial director of BMJ Knowledge, writes:
He also states:
Basically this supports the point I’m making, which is that it’s thoroughly hypocritical of sceptics to shriek about lack of evidence for CAM therapies when the same situation obtains for the majority of conventional interventions.
Any luck in tracking down the original research yet? I’ve spent a while trawling through The Lancet with as many keywords as I can logically extract from the BMJ Clinical Evidence piece to no avail.
February 14, 2008 at 1:32 am
Humber
bewawai,
Thanks for the input. I am Methuselah and under constant medication.
February 14, 2008 at 1:59 am
Humber
Lmso,
I meant by comparison, better than conventional medicine.
I have said before that I am not trying to deny patients their choice. I am diffident about the role of CAM, but I think that it should demonstrate that it can support it claims, or at least acknowledge its limitations.
The trail evidence thus far is contentious. For every document supporting Shang, there is another undermining it. There is considerable disagreement amongst homeopathic researchers on this matter.
I am not sure that the claim of double standards is valid. There may be conventional therapies that do not produce very convincing results, but there are some drugs that are clearly very effective. Homeopathy has yet to produce this sort of result, so the double standard, if there is one, only applies at the margins.
In the current context, homeopathic trials are intended to demonstrate that the principle is sound, rather than the efficacy of a particular remedy. This begs the question as to why they are not more convincing. Put your best foot forward and all that. I know – a lot of satisfied patients.
Remember that conventional medicine also has a very big anecdotal database.
Sorry, no luck with the data yet.
February 14, 2008 at 2:10 am
Humber
Bewawai,
I missed your previous post. No, I am not comparing mercury to nux vomica, by any means.
You act as if mercury is used to deliberately poison patients.
The reason that it is still used, it that a replacement has been hard to find. Teeth have a tough existence. Rather than concentrate on the negative aspects, you may consider it fortunate that such a compound was discovered. Don’t swim out of your depth.
If you have a cavity, Bewawai, you may seek alternatives, but the decay will contunue until you lose the tooth or end up in the dentist’s chair.
I recommend the short route.
February 14, 2008 at 2:55 pm
auquai
The atrocious coverup here –
http://www.publicintegrity.org/GreatLakes/index.htm – fits the well-known pattern of corporate and state denials about industrial biotoxins, and iatrogenesis.
BTW, a post containing this link appeared briefly on http://www.badscience.net this a.m., before being pulled, in common with other inconvenient posts there. Since CAM practitioners are constantly excoriated for avoiding difficult questions, including censoring blog posts, it is only fair to point out that science fundamentalists are just as bad.
February 14, 2008 at 10:27 pm
laughingmysocksoff
Agreed. Which is precisely why so much effort has gone into designing and running trials of homeopathy.
Such equivocal evidence would tend to indicate that not all variables are being adequately accounted or controlled for. These are generally the sort of results you get when this is so (which I’ve argued elsewhere). Small sample sizes don’t help either. It’s also the case that homeopathic trials are a rather heterogeneous collection of (homeopathic) methodologies and trial objectives, so meta-analyses of the entire data set are more than usually prone to the apples-and-oranges argument. More work is plainly needed, but it’s wholly premature to argue, as The Lancet did in 2005, that the present state of the evidence base justifies the judgement of “the end of homeopathy”.
I don’t think it’s as clear cut as your statement suggests.
Firstly, if the order of the figures produced in BMJ Clinical Evidence are any indication, only around 13% of conventional treatments can claim that level of efficacy.
Secondly, homeopathy does have data that support similar levels of efficacy. For example, per Shang et al
Whereupon they of course concluded, according to their initial premise, that in the absence of methodological deficiency, such positive results must all be due to ‘bias’. Homeopathy can’t win in the face of such assumptions. The results of this meta-analysis were already determined from the moment it began as a twinkle in Mathias Egger’s eye.
Well that’s just it. Homeopathic trials don’t all set out with that uniform objective, so the data don’t have that homogeneity of purpose. Many trials are performed to satisfy licensing requirements for homeopathic products in other countries. Many are barely recognisable as “homeopathy”. I’ve already gone into the variety of possible reasons why such equivocal results are obtained at great length elsewhere.
In an ideal world we’d be able to run the large trials needed and repeat them at regular intervals to provide the sort of evidence being demanded, but with limited funding, limited resources, small data sets, etc, what else can homeopathy do? Rocks and hard places come to mind. After all, even conventional trails struggle to obtain funding unless they’re being financed by the pharmaceutical industry, and the pharmaceutical industry won’t fund a trial unless they can smell a profit at the end of it.
February 15, 2008 at 4:00 pm
bewaiwai
auquai- Thanks for the link to the study. Very interesting and horrifying. But you wouldn’t expect any of these skeptics to take on LARGER and important issues like that.
Regarding censorship on the bad science web site- the commercial sponsors of must have been offended.
February 18, 2008 at 2:07 am
Humber
Lmso,
As you know, the pie chart data is not supported, but I assume you are comparing it to homeopathy’s claimed 70% success rate, but to do so is meaningless if the same treatments or patient numbers are not compared. Clinical data need not reflect pharmacological efficacy, but the performance of the medical system. The sheer difference in scale and breadth of treatment makes direct comparisons rather dubious.
Shang’s work has been digested and dissected elsewhere, by everyone. Even within homeopathy results are interpreted in accordance with viewpoint. Earlier positive results by Linde et al, were denied by Walach (entangler) but supported by Oberbaum (localist).
“Agreed. Which is precisely why so much effort has gone into designing and running trials of homeopathy”
“Such equivocal evidence would tend to indicate that not all variables are being adequately accounted or controlled for.”
“It’s also the case that homeopathic trials are a rather heterogeneous collection of (homeopathic) methodologies and trial objectives, so meta-analyses of the entire data set are more than usually prone to the apples-and-oranges argument.”
Quite. That’s the problem. Why is the science so bad?
Too much effort has gone into finding some wriggle room to escape the inevitable result. That is to be expected. A discipline that rejects much of science is hardly likely to adhere to its tenets upon demand, or to satisfy skeptics.
Alternative science knows no failures. Ideas are never wrong, just not yet proven. Negative outcomes are common enough in science, but they seem to be a surprise to homeopathic researchers.
The lack of rigour is all but palpable. Claims of bias and poor methodology are not prejudice, but there for all to see. Where trials are rigorous, the results are negative.
What of Rustrum Roy’s spectography? He has a contentious hypothesis, which he backs with an experimental trial that would embarrass a lab technician. He is an iconoclast, a renegade, and does not care if he proves his point to what he sees as the establishment. Perhaps he even avoids it.
Biased results, and underpowered trials are not ‘nearly right’, but inadmissible. It as if they never took place. Beneviste’s work never took place. The positive results were due to bias by one or more of the researchers, if not outright fraud, yet it is still referred to as if it were valid.
Medical trials are science, but in practice and purpose, they are closer to engineering. Engineers often make working prototypes that are not full implementations of their final design, but demonstrations of the operating principles. These proof of concept models are made to gain investor confidence, and to show them what they could be missing. The engineer puts himself in the position of the skeptic, so that their objections are anticipated and met beforespending time and money. Things go a lot better if both sides are satisfied that the idea will yield the claimed result. CAM scientists seem to lack this common sense, and their trails demonstrate it.
Even if true, the double standard of evidence raises another issue. Trying to gain acceptance against the tide is a common occurrence. If someone in marketing has an idea for a new product of any sort, they will accept that their idea must be presented in a way that may not suit them, but the target audience.
“Many trials are performed to satisfy licensing requirements for homeopathic products in other countries.”
I don’t know of any (but why not both?) In the USA, surely the largest market, the FDA applies only the food regulations. Homeopathic remedies are not required to meet any regulations applicable to drugs. There are some restrictions that apply to OTC remedies, but again, as there are generally no assayable active ingredients, compliance is almost automatic.
“After all, even conventional trails struggle to obtain funding unless they’re being financed by the pharmaceutical industry, and the pharmaceutical industry won’t fund a trial unless they can smell a profit at the end of it.”
Yes, time to market can be 10 years. There are regulatory bodies to satisfy. Legal challenges and misuse to consider. A promising compound may be impractical to produce. Problems not shared by homeopathy.
Pharmacology is business, like any other. If you are taking a moral stance on commercialisation, then I should remind you (and any conspiracy theorists) that mostof Big Pharma’s employees, from marketing to human resources, have spiritual or religious beliefs, rather than science’s minority view of material atheism.
February 18, 2008 at 8:57 pm
laughingmysocksoff
Well we do know from the horse’s mouth that CAM treatments with trial data and unproven efficacy are placed in the ‘unlikely to be of benefit’ category, so even if that category is dominated by CAM treatments, that’s still only a maximum 6% of the total which in no way invalidates the points I was making in my post.
I’m not making direct comparisons, Humber, because direct comparisons — as you rightly say — can’t be made. However, studies that all fall into the same ballpark all fall into the same ballpark, and you can draw inferences from them that at least support calls for further study. GSK’s Allen Roses says 90% of pharmaceutical drugs are only effective in 30-50% of cases. BMJ Clinical Evidence says only somewhere between 26-34% of 2,500 commonly used treatments have some proven benefit. The Bristol study concluded 70%+ of patients reported some improvement with homeopathic treatment. The Berlin study came up with similar percentages and concluded that patients using homeopathy had better outcomes than patients using conventional medicine. Glasgow Homeopathic Hospital‘s ongoing audits of patient response return similar percentages.
It’s worth emphasising that while controls might be absent in these studies, the patient cohorts tend to have a high percentage (80%+) of chronic complaints of which an equally high percentage (80%+) have failed to respond to conventional treatment. If they failed to respond to conventional treatment, in which the placebo effect is likely to be considerably stronger than in homeopathy, then it’s reasonable to suggest that these are patients who are not particularly susceptible to placebo response. If they failed to respond to conventional treatment, then it’s reasonable to suggest that for these patients, homeopathy proved to be the more effective option.
Well of course! That’s the nature of human beings and the nature of medical science! Trial evidence for any intervention is rarely so incontrovertible that everyone agrees with the conclusions, and methodology rarely so robust that nobody can pick holes in it. It’s invariably a matter of perspective and opinion.
Whoops … there go the socks again …
So bad? Homeopathic trials tend to fare rather better than conventional ones these days. Shang et al could only find 9 (out of their 110 selected from … let’s see … a third of a million?) to meet their quality criteria to homeopathy’s 21 (out of 110 from maybe 200?) in their initial sifting.
The science isn’t uniformly “bad” Humber. There are poor trials, of course, but the reason so many homeopathic (and barely “homeopathic”) methodologies are represented in the trial data has to do with the difficulties in trying to shoehorn an individualised complex therapy into the homogeneity criteria of a DBRCT.
Then you’ve clearly been highly selective in your reading. There is no blanket rejection of scientific principles in homeopathy. Just scientific dogma. Some practitioners may not be scientists by training or inclination, but that’s hardly a prerequisite for practicing healing modalities. We know we’re dealing with something that doesn’t find a ready explanation in existing theory, but that doesn’t mean we’re going to abandon everything we’re doing until we can explain it, because explaining it is a very distant second place to the aim of helping people overcome their illnesses. For most patients of homeopathy, it’s enough to experience it working. They don’t much care how it happens. Even supposing it’s all happening through psychosomatic means, clinical studies are indicating it’s considerably more effective than either pharmaceutical drugs or psychotherapy in a wide range of conditions and therefore has enormous potential to be a useful and cost-effective addition to available therapies which is why … d’oh … it’s been proving so popular among GPs.
As for failures, every practitioner has their failures and I don’t know anyone shy of admitting that! You won’t find them published in journals, because there’s nothing constructive to be learned from them. 4 pages of “it didn’t work and I don’t know why or what will” is of no value to other practitioners next to “this worked for this patient in these circumstances”.
Those are broad-brush statements which are not borne out by a thorough examination of the literature. There is as much rigour evident in homeopathic trials as in conventional ones. There’s also as much lack of rigour, and as much bias on occasion, but on balance (inasmuch as you can compare a data set of c200 trials to one of over 300,000) there doesn’t seem to be any evidence of any more absence of rigour or bias than is found in conventional trials. So claims of bias and poor methodology are rather hypocritical, particularly in view of the 21-9 subset identified by Shang et al. And rigorous trials have produced many positive results. The 8 mentioned in my previous reply plus the studies by Jacobs et al in childhood diarrhoea for starters. Check your facts before making such sweeping statements.
Because there are just as many valid reasons for believing the Maddox-Randi circus to be no less biased or potentially fraudulent.
Well there you have it. Beautifully stated. Medical trials are closer to engineering. Oh boy … a whole sock drawer full … thank you for that one!
This, to my mind, is exactly why biomedicine is failing. What did you see when you last looked in the mirror, Humber? A machine? Or a human being? These techniques are perfect for machines and non-living inanimate systems. Applying them to living systems doesn’t work and is little short of disastrous in the long term. That’s principally why the world has come to be in the parlous state it’s in. Living systems are non-linear and have qualities of uniqueness, unpredictability, interdependence. The mechanistic model is grossly inadequate in this context.
The USA is not the largest market for homeopathic preparations, either in value or volume. Most of the trials conducted to satisfy licensing requirements are for the German market.
Because there is no toxicity in homeopathic remedies and they don’t kill and maim people.
What an extraordinary statement! And exactly what has spirituality or lack of it to do with the price of fish? The primary and over-riding purpose of medicine IS TO CURE PEOPLE OF THEIR ILLNESS. Didn’t that even occur to you? And yes, I do take a very firm moral stance where that aim appears secondary to turning in a profit for the stockholders. People’s lives and their quality of life is not a commodity to be bought or sold. Slavery has supposedly been abolished.
And since when was professing to material atheism a prerequisite for considering yourself part of the body of “science”? That sounds more like scientism than science to me.
February 19, 2008 at 11:12 pm
Homeopathic ‘placebo’ is much more effective than conventional medicine’s placebo « Homeopathy4health
[…] Homeopathic ‘placebo’ is much more effective than conventional medicine’s placebo Filed under: evidence, homeopathy, medicine, science — homeopathy4health @ 11:12 pm Tags: BMJ, drug effectiveness, Glasgow Homeopathic Hospital, GSK, homeopathy, placebo Laughing my socks off’s comment on blog entry ‘Socking hypocrisy in anti-cam campaign… : […]
February 25, 2008 at 5:12 am
Humber
“Well there you have it. Beautifully stated. Medical trials are closer to engineering. Oh boy … a whole sock drawer full … thank you for that one!
This, to my mind, is exactly why biomedicine is failing. What did you see when you last looked in the mirror, Humber? A machine? Or a human being? These techniques are perfect for machines and non-living inanimate systems. Applying them to living systems doesn’t work and is little short of disastrous in the long term. That’s principally why the world has come to be in the parlous state it’s in. Living systems are non-linear and have qualities of uniqueness, unpredictability, interdependence. The mechanistic model is grossly inadequate in this context.”
Lmso,
You’re welcome. The cellular collective known as Humber thinks that you have demonstrated its point. Because I suggested that medical trials are engineering, I therefore think of people as machines and am in some way connected to slavery?
Medical trials are closer to engineering, than say, pure research. I did not suggest trial subjects should be held in cattle pens and force-fed drugs, but only that the logic of both processes is similar.
A recent post on a homeopathic site made the claim that only intentional, living organisms are capable of healing. This is what I call wrong. There are many inanimate objects, both natural and man-made, that exhibit self-repair; crystals, amalgamating plastics and even complex machines. That refutes one claim. The immune system is an example of a healing and repair mechanism that does not have intentionality. There goes the other.
How much intentionality is required? Does a cell have enough? A rabbit?
Certainly before Hahnemann’s time, medicine took a largely intentional stance. The healer would administer some remedy or cure, with the intended outcome of healing the patient. Since that time, the very detailed study of the body’s processes and its pathogens has generally allowed science to move from the intentionalstance to the designstance. That’s engineering, and an enormous improvement. Nothing else changes. People are still people, but we now have an addedperspective that was not previously available.
…..“This, to my mind, is exactly why biomedicine is failing.”
Homeopathy is one of many current and discarded medical schemes that rely on one effector or locus to explain the operation of its panacea. Chiropractic has subluxations in the spine, reflexology maps the feet. A cynic might remark that ‘holistic’ is just a euphemism for ‘one-trick pony’
In your comparison of clinical efficacy, you have essentially restricted medicine to pharmacology after the fact so as to mirror homeopathy’s remedy after the fact. Medicine is not holistic, but divides the body and its treatments into groups and in doing so, brings many methods to bear upon them.
Advice is given to eat well and exercise, but where that fails, there is surgery or drugs, failing that, transplants or artificial devices. Vaccination, antibiotics and sanitation are ‘allopathic remedies’, in that they are a result of a materialist view.
It is only a matter of convenience that the goal posts have been shifted to the present, where science has already reduced the incidence of many diseases that homeopathy cannot cure. I thought of listing the scientific achievements of the past two centuries, and how homeopathy is riding on the back of them, but I don’t think I have to.
“Well of course! That’s the nature of human beings and the nature of medical science! Trial evidence for any intervention is rarely so incontrovertible that everyone agrees with the conclusions, and methodology rarely so robust that nobody can pick holes in it. It’s invariably a matter of perspective and opinion.”
See if homeopathy can prove that it can match even the worst case of this so-called poison. http://www.cdc.gov/std/treatment/Cefixime.htm
Historical records and gravestones attest that people now live longer and healthier lives because of science. If medicine is merely suppressing illness, then it looks to me that it makes no difference.
Where is the hypocrisy regarding clinical performance?
The pie-chart results are not explicit enough. It cannot be assumed that because only 38% of remedies are effective, that only 38% of patients are effectively treated (or any other number.) The same applies to the sound-bite of ‘90% of drugs are only 30% effective’.
There is nothing untoward about remarking on these results, but I wonder how it is that homeopathy thinks this represents a gain for them.
(The BMJ informs me that the data for the pie-chart comes from the Dec 2007 issue of
http://clinicalevidence.bmj.com/ceweb/products/concise.jsp, behind a very high paywall)
Do you have evidence that there are false claims in this area? How exactly is homeopathy being suppressed in a manner that is not due to its own inadequacy? I mentioned the ‘proof of concept’ as means by which a pragmatic scientist, one who really wants to get knowledge out to the world, may approach the problem, as opposed to criticizing science and telling more stories of black swans.
Shang et al has been discussed to dust. If there is anything remaining for homeopathy to wring out of it, then it will not be substantial enough to make a difference. The poor quality of the trials is not the only reason to doubt CAM science. There is the previously mentioned lack of drive, but the generally, the approach does not inspire confidence.
“As for failures, every practitioner has their failures and I don’t know anyone shy of admitting that! You won’t find them published in journals, because there’s nothing constructive to be learned from them.”
Big time wrong, Lmso! Failures are very important. Surely you understand what is wrong with publication bias? I am sure you do.
Because homeopathy has no theoretical framework, it is even more important to include negative results than in science because of the difficulty of separating chance from a real effect.
“Because there are just as many valid reasons for believing the Maddox-Randi circus to be no less biased or potentially fraudulent.”
You may say that Randi deceived Beneviste, but that does not explain the latter’s reaction. A reputable scientist has been caught with his hand in the cookie jar, and his work is voided. He publicly protests injustice, and that his work stands. What would you do if you were innocent, Lmso? Wouldn’t you strike while the iron was hot, repeat the same tests (those which you were accused of rigging) then call Randi, telling him to bring his $million with him? Sure you would!
Beneviste does not. He forgoes his previously attested method, and with it, the most rewarding path, to take up a different and even more contentious method.
Is advancing science, regaining a lost reputation, the prospect of a Nobel Prize and a million bucks not enough incentive?
There has been no independent validation of any of Beneviste’s work, except where one or more of his team has been present. It never happened, but its ghost lives on, and is even commercially exploited.
You can hear Randi’s version; http://www.youtube.com/watch?v=tSoNGSsnZ5c
Dana Ullman acts much the same. He makes strident claims, gets caught out making contradictions, and errors of fact, then retreats only to return with another claim.
If Roy follows the scientifically rigid, logical path, he won’t get a result. So he obfuscates, providing just enough information to set the cat amongst the pigeons, but not enough to prove or completely deny his claims. I don’t have to look through the data to recognize flim-flam’scalling cards.
There are a number of scientists who have moved to the dark side. Now recall your words ‘Living systems are non-linear and have qualities of uniqueness, unpredictability, interdependence’. Indeed! Some scientists, someunique beings, become cranks.
With Roy, it’s quite clear that he has never had much time for orthodoxy, and has moved to the cooler kitchen of alternative science where he can romp without supervision.
These men are not the suppressed Einsteins they take themselves to be, but are vaingloriously unable to distinguish between idiosyncraticthinking and genius. They waste everybody’s time.
How is it that a few linked blogs can sink, or at least torpedo so much of CAM’s academic output? I am not suggesting that all CAM scientists are frauds, but that there are some prominent examples, and that the remainder are letting belief get in the way of objectivity.
Lmso, if I thought that homeopathy had a toxin-free panacea, and that medicine was suppressing it for no other reason than to maintain its monopoly, I would be on yourside. However, I can see no evidence to support either claim.
You have earlier described the materialist view as ‘lifeless’, and indicated a leaning towards Buddhist ideas of consciousness, whereas I regard Buddhism as inane. In its quest to understand consciousness, Buddhism gave up at the first hurdle to become subservient to it. Anodyne and of no utility. That’s what I call lifeless!
“Then you’ve clearly been highly selective in your reading. There is no blanket rejection of scientific principles in homeopathy. Just scientific dogma. Some practitioners may not be scientists by training or inclination, but that’s hardly a prerequisite for practicing healing modalities.”
“And since when was professing to material atheism a prerequisite for considering yourself part of the body of “science”? That sounds more like scientism than science to me.”
There is a strong leaning towards material atheism amongst scientists.
http://www.americanscientist.org/template/AssetDetail/assetid/55593
(All other studies show dominance of atheism, though the level depends on the discipline)
A recent vox pop at JREF.
http://forums.randi.org/showthread.php?t=106453
(Interestingly, the difference between groups 6 and 7, at least refutes the claim that skeptics are completely close-minded about the matter).
It has been noted that scientific training does not generally alter a student’s spiritual beliefs. Most have usually settled that matter earlier in life, and are perhaps attracted by the rationality of science. Now, I wonder what sort of mind is attracted to alternative science? That makes a big difference.
Personally, I am rather tired of being told that belief is enough, but I have to live with that. However, I object when such ideas are used against science by those who seem to ignore the real world. I have said to you that medicine is not perfect. You agree, saying we’re all human. That’s true, but it was not my point. Institutionalised medicine is a system Like all systems, there will be errors of control and implementation, meaning that it will never reach its theoretical performance, or even come very close, because to do so would require more energy and management than is practically possible.
The overall performance reaches a point where the incremental gain is insufficient to justify the additional cost. The ‘law of diminishing returns’ is a common simplification.
Individualized treatment is a nice idea, but the good people of the UK make 25 million visits to the GP annually. This means 10minute consultations, and within limits, statistical prescription. Perhaps you see this approach as similar to the ruthless triage of the battlefront, but the fact that medically-trained people are a small percentage of the population, and there are more customers than McDonald’s, perhaps the analogy is apt.
The limitations of the statistical approach are certainly recognized.
http://www.americanscientist.org/template/AssetDetail/assetid/54440
People drive recklessly, take drugs and drink too much. Can homeopathy help here?
Medicine and homeopathy are, as you tell me, two completely differentideas. If you are going call the materialist view a failure, then I am afraid that I can’t allow you to restrict your comparison to pharmacology. Medicine is branch of material science, and therefore takes a comprehensively materialist view. This view is denied by homeopathy, and is not part of Hanehman’s ideology. Homeopathy must have an independentsolution for all of the medical successes that currently lie outside its purview. To make a fair comparison, we would need to strip out all of medicine’s achievements since Hanhmenan’s time, and then see how homeopathy would fare without them. I predict ‘fullhouse’ at the cemetery.
“What an extraordinary statement! And exactly what has spirituality or lack of it to do with the price of fish? The primary and over-riding purpose of medicine IS TO CURE PEOPLE OF THEIR ILLNESS. Didn’t that even occur to you? And yes, I do take a very firm moral stance where that aim appears secondary to turning in a profit for the stockholders. People’s lives and their quality of life is not a commodity to be bought or sold. Slavery has supposedly been abolished.”
Well, agreed, but can you separate the turning of a profit from the production of drugs? From the rest of commerce or public demand? If so, then who is it that is ‘poisoning’ people? I don’t think that is the intention of the (materialist) researchers, do you?
“The USA is not the largest market for homeopathic preparations, either in value or volume. Most of the trials conducted to satisfy licensing requirements are for the German market.”
You are right, it seems that the US market is in decline, but I don’t think that German regulations include clinical efficacy for dilutions below 12C?
March 3, 2008 at 1:12 am
laughingmysocksoff
Thanks for the considered reply, Humber, and sorry it’s taken a while for me to get back to you.
Ah no. The slavery comment was attached to the notion that appears prevalent in some sections of the pharmaceutical industry that health is a commodity to be bought and sold (that’s not conspiracy theory, that’s fact, and commented on extensively in several medical journals), and has nothing whatsoever to do with my comments about your assertion that medical trials are closer to engineering, so let’s not get everything all conflated here.
Well since I didn’t make that assertion, I can’t really comment on it, but I think it depends to some extent on how you define ‘self-repair’ and ‘intentionality’. I’d agree with you that all sorts of interesting things can exhibit self-repair. I’m not sure how you’d prove that the immune system does or doesn’t possess intentionality though. You can’t separate it and its function from the intentionality that exists in the system. Where does the immune system begin and end? Can you take a scalpel and remove it from the body of a person to study it in isolation to see what intentionality it might possess? Of course not. Its existence and function is entirely contingent on the living being of which it’s part. And in any case, ‘immune system’ is an arbitrary distinction. It’s a cognitive construct, a product of a particular way of conceptualising the workings of the organism. So you can ascribe whatever properties you like to it really because it’s not so much a thing as an idea.
So much of what you write (and equally what I write too) is a matter of perspective, fundamental assumptions, circular logic and semantics. If you think this doesn’t apply to something as ‘scientific’ as medicine, think again. It’s as well to bear in mind the perspective of epidemiologists such as Robert Hudson:
““Perhaps no one sentence captures the history of changing notions about disease better than a paraphrase of Humpty Dumpty’s haughty admonition: “When I use the word disease, it means just what I choose it to mean – neither more nor less.” Disease has always been what society chooses it to mean – neither more nor less. A number of important considerations lead to this generalisation. Among these are the following: (1) the definition of disease has varied with time and place in history; (2) the names assigned to diseases are ultimately abstractions, although it is useful at times to act as though they are real; (3) what we mean by diagnostic terms, as with words in general, can be discerned more accurately by what we do with them than what we say about them.”
or Jon Arrizabalaga
“Put plainly, every disease entity is an intellectual construction that is peculiar to some form of medicine; and every form of medicine is nothing but a historical variable in any human community.”
and realise that the biomedical model is no exception. Likely in 200 years time (if we haven’t completely destroyed the Earth’s ability to support life and died out by that time) we’ll be as amused by present theories and practices as we are now by blood-letting and leeches.
You seem to be making an assumption throughout my posts here that I’m somehow trying to “prove” homeopathy or score points on its behalf. Granted you can read my posts that way, but that’s not why I started this blog. Its purpose was to set out to show that the evidence for homeopathy is mixed, which it is, not that no evidence exists or that it’s all negative, which is what commentators like Goldacre, King, Colquhoun and others had been trying to assert, and in doing so persuade PCTs and the like to decommission homeopathic services. There is quite a substantial gap between mixed evidence and no evidence at all. One means the jury’s still out. The other means it’s delivered its verdict.
I’ve made no bones about the fact that trial evidence for homeopathy is equivocal, but I’ve also said that there’s more than enough evidence from case history and clinical studies to at the very least justify ongoing study. The evidence does not justify discontinuing services. This is premature and based on prejudice and a distortion of the available evidence.
I also said I’d talk about the nature of proof in general, and in doing so I’ve tried to show how all thought systems are ultimately self-referential feedback systems that produce their own proof. But that they’re all based on assumptions which are open to question, and that this is no less true of ‘science’ than it is of anything else, thus distinctions between different kinds of evidence based on their apparent verifiability according to a particular mind set aren’t necessarily supportable. You can dismiss that as post-modernist claptrap if you like, but it doesn’t make it any the less plausible.
You seem to draw greater distinctions and divisions between different medical systems than seems justified to me in practice. Those distinctions are in many cases more conceptual than real — useful to get a comparative point across perhaps, but not relevant in use. I don’t think there are many CAM therapists who see their therapies as some complete panacea for all the ills of humanity. A therapy may be capable of treating the whole person in any state of illness, but that doesn’t mean that it’s necessarily the right therapy for that individual in his particular circumstances. Nobody’s going to recommend going to see a homeopath if you’ve just broken your leg and it needs setting! CAM therapists work with every bit as much of a multi-disciplinary approach as biomedical specialists.
We could carry on ad nauseam arguing the toss, and get nowhere because to each of us our world views are utterly self-evident and consistently demonstrable, even scientifically so, within their own terms. You’ll never see the validity in other systems if you’ve never got as far as questioning the underlying assumptions which create the circular logic within your own system. Having once inhabited the scientific world view and then moved beyond it I guess that makes me a crank in your book, but I’ll take being a crank any day to the sheer hubris of imagining my way of seeing things is the only way there is and everyone else is a crank or an idiot.. As Giordano Bruno said, “Truth does not change because it is, or is not, believed by a majority of the people.”
This reminds me of nothing so much as the British Government’s present Early Years Foundation Stage initiative which makes it mandatory for all parents and carers to make sure each three-year-old ‘understands that s/he can expect others to treat her or his needs, views, cultures and beliefs with respect’. Hmmmmm … The socks would have flown out the window on that one, if it wasn’t too horribly serious to get cold feet over. The pigs are at the table and using knives and forks.
But surely you need to look at this more holistically? The good people of the UK make 25 million visits to the GP annually, largely because they’ve come to expect magic bullets for every little problem and have been encouraged to take less and less responsibility for their own health. Several CAM therapies, because of their outlook, tend to encourage individuals to be far more responsible for their own health. There are some studies to show (will reference later — it’s too late right now, but I think it was the Berlin one) that homeopathic treatment leads to significant reductions in physician visits.
Where did I call the materialist view a failure? I think you’re making a different distinction there to the one I made. I said that applying the mindset of an engineer to living systems is pretty disastrous because living systems aren’t machines. You can see evidence of such thinking in all the short-sighted linear logic applied to ecosystems the world over and its terrible consequences. The mechanistic model is grossly inadequate in this context. Ditto in medicine where the human being is fragmented into all its various systems with a specialist for each and nobody looking at what’s happening to the whole person.
There are just as many blogs, if not more, taking various conventional studies apart, but with around 300,000 to aim at compared to a few hundred CAM trials it’s inevitable the anti-CAM blogs will have a disproportionate impact. And as for letting belief get in the way of objectivity, I suggest you go check the mirror. As I’ve repeatedly tried to show, your ‘objectivity’ isn’t objective. It’s a viewpoint based on a whole set of assumptions that are open to serious question (which I’ve detailed eslewhere, so won’t go into again here).
I don’t think you can generalise. I don’t imagine it’s the intention of anyone within the system to poison anyone, though there may be more than a few in marketing departments and the like who are so caught up in their niche function that they lose sight of the bigger picture. Nobody likes to hear bad news either. The tendency is to dismiss it as an aberration or ignore it and hope it’ll go away. That can be largely unconscious or it can be deliberate. But you surely can’t ignore the amount of column-inches devoted to pharmaceutical companies’ highly dubious research and marketing strategies, the widespread disease mongering that goes on, and the suppression of studies that could have resulted in far fewer lives lost if dangerous drugs had been recalled when evidence of their harm was first available.
March 26, 2008 at 6:03 am
ez
To humber,
“A recent post on a homeopathic site made the claim that only intentional, living organisms are capable of healing.” If you refer to my post at the hpathy.com forums, then you must have misunderstood, and I had no chance to write you because the thread was closed.
What I meant is that it may be understandable that one could feel the need for intervention if something we consider inanimate went wrong (again, it is only our point of view), but with clearly living things – this is not an appropariate approach because they clearly possess the self-healing, self-correcting mechanisms, and external intervention disregarding the totality of the situation is bound to fail. You have indeed written that seemingly inanimate things, such as crystals, can restore their original form with time – I have thought about it, and indeed, you are right, but that means that OUR – human – definition of what life is maybe too restrictive, and actually everything around us may well be alive in the sense of ability to procreate, change and repair themselves – and indeed the fact that the technique of preparation of homeopathic remedies permits to “extract” some specific properties from “inanimate” things like sand or metals underscores this possibility – it’s just that the “life-cycle” of these entities is too slow for us to notice, and unless several generations of humans can concentrate on careful observation of a certain object – which they can if they stop being autistic as a whole and continue to ignore and destroy nature and everything around them, – then it will be possible to notice what’s really going on around us…
However, I don’t remember mention anything about intentionality? So maybe this was not my comment that you are referring to?
You also write: “People drive recklessly, take drugs and drink too much. Can homeopathy help here?” The answer is absolutely “yes”, and it is indeed very restrictive (again) to think that this sort of thing DOES NOT have any relation to people’s health and disease. I urge you to take a broader view at life, you’ll notice many interesting things, I assure you!
June 8, 2008 at 10:28 am
James Pannozzi
Well said laughingmysocksoff, well said indeed!!
“Its purpose was to set out to show that the evidence for homeopathy is mixed, which it is, not that no evidence exists or that it’s all negative, which is what commentators like Goldacre, King, Colquhoun and others had been trying to assert, and in doing so persuade PCTs and the like to decommission homeopathic services. There is quite a substantial gap between mixed evidence and no evidence at all. One means the jury’s still out. The other means it’s delivered its verdict.”