Notes On 'Trick Or Treatment'- Chapter 3- Homeopathy by Ernst & Singh.

Sorry for the length between posts on my look at this book, they're involved and I've had my head in other things. This week we investigate homeopathy and its efficacy.

Definition

"A system of treating illness based on the premise that like cures like. The homeopath treats symptoms by administering minute or non-existent doses of a substance which in large amounts produces the same symptoms in healthy individuals. Homeopaths focus on treating patients as individuals and claim to be able to treat virtually any ailment, from colds to heart disease." (Ernst & Singh, p92, 2008)

Homeopathy, according to Ernst and Singh has gained huge popular status in the last couple of decades (p93), and they suggest that from this a kind of argument from popularity is occurring whereby people use (and promote) it simply because it is popular.

The authors trace the beginnings of homeopathy to Samuel Hahnemann who used a Malaria treatment, as a cure all tonic, working under the assumption "if I take something that cures me of illness it will make me feel even better if I'm not sick". This, however made his health decrease, moreover, it led him to experience some of the symptoms of Malaria. This gave a Hahnemann a thought, that what if he experimented with other treatments to see if he got the same results? He did, and he did.  He, by reversing the logic of his experiments came up with an ultimate principle: "that which can produce a set of symptoms in a healthy individual who is manifesting a similar set of symptoms". (pg95) This bizarrely led Hahnemann to the conclusion that he could improve remedies by diluting them (to this day it still remains a mystery why he came to this conclusion).

Hahnemann was not without his merits, he tested his hypothesis on others, administering daily doses (in an experimental procedure he called "provings") to several healthy people, who were asked to keep detailed diaries of their symptoms. This gave Hahnemann some figures with which to work from, he argued that the identical remedy given to a sick person could relieve the same symptoms (p96).

Homeopathic procedure
This is where it gets interesting, and well, bizarre (more so?), Ernst and Singh explain the procedure to accrue homeopathic remedies:

"If a plant is to be used as the basis of a homeopathic remedy, then the preparation process begins by allowing it to sit in a sealed jar of solvent, which then dissolves some of the plant's molecules. The solvent can be either water or alcohol, but for the ease of explanation we will assume it is water...After several weeks the solid material is removed- the remaining water with its dissolved ingredients is called the mother tincture. 

The mother tincture is then diluted, which might involve one part of it being dissolved in nine parts water, thereby diluting it by a factor of ten. This is called a 1X remedy, the X being the Roman numeral for 10. After the dilution, the mixture is vigorously shaken, which completes the potentization process. Taking one part of the 1X remedy, dissolving it in nine parts water and shaking again leads to a 2X remedy. Further dilution and potentization leads to 3X, 4X, 5X and even weaker solutions- remember that Hahnemann believed that weaker solutions led to stronger remedies." (Ernst & Singh, p97, 2008) 

There was a reason I put such a long quote up, I want you, the reader, to fully appreciate just what homeopathy is and what it sells you (at a high premium). Ernst and Sing accentuate their point:

"A 4X remedy, for instance means that the mother tincture was diluted by a factor of 10 (1X), then again by a factor of 10 (2X), then again by a factor of 10 (4X), and then again by a factor of 10 (4X). This leads to dilution by factor of 10x10x10x10, which is equal to 10,000... homeopathic pharmacists will usually dissolve one part of the mother tincture in 99 parts of water, thereby diluting by a factor of 100. This is called 1C remedy, C being the Roman numeral for 100. Repeatedly dissolving by a factor of 100 leads to 2C, 3C, 4C and eventually to ultra-dilute solutions.

For example, homeopathic solutions of 30C are common, which means that the original ingredient has been diluted 30 times by a factor of 100 each time. Therefore the original substance has been diluted by a factor of 1,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,0000,000,000,000,000. This string of naughts may not mean much, but bear in mind that one gram of the mother tincture contains less than 1,000,000,000,000,000,000,000,000 molecules... The bottom line is that this level of dilution is so extreme that the resulting solution is unlikely to contain a single molecule of the original ingredient (emphasis added). In fact the chance of having one molecule of the active ingredient in the final 30C remedy is one in a billion, billion, billion, billion. In other words a 30C remedy is almost certain to contain nothing more than water. (emphasis added)" (Ernst & Singh, p98-9, 2008)

Again, sorry for the long quotes but for me personally that should be the end of this post, what more do you need to know about homeopathy?

Ernst and Singh continue mentioning that some homeopathic pharmacists stock 100,000C remedies which means they've diluted 30C remedies "already devoid of any active ingredient" further by a factor of 100, another 99,970 times, this costs money, upwards of 1,000 pounds! (p100)

Obviously from a scientific perspective there is no reason a homeopathic remedy should work (apart from the placebo effect). There are some ad hoc theories given by homeopaths to describe how it works: some suggest that the remedies have a "memory" of the original ingredient (p100), Hahnemann proposed that a "vital force", something close to a spirit, determined a persons well being (p105), they have also been known to hold a pendulum over a shortlist of possible remedies to determine which one to use (p104) . The authors continue explaining just what homeopathic remedies have been suggested to be effective on: diarrhoea, coughs, headaches, to arthritis, diabetes and asthma, from bruises and colds to cancer and Parkinson's disease (pg100).

Both DARPA (U.S Defense force), scientific studies and even James Randi have tested the efficacy of homeopathy, with no positive results. In 1999 Dr Andrew Vickers meta-analysed 120 research papers on homeopathy and found no reproducible effect (p125). In fact James Randi is still offering his $1million dollar prize to anyone who can demonstrate its efficacy, no-one has. Randi also ingested sixty-four times the dosage of a homeopathic sleeping remedy before a meeting of the U.S congress and "didn't even feel drowsy." (p126)

Conclusion
If you want to drink water please use filtered bottled water, if you want to get medical treatment, see your doctor!

Reference
Ernst E., Singh,. S. (2008). Trick Or Treatment. New York, New York. W.W Norton & Company. Pp- 93,93,95,96,97,98,99,100,104,105,125,126.

Notes On 'Trick Or Treatment'- Chapter 2- Acupuncture by Ernst & Singh

Before we begin we should define our terminology, Ernst and Singh define Acupuncture as such:

"An ancient system related to the flow of a life force (Ch'i) through pathways (meridians) in the human body. Acupuncturists place fine needles into the skin at critical points along the meridians to remove the blockages and encourage a balanced flow of the life force. They claim to be able to treat a wide range of diseases and symptoms." (Ernst & Singh, pg-40, 2008)  

Before the Acupuncturist can attempt to place needles along the patients meridians (which generally go to about 1-10cms in depth) they need to begin with a diagnosis of the patient which is relies on 5 techniques known as inspection, auscultation, olfaction, palpation and inquiring (for more on what that means see pg 44).

The authors trace Acupuncture's supposed origins to the Mongolian war, 2,600 B.C where according to legend  a warrior was supposedly shot by an arrow which, instead of killing him, cured him of a longstanding illness (pg 42). Despite this tale and a long history of it's usage, is there any reason to believe that Acupuncture actually works though?

There have been many demonstrations of it's seeming authenticity, originating in China, like that in 1970 of a patient going through open heart surgery with only the power of Acupuncture to dull the pain. Colour photos were taken of the smiling patient with an open chest (a similar demonstration was shown as late as 2006 on the BBC TV series "Alternative Medicine"), however it now seems likely that the Chinese (the BBC TV) demonstrations were faked, and  involved supplementation by local anaesthetics, sedatives and other means of pain control (pg 48).

This "evidence" did create a mad rush for Acupuncture practitioners in the 70's, and in response, during that time, the World Health Organisation (WHO) summarized the evidence for Acupuncture concluding that there were 20 conditions that lent themselves to it's treatment, including tonsillitis, the common cold, bronchitis, asthma, duodenal ulcers, dysentery, constipation, diarrhoea, headache and migraine, frozen shoulder, tennis elbow, sciatica, low back pain and arthritis (pg 51).This added credibility (as WHO is a widely respected organisation) to Acupuncture as a practice, resulting in the slow acceptance of Acupuncture by western doctors, the only problem, was the mechanism that caused the needles in specific meridians to interrupt the flow of Ch'i, as these terms "have no meaning in terms of biology, chemistry or physics, but rather they are based on ancient tradition." (Ernst & Singh, pg-52, 2008)

Several theories were developed to attempt to demonstrate mechanisms, (1) being the " gate control theory", (2) being the existence of chemicals called "opioids", but unfortunately for Acupuncturists both of these theories fell to something a little more mundane, the placebo effect. The word 'placebo' is Latin for 'I will please' and it was "used by writers.. to describe insincere expressions that nevertheless can be consoling" (Ernst & Singh, pg-57, 2008). The reason for this? Ernst and Singh discuss 3 criteria that enhance the likelihood of bunk treatments causing the placebo effect; the doctors reputation (or administrators reputation), the cost of the treatment (the more it costs the more it must work), and the novelty of the product used (for an in-depth analysis of the placebo effect, on whether the benefits it produces are worth the risk, and whether it is a Pavlovian response or not please see pages 57-62).

Improvement of trial methodology
The problem of the placebo effect forced practitioners to re-define their clinical trial methodology, to keep the results hidden from the participants and the doctors performing the trials, an experiment methodology called "double blind" was developed, but what is it exactly? To answer that we must demonstrate what standard trials consist of, to quote Ernst and Singh:

"The simplest for of clinical trial involves a group of patients who receive a new treatment being compared against a group of similar patients who receive no treatment. Ideally there should be a large number of patients in each group and they should be randomly assigned. If the treated group then shows more signs of recovery on average than the untreated group, then the new treatment is having a real impact.. or is it?" (Ernst & Singh, pg-63, 2008)

This details a simple clinical trial, with only a test group and a control group, Ernst and Singh continue:

"We must now also consider the possibility that a treatment might have appeared to be effective in the trial but only because of the placebo effect. In other words, the group of patients being treated might have expected to recover simply because they are receiving some form of medical intervention, thus stimulating the beneficial placebo response." (Ernst & Singh, pg-63, 2008)

This led to the development of the blind trial (the patients are unaware if they are the control group or the test group) and the double blind trial (the doctors administering the test and the patients in the test do not know who is in the control group or the test group). The benefit of course being; the experimenters have the best chance to remove unconscious bias and the placebo effect.

This new methodology allowed clinicians to go back and look at the WHO meta- analysis and see which trials were high quality and which weren't, which drastically reduced the support for Acupuncture. In the 90's skeptics pushed for "a major reassessment of Acupuncture, this time with placebo-controlled clinical trials involving sham needling" (sham needling is a method to make it seem to the patient as if they are being needled when they aren't) (Ernst & Singh, pg-69, 2008) .

Acupuncture has since been tested and the summary of that literature has been reviewed by an organisation called "The Cochrane Collaboration", the reason they are superior to WHO is due to their acceptance of only the trials with the best methodology, as opposed to WHO, who published "nothing more than casual uncritical overviews." (Ernst & Singh, pg-76, 2008)

What are the Cochrane Collaboration's primary results? Ernst and Singh summarize: 

"1. Cochrane reviews deem that the evidence from clinical trials does not show acupuncture to be effective.
2. Cochran reviews conclude that the clinical trials have been so poorly conducted that nothing can be said about the effectiveness of acupuncture with any confidence.
3. The research is so poor and so minimal that the Cochrane Collaboration has not even bothered conducting a systematic review." (Ernst & Singh, pg-78, 2008)

Cochrane has recently given it's tempered support behind Acupuncture (it's important to note their support is half hearted, they do not find the evidence "fully convincing") to help with pelvic and back pain during pregnancy, post-operative nausea and sweating, low back pain, neck disorders, chemotherapy induced nausea and sweating and bedwetting (most beneficial procedures relate to pain). The amount and quality of evidence needs to be improved before any strict recommendations can and should be recommended (pg 78-9).

Conclusion

Ernst and Singh summarize by stating that "if acupuncture were to be considered in the same way that a new conventional painkilling drug might be tested, then it would have failed to prove itself and would not be allowed in the health market." (Ernst & Singh, pg-84, 2008) It seems that Acupuncture's seeming reluctance to disappear has less to do with it's efficacy and more to do with the multi-billion dollar industry surrounding, and promoting it (much like of the supplement industry). Whatever benefits there are to Acupuncture they are small, the cost of the procedure outweighs the possible benefit of the placebo effect and there are far better (and cheaper) treatments for pain relief with adequate evidential support.

Reference
Ernst E., Singh,. S. (2008). Trick Or Treatment. New York, New York. W.W Norton & Company. Pp- 40, 42, 58, 51, 52, 57, 63, 69, 76, 78, 79 .

Notes On 'Trick Or Treatment'- Introduction & Chapter 1 by Ernst & Singh.

I've just started this book on the advice of Daniel viz. my Naturopathy blog the other day. While this is not strictly on that subject this book discusses so-called 'Alternative Medicine' (hereafter: "AM"), as this is a subject of this blog I shall include it (as well as posting it on my other blog too) here.

This book, at the introduction sets itself up as a science based book, explaining why that it is:

"Science employs experiments, observations, trials, argument and discussion in order to arrive at an objective consensus on the truth. Even when a conclusion has been decided, science still probes and prods its own proclamations just in case it has made a mistake, In contrast opinions are subjective and conflicting, and whoever has the most persuasive PR campaign has the best chance of promoting their opinion, regardless of whether they are right or wrong." (Ernst & Singh, pg-1, 2008)

They also define AM as follows:

"our definition of alternative medicine is any therapy that is not accepted by the majority of mainstream doctors, and typically this also means that the alternative therapies have mechanisms that lie outside the current understanding of modern medicine. In the language of science, alternative therapies are said to biologically implausible." (Ernst & Singh, pg-1, 2008)

As we see, on the first page, much of what I was trying to say, admittedly less effectively in the Naturopathy blog, is discussed here, and is in fact their manifesto. The authors are trying to distinguish between what they later call "evidence based medicine" (hereafter "E-BM") and opinion based medicine (and the important differences between both). Ernst and Singh take quite a strong stance on science, but the authors justify this by establishing just what we have science to thank for, in the sense that, everything we know about the universe, medicine, antiseptics, eradication of disease are all built upon "scientific foundations" (pg 5), we can apply their meaning to these purposes only without getting bogged down in a discussion about worldviews (at least in the first chapter anyway). They go so far as to claim that "the scientific method is without a doubt the best mechanism for getting to truth" (pg 5), which I personally agree with (or at least admit it is at the top of a very short list of things), but can see others contending that issue (though it is hard to argue with its results!).

Chapter 1- How Do You Determine The Truth?
In this chapter Enrst and Singh begin to define what they mean by an E-BM approach:

"(evidence-based medicine) has revolutionized the medicine practice, transforming it from an industry of charlatans and incompetents into a system of health care that can deliver such miracles as transplanting kidneys, removing cataracts, combating childhood diseases, eradicating smallpox and saving literally millions of lives a year." (Ernst & Singh, pg-7, 2008)

They go through several stories (including the apparent murder of George Washington [pg 11] due to the inaccuracy of his physicians) demonstrating some horrible techniques previously performed (bloodletting and leeching for example). Leading into the first uses around the time of Washington's death (1790's) of E-BM by Scottish Naval surgeon James Lind (pg 22-3), who Enrst and Singh accredit with being the first on record to perform clinical trials on the sailors of his ship who were dying from scurvy (discovered later to be caused by a lack of fruit on the boat), even if he failed to publish his accounts (which Enrst and Singh say is important as it gives others a chance to review, critique and test your methodology and conclusions pg 22).

The authors continue to weave a tale through history discussing the advances made in science and E-BM medicine by the lights of radical ideas (clinical trials, randomized trials etc), often those ideas pushed against the establishment and under opposition (as in the case of Hamilton who did the first randomized clinical trial to understand the mechanisms of bloodletting, pg 22). Enrst and Singh quote Alexander MacLean (who used medical trials in India in 1818 to test his treatments) in regards to those who practised medicine without any evidence as:

"a continued series of experiments upon the lives of our fellow creatures." (Ernst & Singh, pg-23, 2008)

From this we can see that even almost 200 years ago there was resistance by some people to the concept of merely letting doctors and health care professionals simply have at their patients, or running their practices based on authority, tradition, ad hoc reasoning or confirmation bias, that a call to reason was apparent. As Ernst and Singh elaborate:

"Prior to the clinical trial a doctor decided his treatment for a particular patient by relying on his own prejudices, or on what he had been taught by his peers, or on his misremembered experiences dealing with a handful of patients with a similar condition. After the advent of the clinical trial, doctors could choose their treatment for a single patient by examining the evidence from several trials, perhaps involving thousands of patients." (Ernst & Singh, pg-23, 2008)

This leads Enrst and Singh on to discussing the crux of this chapter, E-BM, how people outside of the medical establishment find it "cold, confusing and intimidating" (pg 24-5) which is something I've certainly noticed, I would also add that people tend to have an interesting distrust of E-BM (or perhaps pharmaceutical companies?). I think Ernst and Singh are referring more to proponents of AM, and how they perceive the E-BM crowd as trying to protect it's own members, their treatments and excluding outsiders (pg 26). They counter this by suggesting that E-BM actually works in an opposite fashion (pg 26) , that any remedy or cure, can be accepted by an E-BM advocate if it has adequate evidential support (more on exactly what that means later in the next chapter on Acupuncture where Ernst and Singh go into great depth on clinical trial methodology), as we will see below with the case of Florence Nightingale. They temper the response to E-BM with a reminder about how the world was before the widespread use of clinical trials (the examples of deaths in the book in a matter of 200 years runs into the millions, pg 25), the amount of unnecessary death was rampant.

An interesting story they tell is that of Florence Nightingale, who I knew in name only, (her story is an interesting one, for the full account see pages 26-31), she managed to show another benefit of E-BM and that is; in using it to disseminate the information gleaned from clinical trials. As Ernst and Singh elaborate:

"The results from scientific tests are so powerful that they even enable a relative unknown as Nightingale- a young woman, not part of the establishment, without great reputation- to prove that she is right and that those in power are wrong, Without medical testing, lone visionaries such as Nightingale would be ignored, while doctors would continue to operate according to a corrupt body of knowledge based merely on tradition, dogma, fashion, politics, marketing and anecdote." (Ernst & Singh, pg-31, 2008)

This demonstrates at least one example, and a stark one it is, of how the apparent medical establishment, who according to some, don't listen to the advice of outsiders, had to listen and be convinced by the evidence provided to them. It seems evidence is all it takes to convince people, if AM could provide some, perhaps we would listen? I'm getting ahead of myself a bit though.

A final example of the benefits of E-BM and perhaps one of the greatest findings of all time is the work done in 1954 by Hill and Doll in regards to the dangers of smoking. They started a study in 1951 to investigate smoking's link with cancer, they used 30,000 British doctors, to study over 5 decades, yet a clear pattern emerged in 1954! The cigarette companies fought Doll and Hill but they fought back:

"and demonstrated that rigorous scientific research can establish the truth with such a level of authority that even the most powerful organizations cannot deny the facts for long. The link between smoking and lung cancer was proved beyond all reasonable doubt because of evidence emerging from several independent sources, each one confirming the results of the other." (Ernst & Singh, pg-32, 2008)

Which leads Ernst and Singh into another salient point I think it worth mentioning about E-BM:

"It is worth re-iterating that progress in medicine requires independent replication- i.e similar studies by more than one research group showing similar findings. Any conclusion that emerges from such body of evidence is likely to be robust." (Ernst & Singh, pg-33, 2008)

Conclusion
This chapter to me at least, really demonstrated some of the horrors that have been committed, quite innocently mind you, by faulty methodology, by not following the evidence where it leads and allowing tradition to run the schema by which a doctor operates. Thankfully there were multiple visionaries who saw ways to independently and objectively verify their methods, so as to base their medicine on the evidence. Millions (and more) lives have been saved due to the advances in E-BM, in treatment, vaccines, hygiene, cures etc, all based on sound evidence, testing, review and publication. If we continue to treat people with methods that don't pass evidential muster, then we are rolling the dice with the outcome, which is a regressive mindset, one we fought, with a major loss of life, to shed ourselves of.

From this we move onto an analysis of Acupuncture. Stay tuned for more.

Reference
Ernst E., Singh,. S. (2008). Trick Or Treatment. New York, New York. W.W Norton & Company. Pp- 1, 5, 7,  22,  23, 24, 25, 26, 31, 32, 33.