The rise of humbug medicine

This last weekend's column in the Kingston Whig-Standard.

Calgary: In March this year seven-year-old Ryan Lovett died as result of cardiac arrest. His mother, after years of homeschooling her son, decided to ‘treat’ his strep infection not with antibiotics but with homeopathic concoctions and other herbal remedies.

The poor kid was bedridden for about 10 days and eventually died an entirely preventable death at the hands of his fanatic mother who had decided that her beliefs in homeopathy and ‘alternatives’ to modern medical treatments were more valid than scientific evidence. She has since been charged with criminal negligence and one can only hope that she will face the full force of the law for her omission to take her son to an actual doctor for appropriate medical care.

Tragic cases such as this are more commonplace than the more sane parents in our midst might think. Every other week such cases are reported from some place or another just in our hemisphere. No doubt there are many others who don’t even make it into the news.

It’s understandable that some people would grow weary about the integrity of pharmaceutical industry-sponsored clinical research and the medications that get subsequently approved on its evidence. Quite a few high-profile cases have made the news headlines over the years. Anyone remember Vioxx? Food and Drug Administration specialists in the USA estimated that this drug led to about anywhere between 80,000 and 140,000 heart attacks, of which a large percentage resulted in the death of the patient. There has been a lot of forth and back about the data and some suggestion has recently been made that particular patient groups could actually still benefit from this drug. Still, the baseline is that a lot of people died because the drug continued to be marketed when it was known that there were significant health risks attached to taking it.

What’s the difference between cases like the Vioxx scandal and homeopathic concoctions, herbal remedies, and whatnot? Simply put: putting your lives in the hands of purveyors of alternative, complementary etc. etc. ‘medicine’ is a bit like saying that given that modern medicine has its flaws, I’m switching to witchcraft. There is zero evidence that homeopathy works, or most of the herbal remedies that are also on the market. In fact, just this week a major study was released in the Annals of Internal Medicine, demonstrating that the vitamin concoctions that are sold to us in pharmacies and health food stores are completely useless. They are one of the reasons for why urine in our part of the world has been described as the most expensive fluid there is. We really simply release those vitamins and homeopathic concoctions right back into nature. Zero positive health effect for us.

In mainstream medicine at least we have a shot at rectifying mistakes. We have methods that eventually permit us to determine whether a particular drug works, and what its short-, medium- and long-term effects are. In hocus-pocus ‘medicine’ there isn’t even evidence – flawed or otherwise – when a concoction is given by a ‘practitioner’ to a patient. I am not suggesting that all those herbal remedies are necessarily useless. The reality is though, until they have been tested in methodologically sound clinical research nobody knows. Once they have been tested in a clinical trial and have been shown to work they cease to be alternative remedies. We call them medicine and you can get the prescribed by your doctor and some of them by some nurses.

Meanwhile in Ontario the association of naturopaths is lobbying the provincial government to regulate them as if they were a body made of professionals. They even lobby for the right to prescribe medication. For an organisation that’s representing a body of ‘practitioners’ who are overwhelmingly deeply skeptical of mainstream science and who consider the gold standard of clinical research, namely randomised controlled clinical trials, not very useful, that’s a bit rich. If you go to any of their ‘homemade’ colleges (they call themselves accredited but their accreditation is really by a body made up of colleges like themselves) you will come across a hell of a lot of unscientific nonsense. The principal idea here is a naive trust in nature’s ability to heal our disease-afflicted bodies. We are supposed to trust in our body's ability to heal itself.

Funny enough, they charge for advice based on that insight. Turns out, many more men than women follow this advice regardless of the existence of naturopaths and wait for their bodies to heal themselves. Their health outcomes are significantly poorer as a result of this. Men are much less likely than women to see doctors when they should seek medical care, hoping that their body will heal itself. That’s one of the reasons for why men die in the average about five years earlier than women.

In a rational world the naturopaths lobbying our provincial government would go nowhere. However, it looks as if they will become a self-governing health care profession some time in 2014, courtesy of our Regulated Health Professions Act. They will even have their own regulatory college, much like doctors have. This is completely bizarre. Doctors in Ontario are obliged to provide patients (as part of the informed consent process) with high levels of information about the evidence supporting the course of action they are proposing. The nature of naturopathic ‘medicine’ is such that there is no evidence worth the name that ‘practitioners’ can rely on during their consultation. Meanwhile they promise to manage conditions such as diabetes, cardiovascular diseases and so on and so forth.

What’s next, Ontario? A self-regulating College of Astrology? Welcome to Ontario 2014. Happy New Year!

Udo Schuklenk holds the Ontario Research Chair in Bioethics and Public Policy at Queen’s University, he tweets @schuklenk

Against the use of non-certified health 'remedies' in resource poor countries

My Editorial from the December issues of Developing World Bioethics.

Homeopathy organisations have taken to the skies to help sick people in resource poor countries as well as disaster zones. The thing about homeopathy is, of course, that there is zero evidence that homeopathic concoctions have any effect beyond that of other placebos.[1]Governments such as the UK's have clamped down on the quack therapy degrees that flourished for a good number of years in parts of its university sector. In 2007 a whopping 5 BSc degrees in homeopathy were offered; today there is none.[2]

While one could appreciate these homeopaths' good intentions, it is deeply unsettling that people without proper medical training use donations provided by their supporters to travel to developing countries and essentially apply their unproven concoctions on sick and dying people. During Haiti's recent cholera epidemic, on their own account they provided ‘remedies’ to cholera patients.[3] The term ‘remedy’ is probably carefully chosen by these people who show up in impoverished Haitian communities in medical-doctor-like white coats,[4] clearly giving the impression to the undereducated local populace that they are health care professionals. This masks to the uninitiated observer as well as to the local patients that their remedies are precisely that, concoctions that have no proven medicinal value. They are not medicines. The homeopathic emperor really is naked. I didn't say it first, but it is still true.

David Shaw, writing in the British Medical Journal, reports that ‘training’ programs have been set up that ‘train’ locals in homeopathy. He writes, ‘the creation of homeopathic pharmacies increases the likelihood that Haitians will not obtain effective treatments for future illnesses. Training 38 people as homeopaths simply compounds the unethical effects of Homeopaths Without Borders' presence in Haiti, as does the attempt at legitimisation represented by their attempt to obtain official licences.’[5]

A different example: other activists reportedly traveled from the USA to virulently anti-gay Jamaica to ‘heal’ gay Jamaicans and turn them into heterosexuals.[6] Vulnerable Jamaicans were subjected to treatments that are known not to work. What is by now illegal in many jurisdictions, namely offering and providing treatments for homosexuality, is now exported to resource-poor countries. Damage is predictably done to the psychological well-being of perfectly healthy gay Jamaicans.

It appears to be the case that the developing world has become a playground for the vaguely health-related activities of activists that have been thoroughly discredited in the wealthier and better educated parts of the world. These are shocking developments.

It is an interesting question how one should approach an ethical critique of these sorts of activities, namely of well-heeled Westerners abusing their privileged situation to inflict at best unproven medical concoctions and treatments on vulnerable populations in resource poor countries. If they were professionals (say in the Jamaican case if they were psychologists or psychiatrists, or in the Haitian case medical doctors or nurses) one could report them to their professional regulatory bodies. Unfortunately, these people are not professionals, hence appeals to ethical professionalism or professional bodies fail. Appeals to common sense are also likely to fail, because who other than a fanatic would want to travel to other countries to spread the word about concoctions that they know are not taken seriously by specialist professionals in their home countries?

Ethically, all that's left to say for the Haitian situation is that it is harmful to use such unproven concoctions and therapies on patients seeking help. It is also unacceptable to present oneself as a health care professional when one is not. For actual health care professionals providing homeopathic concoctions, the charge would be that they are acting unprofessionally by not providing standard, proven medical care. Cholera cannot be addressed with unproven homeopathic remedies. People will inevitably get hurt. For the Jamaican case, the harm to perfectly healthy people is again what is at issue. It will be distressing to these people both to undergo whatever ‘therapy’ is visited upon them, and it should be just as distressing to note that they failed, given the prevalent anti-gay sentiments in the country.

Harm is also done to impoverished communities by the fundraising activities of these organisations. Gullible donors will waste valuable financial resources that could go to actual sensible health care or development goals and that will instead be diverted toward the establishment and dissemination of quack therapies and treatments in resource poor environments.

To my mind governments in the West should police these activities in the same manner that they police the activities of sex tourists who travel to resource poor countries to exploit children. Equally, governments in Haiti, Jamaica and elsewhere should not permit their most vulnerable citizens to be abused by representatives of such organizations.

• 1
  K. Smith. Against homeopathy: a utilitarian perspective. Bioethics 2012; 26(8): 398–409.
  

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• 2
  D. Colquhoun. 2012. Complementary medicine course in varsities: how I beat the varsity quacks. The Telegraph January 31.http://www.telegraph.co.uk/science/science-news/9051103/Complementary-medicine-courses-in-universities-how-I-beat-the-varsity-quacks.html [Accessed 6 October 2013].
• 3
  L. Fox. 2013. Continuing Ed and Clinic with the Port-au-Prince Homeopaths Communitaires. http://homeopathswithoutborders-na.org/?p=1343 [Accessed 5 October 2013].
• 4
  If images on their website are anything to go by.
• 5
  D. Shaw. Homeopaths without Borders Practice Exploitation not Humanitarianism. BMJ 2013; 347: f5448.
  

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  U. Schüklenk & R. Smalling, Queer patients and the health care professionals: regular arrangements matter. Journal of medical humanities 2013; 34(2): 96.
  

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There's medicine and then there's other stuff

Today's piece from the Kingston Whig-Standard on 'alternative medicine'.

It’s one of those things: you better not criticize homeopathy or else there will be a deluge of complaints from homeopathy ‘practitioners’ as well as satisfied ‘patients’ questioning your motives, your connections to that oh-so-evil pharmaceutical industry, and whatnot else.

Well, let me start this off then by saying that I am not an industry shill, that — to the best of my knowledge — I own no shares in pharmaceutical companies and that I am not paid by any pharmaceutical company to say what I am about to say.

How do we establish whether a particular chemical substance works as medicine? We test it elaborately in clinical trials. Typically we test the substance first in animal experiments. That has its own set of ethical issue that I won’t go into today. Then we move from animal experiments to toxicity tests in a small number of people. All we want to find out here is whether a particular candidate drug is safe. Once we have established that it’s sufficiently safe to test it on a much larger number of people we begin in all earnest clinical trials. Here we compare our candidate drug either against an already existing drug — to see whether it fares better or worse — or against a placebo if we have no gold standard of care. These trials, while not perfect, give us pretty good indications of whether something ‘works’ for particular conditions. Based on the evidence accumulated in these clinical trials drugs get eventually approved (or rejected, as the case may be) by Health Canada, the FDA in the United States and their equivalents elsewhere. It is a system that isn’t perfect, but as far as the scientific method goes, it’s the best that we can do.

Then there is other stuff out there in the business of health care. Plenty of ‘complementary’, ‘alternative’, ‘natural’, you name it concoctions. We know of many of them that they either definitely do not work at all or that they can in fact be bad for your health. There is ever more evidence accumulating that those much praised anti-oxidants in many ‘natural’ products, for instance, might actually be detrimental to our health. What all these concoctions have in common is that they have not been rigorously tested. Had they been tested they would already have lost their cloaking device of ‘natural’, ‘complementary’ and ‘alternative’. Simply put: any such concoction can in principle be tested for safety and efficacy. Once they have been tested we can know whether they work or not. Once we know they become standard medicines or they are discarded. After all, most of them have chemical substances at their heart that do something, but until we test what they do, they’re just that, untested concoctions that may or may not do what their buyers hope they will do.

Strangely these concoctions can be bought as ‘remedies’ of some sort or another in many alternative health food stores, and sadly even pharmacies. They are actually really expensive, too. I went to such a store a few months ago, and I couldn’t believe how much these little plastic bottles with their miracle powders and natural pills of sorts cost. It all seemed like a rich people’s hobby to me. In any case, this begs the question of why Health Canada approves the sale of such concoctions.

According to an editorial published in the British Columbia Medical Journal, Health Canada has approved the sale of various homeopathic concoctions as flu remedies. They are supposed to prevent flu and its related symptoms. Well, to cut a long story short, these homeopathic concoctions are nothing other than super-highly diluted infectious agents that are orally administered. They are so highly diluted that often you can’t find anything other than water in these homeopathic remedies. The danger here is that people choose to ‘protect’ themselves against the flu by using such untested concoctions. None of them have been shown to actually protect against the flu. Health Canada is seemingly OK with this status quo. It notes on its websites that these concoctions can be used safely as long as the directions from the manufacturer are followed. Funny enough, they can be used safely, because they don’t actually do anything. You could also drink water from the tap safely that’s properly treated. Do you recall the mass ‘suicide’ attempt by homeopathy critics a year or so ago? They publicly, all over the world, ‘overdosed’ on homeopathic sleeping remedies. Ignoring the warning labels they downed full bottles of homeopathic sleeping pills, and, surprise, surprise, they didn’t even get tired.

Health Canada now requires such remedies to show warning labels stipulating that they are not meant to replace properly tested vaccines. That’s all nice and well, but it begs the question why health remedies that have not been shown to have any demonstrable health effects should be on the shelves of health food stores, pharmacies and other outlets at all? The British Columbia Medical Association got it right when it insisted that Health Canada should only permit the sale of such concoctions after they have been shown to be both safe and effective. That is not the case today. There is a reason why the English National Health Service closed down its last homeopathic non-treatment facility, aka hospital. It just doesn’t work.

There is another danger in our regulatory agency’s approach to these kinds of remedies. By virtue of its stamp of approval people skeptical of mainstream vaccines might think of them as possible alternatives, despite the agency’s disclaimer. After all, Health Canada has approved these concoctions for sale. The fewer people get vaccinated, the weaker we are as a group. Herd immunity prevents outbreaks of infectious illnesses, but it requires that most of us participate. We know that in communities with high levels of resistance to mainstream vaccines infectious disease outbreaks occur. Alternative untested flu concoctions will likely contribute to such occurrences if Health Canada does not stop their sale as health products.

Udo Schuklenk teaches bioethics at Queen’s University, he tweets @schuklenk.

Selling out Universities

How about a Pfizer Chair in Bioethics? With Pfizer's track record in Nigeria and elsewhere, the company has fallen over itself by way of linking into biomedical ethics. For better or worse, I do know that the company has begun funding biomedical ethics positions in the developing world. Anyway, I'm not after Pfizer today really. I came across a post on a German language science blog indicating that the Charite, one of the country's most prestigious hospitals and the teaching hospital of Humboldt University's (Berlin) medical school, has just appointed a Chair (ie an externally funded professor in this case) in 'alternative medicine'. The appointee will dedicate her work to the study of homeopathy (a quack form of medicine that essentially relies on an active substance being sufficiently diluted in water till nothing is left of it), acupuncture and Quigong, some Chinese quackery. Well, the thing is that we know already from study after study that homeopathy offers nothing much other than a placebo effect, yet the Humboldt University in its press release indicates what its Chair is meant to achieve. The appointment of the Chair is meant to diminish the skepticism of mainstream medicine toward homeopathy. There's a reason for this, much like with Pfizer's bioethics sponsorship in developing countries, the Chair is funded by a vested interest group, the Karl and Veronica Carstens Foundation. The Foundation is named after the late German President Karl Carstens, much like Prince Charles in the UK a fan of anything 'alternative' and 'complementary'. The Foundation's main objective is to mainstream homeopathy and other methods of 'natural healing'.

What is remarkable about all of this is that a leading German university has agreed to establish a Chair in Medical Quackery that is designed to integrate medical quackery into mainstream medicine, because it received external funding for that specific purpose. Well, this at least according to the well referenced science blog entry I mentioned earlier. The question, of course, is whether this act of intellectual prostitution is any worse then the regular selling out of universities to pharmaceutical companies, religious foundations and others.

(Hopefully) the UK's last homeopathic 'hospital' to close its doors soon

The Observer newspaper reports that the UK's last homeopathic 'hospital' might be about to be closed because the NHS's Primary Care Trusts will refuse to reimburse patients 'treated' there. That's pretty good news. I doubt anyone other than avowed homeopathy fans such as the Queen (yep, HRM etc etc) and her son Prince Charles will miss the outfit. Surely, as a matter of public policy it cannot be that tax monies are being spend on 'treatments' of truly unknown benefit. There is no (I am not exaggerating here) independent scientific evidence supporting the idea that homeopathy works. So, if patients are keen on placebos, we should be able to find a slightly cheaper way than a costly 'hospital' requiring millions of tax monies every year for its up-keep. It is surely unethical to waste health resources that could be poured into buying and distributing medicine proven to work.