You and Yours Radio 4 Friday

December 15th, 2005 by Ben Goldacre in alternative medicine, bad science, bbc, homeopathy, onanism, references, statistics | 94 Comments »

I just said this on Radio 4, Homeopath David Spence responds on the show afterwards.

You’ll be able to listen to it again over the internet from 3pm:

www.bbc.co.uk/radio4/youandyours/items/01/2005_50_fri.shtml

Homeopathy is certainly popular, and I have no problem with people wanting to use it, enjoying it, and feeling a benefit from it. What I do object to is people misrepresenting the evidence for how useful it is, or misleading the public about the science behind it. Recently, a customer satisfaction survey from Bristol Homeopathic Hospital was being touted in the media as scientific evidence that homeopathy works. We were told, by the BBC amongst others, that this customer satisfaction survey “contradicted” in quotes, the robust scientific evidence which shows that homeopathy is no better than placebo.

When I say “scientific evidence”, there’s nothing mysterious or complicated here: you simply take a group of people who’ve been to a homeopath, and for half of them, you switch their homeopathic pills for placebo pills. It turns out that the people who get the placebo pills do just as well as the people getting the real homeopathy pills.

Sometimes, a study crops up where homeopathy performs better than placebo. But if you collect the figures from all the little studies, add them all up, and do one big count, you find, overall, again, that homeopathy is no better than placebo. That’s called a “meta-analysis”, and there was a very large well–reported one recently in the Lancet which showed, again, that homeopathy was no better than placebo.

Homeopaths have reacted to this placebo finding in various amusing ways. Many have simply denied that this damning evidence even exists: The British Homeopathic Association provide a list of systematic studies called “meta-analyses” on their website. I say list, but in fact, they only mention a few small flawed ones that go in their favour, and simply ignore all the large robust studies showing homeopathy is no better than placebo. I think that’s very deceitful.

Some homeopaths say, well, homeopathy, its not about the pills, it’s about the consultation, the ceremony, the whole process, comparing it to placebo is missing the point. A view I heartily endorse: I believe placebos are very powerful, and homeopaths are good at maximising the placebo effect. But to do that, they have to maintain the illusion that the pills work, and so they must deny the placebo evidence.

So what is this new evidence from Bristol, that we’re invited to believe can contradict all these large careful trials?

They took a few thousand patients, in a homeopathy clinic, and asked them if they thought they’d got any better since having homeopathy. That’s a customer satisfaction survey. It’s an interesting finding. But it’s got some major flaws: and most of them were glossed over by the media, and by the homeopaths who did the survey.

Firstly, for all we know, the patients could have got better by themselves. As people often do. Lots of things, even chronic illnesses, wax and wane: the menopause, one of the illnesses they studied, clearly gets better with time. For all we know, people on placebo might have felt better after that much time. People on a waiting list, even, might have felt better. Their study assumes that homeopathy takes the credit for the perceived improvement.

And there’s so much information missing. Were the people in their clinic also receiving conventional treatments? Presumably many were. For all we know, that’s what got them better. And what did they measure? They didn’t bother to use any of the standard research questionnaires for how unwell people feel, nor did they compare how unwell they felt to start with, with how unwell they felt later. People had to remember, on the spot, how unwell they were in the past, and then tell the homeopath whether they felt better or not.

And who were the homeopaths asking? People who chose homeopathy. And even then, they only looked at the people who came back to their clinic. They tell us nothing about the people who never came back after the first appointment. Did they decide it was rubbish? Did they get worse? Did they die? They are conveniently ignored, wiped from history, just like the British Homeopathic Association ignores the trials it doesn’t like.

Simply ignoring inconvenient patients, and inconvenient data, isn’t science.


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94 Responses



  1. Jen Wight said,

    December 16, 2005 at 12:45 pm

    What do you think about homeopathic vets? They are often given as evidence for the validity of homeopathic treatment?

  2. Michael Harman said,

    December 16, 2005 at 1:03 pm

    On veterinary homeopathy, have a look at the topic “Homeopathic vets come under fire (New Scientist)” in “The Forums are Open” (click on the badscience link under that heading, then “Bad Science”).

  3. Ben Goldacre said,

    December 16, 2005 at 1:09 pm

    For the efficacy of homeopathy in animals and children, I say: show me the references, show me how it was measured and blinded, show me the meta-analysis, and show me the funnel plot.

    Incidentally, here is the British Homeopathic Association page where they list the major meta-analyses. As you can see, they list only one, the Linde one, that was positive (and a couple of small disease specific ones that give the result the Homeopathic Association wants). They ignore all the subsequent meta-analyses, including the massive Egger one in the Lancet that rightly received a huge amount of media coverage.

    Interestingly, even the Linde meta-analysis that they do reference was subsequently shown to have serious methodological flaws, and exactly the same data was re-analysed, by some of the same authors no less, and they found that in fact the data showed no benefit of homeopathy over placebo. This fact is also ignored by the British Homeopathic Association.

    I cry foul.

    www.trusthomeopathy.org/case/res_research.html

  4. Ben Goldacre said,

    December 16, 2005 at 1:15 pm

    In case the British Homeopathic Association change their references page after my criticisms, here is a record of what it says:

    Comprehensive meta-analyses of clinical trials in homeopathy

    The widely accepted ‘gold standard’ for assessing the efficacy of a treatment is a meta-analysis or systematic review of randomised controlled trials (RCTs). Since 1991 there have been five published meta-analyses of homeopathic RCTs, and all conclude that homeopathy has a positive and specific effect beyond that of placebo.

    The best summary of this evidence was provided in a meta-analysis of placebo-controlled trials of homeopathy in human subjects, published by Linde et al in the Lancet in 1997.1 A total of 89 double-blind, randomised, placebo-controlled trials was included in the analysis. The results strongly supported a statistically significant difference overall between homeopathy and placebo.1 This conclusion is compatible with those in other meta-analyses of research in homeopathy (Table 1). A key issue is that very few individual medical conditions have been the subject of rigorous investigation in homeopathy, and so there are little research data to review in a systematic way. It was for this reason that Linde et al came to the additional conclusion that there is ‘insufficient evidence … that homeopathy is clearly efficacious for any single clinical condition’.

    Importantly, all such meta-analyses and systematic reviews have concluded that more research in homeopathy is warranted. This is a view strongly supported by the British Homeopathic Association and the Faculty of Homeopathy. It should be highlighted too that, since 1997, focused meta-analyses of published trials in four specific medical conditions – childhood diarrhoea,2 hayfever,3 post-operative ileus4 and rheumatoid arthritis5 – have provided support for the treatment effectiveness of homeopathy.

    1 Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of homoeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet 1997; 350: 834-43.
    2 Jacobs J, Jonas WB, Jimenez-Perez M, Crothers D. Homeopathy for childhood diarrhea: combined results and metaanalysis from three randomized, controlled clinical trials. Pediatr Infect Dis J 2003; 22: 229-34.
    3 Lüdtke R, Wiesenauer M. A meta-analysis of homeopathic treatment of pollinosis with Galphimia glauca. Wien Med Wochenschr 1997; 147: 323-7.
    4 Barnes J, Resch K-L, Ernst E. Homeopathy for postoperative ileus? A meta-analysis. J Clin Gastroenterol 1997; 25: 628-33.
    5 Jonas WB, Linde K, Ramirez G. Homeopathy and rheumatic disease. Rheum Dis Clin North Am 2000; 26: 117-23.

  5. Tessa K said,

    December 16, 2005 at 1:19 pm

    Even (domestic) animals respond to the placebo effect. They know they are being treated, for example. Only a test on wild animals that had never been in contact with vets would be a true test (if the variabls could be eliminated).

    Children too, know that they are being given ‘medicine’ that will make them feel better, even small kiddies. It might be interesting to conduct a test on new-borns who have no experience of being treated by anyone to see if the placebo effect still worked on them (this may be unethical though…).

    There’s a thread somewhere here about homeopathic vets.

    I wonder if there has ever been a homeopath who has ‘seen the light’?

    Keep up the good work, Doctor Ben.

  6. Teek said,

    December 16, 2005 at 1:20 pm

    which would you say is worse, homeopaths conducting such a flawed study in the first place, or faithful, unquestioning reporting of the study as “evidence” that homeopathy works…?

    I.M.O it’s the latter that causes more problems. those with vested interests are always going to produce “scientific evidence” that the treatment they’ve staked their careers on works, that’s partly the problem with some clinical trials from large pharmaceutical companies. it’s the job of the media and those reading these studies to separate biased, flawed, badly sourced data from well-conducted studies that are properely controlled.

  7. Ian said,

    December 16, 2005 at 1:34 pm

    In a related idea, I’ve been looking into chiropractic treatment and have had a practicing chiropractor tell me that he has plenty of ‘anecdotal evidence’ but nothing else for preventive treatment given to young children. Basically, you treat kids *before* any symptoms show up – bearing in mind chiropractic in adults shows some use in lower back pain but little else – and then take credit when they can walk properly when they grow up!

    I understand that chiropractors have a vested interest in protecting their profession. But how come the NHS not only refrains from pointing out the lack of evidence, but in some areas includes chiropractos in their teams?

    Hmm… could we complain to NICE or whoever’s responsible that evidence-based treatment should apply to all treatments offered by the NHS, especially where that treatment may be to children?

  8. Mark said,

    December 16, 2005 at 4:15 pm

    Is the Bristol paper available on-line somewhere? David Spence’s responses mostly raised questions which can only be addressed by looking at the detail of the paper. Is 5% drop out significant? What medical tests were done to measure the baseline and improvement? etc

  9. oharar said,

    December 16, 2005 at 4:34 pm

    Mark:
    There’s a link here:
    www.badscience.net/?p=188
    and the pdf is here:
    www.liebertonline.com/doi/pdf/10.1089/acm.2005.11.793?cookieSet=1

    Spence’s comment that a baseline was established is sort-of true. This is what they say:

    “The outcome score was assessed during the consultation, with patients being asked to rate their overall improvement or deterioration compared to their status at first visit. Objective parameters were incorporated in the assessment whenever possible…”

    But there are no details about how the objective parameters were included: were they included objectively?

    Oh, and I also noticed this comment in the “Study limitations” section:
    “Comparison groups were not included by design, although such a design has been successfully implemented in homeopathy research.”

    By design?

    Bob

  10. Ben Goldacre said,

    December 16, 2005 at 4:44 pm

    I highly recommend reading the paper.

    Bob: the baseline may have been measured, but they did not report that data.

    As you can see, from the brief (one paragraph) results section, their only reported outcome measure is the subjective decision of the patient on whether they got better or not, rated on a seven point scale.

    He might say on the radio that they took all those other measurements he described, some at baseline, some objective measurements of illnesses, such as peak flow – and well done to them – but they don’t actually report the results of those measurements in the paper, at all, anywhere! Too weird!

    www.liebertonline.com/doi/pdf/10.1089/acm.2005.11.793?cookieSet=1

    “Patients scored their outcomes at every follow-up consultation, and data are presented here only for their outcome scores at their most recent follow-up attendance (i.e., the perceived change between their most recent attendance and their first attendance). Outcome scores from the total patient population are shown in Table 4. Of the patients, 50.7% rated their overall health change as better or much better. Some degree of improvement was seen in 70.7% of patients. Overall 23.1% of patients reported no changed during treatment, and 3.1% reported deterioration.”

  11. Teek said,

    December 16, 2005 at 4:56 pm

    ben, while you’re around, a quick unrelated point – UCL’s Bloomsbury theatre is licensed to hold film shows regardless of copyright etc, if you’re still interested…

    oh, and the Bristol study is pretty awful, even if the Telegraph describes Spence as “a silvery-haired gentleman with a soft, listening manner and eyes as bright as quartz…”

  12. Ben Goldacre said,

    December 16, 2005 at 5:04 pm

    For absolute clarity here, because I really am absolutely completely bowled over by this:

    You and Yours: What about this business of you neglecting to use the conventional medical research standard questionnaires for how unwell people felt to start with, how unwell they feel later, you simply ask people, he says, to remember on the spot how unwell they were in the past and then to tell you the homeopath whether today they feel better or not?

    Dr David Spence:
    Absolutely again totally untrue statement by Dr Goldacre. He says in his piece, did they measure how patients were at the baseline? Yes, very clearly stated in the study that that is done, a detailed account of that is taken, so that is always the baseline from which improvement or lack of improveement is judged, and one doesn’t expect the patient to remember such things, its clearly recorded, and as many medical parameters are used as is possible.

  13. Paul said,

    December 16, 2005 at 6:06 pm

    This is quite breathtaking. The interviewer clearly didn’t have the expertise to challenge this charlatanry but he told a blatant fib on national radio. ..

    Or did he? Actually, all he says is that the baseline measures were taken but is conveniently vague on how, if at all, they were used. Hmmm

    Anyway, more good work by the redoubtable Dr. Goldacre.

    I shall be in contact with the GMC to see if Dr. Spence’s behaviour is considered in keeping with “Good Medical Practice”

  14. TimQ said,

    December 16, 2005 at 6:31 pm

    “Absolutely again totally untrue statement by Dr Goldacre.”

    Spence may regret that foolish line.

  15. BSM said,

    December 16, 2005 at 10:53 pm

    “Even (domestic) animals respond to the placebo effect. They know they are being treated, for example. Only a test on wild animals that had never been in contact with vets would be a true test (if the variabls could be eliminated).”

    Having looked at this nonsense in some detail for the past 3 years I would say that a ‘real’ placebo effect has very little genuine impact on animals, and I doubt it has much impact on people suffering from real diseases as opposed to the psychosomatic and near-imaginary problems that is the stock in trade of the homeopath. Show me consistent evidence of cancer cured by the placebo effect and I will reconsider.

    With respect to Spence and his bullshit claims. Of course the patients wil have had a baseline assessment. These are homeopaths and they have to fill their extended consultations with something, so they write down every fiddling detail that the patient can bring to mind from the colour of their first poop to the number of times they sneezed as a 12 year old. This is baseline assessment but not as we know it, captain. They collect huge amounts of data but in an entirely disorganised manner so that they can impose on it any conclusions they want- indeed this imposition of a narrative by the homeopathic practitioner on the meanderings of their patients is at the heart of their art. What they studiously avoid is anything that is objectively measurable and comparable before and after, or with and without treatment.

    As an example of the protean nature of homeopathy, the remedy ‘Sulphur’ has more than 1,000 symptoms associated with it. Since the job of the homeopath is to match remedy to patient, it would be hard to fail if some of the remedies allow you to select from over 1,000 points of contact with a specific patient.

    In esence, homeopaths have a vested interest in keping things vague, as Spence has most assuredly done. This means that their activities are entirely unconstrained and they can tell the patient any old nonsense with little fear of being caught out under their own rules.

    “Absolutely again totally untrue statement by Dr Goldacre.”

    Go, get him, Ben.

  16. BSM said,

    December 16, 2005 at 11:06 pm

    I’ve cross-posted to JREF on this topic.

    forums.randi.org/showthread.php?t=49148

  17. BSM said,

    December 16, 2005 at 11:13 pm

    I’ve just listened to the whole piece now and Spence has REALLY pissed me off

    “What about [Ben Goldacre’s] point that homeopathy is, in fact, the placebo effect”

    “Well, it’s an interesting point. I think one of the things that is interesting that might suggest that isn’t the case is the effect that homeopathic medicine has on animals and on very small children who are unaffected by the placebo response.”

    They’re also unaffected by your sugar pills you moron!!! He is as bad as I’d feared and everything I have said about Spence’s paper turns out to be true.

  18. Mojo said,

    December 16, 2005 at 11:44 pm

    Another point to make here with regard to the baseline (and apologies if someone else has already made it and I’ve missed it) is that patients were asked if they felt better than when they started the homoeopathic treatment.

    The patients involved were being treated for chronic conditions. These conditions come and go; sometimes they will be a little better, sometimes a little worse.

    It is likely that patients will search out and start new treatments at times when their symptoms are worse than usual (if I was desperate enough to try homoeopathy, things would be pretty bad).

    So in the Bristol study, even a return to “average” could be regarded as a positive outcome.

  19. Ben Goldacre said,

    December 17, 2005 at 12:20 am

    Ah, you’re talking about regression to the mean.

    Can we just, please, before anybody else troubles themselves about the baseline, make this quite clear: they might say they measured it, but they don’t tell us what it is, for any single subject, they didn’t use it in the results, or do any calculations on it, nor did they measure the current health status and compare it to the baseline state. They just tell us they measured it. They might as well have not bothered. In fact, why did they bother telling us they took a measurement, if they weren’t going to tell us what it was, or use it for a comparison?

    It’s a bit like when he says, it’s not true we ignored the people who dropped out, we told you how many of them there were. Not good enough. Include them in your results, do a real world intention to treat analysis: ASSUME THE WORST about your dropouts like every other researcher does when they are lost to follow up.

    The only data in this paper is this: they asked people if they felt better, at one point in time. That’s all that’s in the paper. And whatever Spence says, taking just one single point of data from each subject is not a longitudinal study. What’s longitudinal about it? It’s a customer satisfaction survey.

  20. Hummm said,

    December 17, 2005 at 12:34 am

    There’s no mention of ethics clearance or consent in the paper, which is also very unusual. Although possibly not as unusual as boasting on the radio about meauring loads of data but leaving it all out of the results section. They must have got it though, surely? At least LREC approval?

  21. Mark said,

    December 17, 2005 at 7:24 am

    Thanks to those who provided the link to this paper. While I wholehearted agree that it is faulty paper I do think it is important to be accurate in the criticisms. Ben wrote on Nov 26th:

    And what about the data collected: did they measure how patients were at baseline, and compare how they were later in time, at follow up? No, they just asked patients later to remember how they were when they first came, and decide retrospectively whether they thought they were any better:

    The paper actually says:

    At the first consultation the current state of health and the nature and severity of each patient’s symptoms were evaluated and recorded in detail. These details provided the baseline from which treatment was commenced. At each subsequent
    consultation the outcome score was assessed as an overall outcome compared with that initial baseline assessment (i.e., the perceived change since that first attendance).

    I agree that this does not give nearly enough detail but it is also clearly different from just asking them to remember how they felt when they first came.

  22. Penta_Water_UK said,

    December 17, 2005 at 9:45 am

    Ah yes…….!!

    I say Homeopathy works, listen carefully to Dr David Spence’s voice…then compair it to Dr Ben Goldacre….the result is that without homeopathy, you sound all girlie and with homeopathy, you get a deep “manly” voice on Radio 4. :-)

  23. Ben Goldacre said,

    December 17, 2005 at 1:52 pm

    [coughs] I think its important to be accurate in the criticisms of my criticisms. This paper is unusually subject to many sources of bias. Bias is where there are sources of errors in the results collected which are not random, things that systematically skew the measurements taken in one direction or another, in this case, in favour of homeopathy.

    Now, there is clearly exclusion bias: the subjects who withdraw from the homeopathy clinic are probably those who benefit least, and these people, who benefit least, are excluded from the final results data, leaving behind those who benefit most, who then report a benefit to their homeopath. Nice.

    Moving on, among the many other sources of bias, the most worrying ones are those introduced at the time where they actually take the one, single, measurement they report: the patient’s decision, on a 7 point scale, of whether they feel better or not. There are serious worries here.

    Firstly, the patient is in a room with a homeopath, probably the one who treated them, and probably their own homeopath gets to see the answer they give of how pleased they are with their treatment (we’re not told if it is their homeopath, which is again a failing since this would be a major obvious criticism of the methodology): being realistic about a doctor patient relationship, that set up is likely to have a significant effect on the response any patient will give.

    Secondly, there is the problem of recall bias, which I was alluding to above: people may not accurately recall how well or unwell they were, for example. Now, this aspect of the methodology is not made clear in the paper, which is a shame because it really is important. It is gradually starting to become clear that what they may have done when asking patients if they felt better is as follows: the homeopath read back through the notes with the patient, the homeopath discusses with the patient how unwell the patient was when they first came, and describes the course of their illness over time, from the homeopath’s notes, discussing with the patient whether they felt better or not.

    That, let me say, is about as far away from neutral data collection as you can get. It is the polar opposite of blinded assessment. If it doesn’t skew your data, change the response you get from patients, in favour of homeopathy, I don’t know what does. It’s a far greater source of systematic error in favour of homeopathy than mere recall bias, in my opinion. And, of course, recall bias is still a factor anyway.

    I said this, criticising the recall bias:

    “And what about the data collected: did they measure how patients were at baseline, and compare how they were later in time, at follow up? No, they just asked patients later to remember how they were when they first came, and decide retrospectively whether they thought they were any better.”

    It turns out it’s far worse than that. The researchers HELPED patients to remember how they were when they first came, and so helped them to decide retrospectively whether they thought they were any better. That, I feel, is not clear from the methods section: it’s so far away from what researchers would normally do that it might have benefitted from being clearly flagged up, especially as it is such a key source of bias.

  24. Morag said,

    December 17, 2005 at 2:10 pm

    Given the methodology as described, I’m just astonished that they did so badly! Only about half the patients reporting “better” or “much better”. Gosh.

  25. Mark said,

    December 17, 2005 at 5:21 pm

    Ben

    I don’t deny the study is rubbish and subject to all sorts of bias . But you quite clearly accuse them of not making any kind of initial baseline assessment and they equally clearly say they did. Were they lying? How do you know?

    Cheers

  26. Ben Goldacre said,

    December 17, 2005 at 5:57 pm

    Making an assessment in your clinic when someone arrives, that you later remind them of yourself, before asking them whether they think they’ve got better, is not the same thing as “collecting baseline data”. Especially when you don’t even report the results.

    “You quite clearly accuse them of not making any kind of initial baseline assessment and they equally clearly say they did.” I accuse them of not collecting and reporting baseline data. Obviously everyone who goes to see a doctor (or indeed a hairdresser) has an “assessment”, in the normal process of a first appointment. That is not the same thing as collecting useable data which you analyse and report.

  27. Mark said,

    December 18, 2005 at 7:03 am

    I just noticed I am repeating discussion that already took place. I apologise.

  28. Tony said,

    December 18, 2005 at 8:49 am

    Mark,
    I think what Ben is saying is that they may have “recorded a baseline”, but what they and how they did it isn’t described in the paper. That means to all intents and purposes, it didn’t happen.
    If Ben is right and they did record a baseline, but only afterwards and only with help from the homeopath, then that isn’t a baseline at all. Or at least, not a valid one.

    Tony

  29. Ben Goldacre said,

    December 18, 2005 at 12:14 pm

    “I think what Ben is saying is that they may have “recorded a baseline”, but what they and how they did it isn’t described in the paper. That means to all intents and purposes, it didn’t happen.
    “If Ben is right and they did record a baseline, but only afterwards and only with help from the homeopath, then that isn’t a baseline at all. Or at least, not a valid one.”

    I dont know if youre doing this to frustrate me, but like I say a thousand times, they dont report any baseline data, they just say they collected it. Do read the paper if you wish.

  30. Tessa K said,

    December 18, 2005 at 1:18 pm

    BSM (post 15) I agree that homeopathy has no effect on serious diseases and only a reported effect on minor ailments. But then, most things that affect us (and animals) are fairly minor and likely to get better in the long run anyway. From what I’ve read, there is a placebo effect on animals, even if only to calm them down and reduce symptoms like pain and swelling (which are responsive to the placebo effect) and so speed up apparent healing.

    In humans, the placebo effect seems to work on things like depression, allergies, pain and a couple of other things I’ve forgotten, as well as self-resolving conditions like menopause. It’s something to do with signals the brain sends/receives that stimulate pain/allergy etc responses. Not that this makes homeopathy any less bollocks.

    One thing I don’t understand about homeopathy is, if each patient is different and needs a lengthy consultation to arrive at a ‘diagnosis’ and the right remedy, how come you can go into any chemist or health food store and buy ready-made remedies for specific problems off the shelf? How do these work? Has there been any study of the effects of non-practitioner prescribed (self-dosing) remedies?

  31. Ben Goldacre said,

    December 18, 2005 at 1:23 pm

    “One thing I don’t understand about homeopathy is, if each patient is different and needs a lengthy consultation to arrive at a ‘diagnosis’ and the right remedy, how come you can go into any chemist or health food store and buy ready-made remedies for specific problems off the shelf? How do these work?”

    Homeopaths themselves get tied up in terrible knots trying to think themselves out of this one. Is it the consultation? Is it the pills? This piece I wrote on the subject was, as it happens, based on some rather confused utterances by the other author of this same Bristol paper:

    www.badscience.net/?p=161

  32. Morag said,

    December 18, 2005 at 10:37 pm

    Tessa K said, “From what I’ve read, there is a placebo effect on animals, even if only to calm them down and reduce symptoms like pain and swelling (which are responsive to the placebo effect) and so speed up apparent healing.”

    You’ve been reading propaganda. There’s no way any “placebo” effect can reduce swelling. And the only way it can reduce perceived pain is if the patient knows they’ve received medical attention and is anticipating an improvement. Clearly, this does not apply to animal patients. As for “calming them down”, well, a pat on the head and a kind word tends to do that, without any need to reduce the effect by prising their jaws open and making them swallow a sugar pill.

    The way homoeopathy works on animals is simply by suggesting to the owner (who is usually a believer and has in any case paid money for this) that the animal appears to be better. It’s remarkable how easy this is. Ethical vets try to be honest with their clients, but you really wouldn’t credit what you can persuade an animal owner to believe if you don’t have too many scruples – or indeed are deluded yourself.

  33. Tessa K said,

    December 18, 2005 at 11:41 pm

    Morag – fair enough. I got it from a book called Placebo.

  34. Tessa K said,

    December 18, 2005 at 11:50 pm

    ben: >>They might flick through and they might just be spot on>>. Huh? And homeopaths are happy about this misuse of their ‘medicine’?

    It’s not like they are making money out of it as it’s the manufacturers who make the profit. How come the people who are so down on Big Pharma haven’t picked up on this?

    It’s not like someone popping into Superdrug for an aspirin when paracetamol might be better suited. It’s more like someone buying an over-the-counter hayfever treatment (a proper one) when they have thrush. Well, it might work….

    I suppose that the homeopaths don’t dare say anything too much as it might expose them to some difficult questions.

  35. RS said,

    December 19, 2005 at 8:50 am

    “Is 5% drop out significant?”

    Not usually, but this one is likely to directly skew the results. Normally you’d have a control group and you could see whether there was a large difference in dropout – which would suggest that one of the treatments either didn’t work, or had nasty side effects.

    I think claiming you used objective measurements without actually reporting any of them is a really good idea, i think I’ll use it in my research. ‘Oh, yeah, I counted loadsa stuff, and measured all kinds of things, but I’m just going to present my subjective unblinded judgements in the paper’.

  36. Teek said,

    December 19, 2005 at 9:08 am

    RS: ‘Oh, yeah, I counted loadsa stuff, and measured all kinds of things, but I’m just going to present my subjective unblinded judgements in the paper’.

    this methodology is from the well-known “Pseudoscience” school of scientific training. By claiming that something was measured, and then not telling anyone what the measurement was or how it was done or how it affected the results, the investigator is behaving in a manner equivalent to a child that knows he’s dones something wrong putting his fingers in his ears and screeming “I didn’t do it, he started it, I’m a good boy…” over and over.

  37. Ben Goldacre said,

    December 19, 2005 at 9:30 am

    From: Ben Goldacre
    Sent: 16 December 2005 17:22
    To: David.Spence@ubht.swest.nhs.uk
    Subject: fao: dr spence

    Dear David,

    regarding the You And Yours discussion today: are we talking about the same paper?

    You and Yours: What about this business of you neglecting to use the conventional medical research standard questionnaires for how unwell people felt to start with, how unwell they feel later, you simply ask people, he says, to remember on the spot how unwell they were in the past and then to tell you the homeopath whether today they feel better or not?

    Dr David Spence: “Absolutely again totally untrue statement by Dr Goldacre. He says in his piece, did they measure how patients were at the baseline? Yes, very clearly stated in the study that that is done, a detailed account of that is taken, so that is always the baseline from which improvement or lack of improvement is judged, and one doesn’t expect the patient to remember such things, its clearly recorded, and as many medical parameters are used as is possible.”

    The paper I read is here:

    www.liebertonline.com/doi/pdf/10.1089/acm.2005.11.793?cookieSet=1

    Your only reported outcome score in the results section is the likert scale, self-rated, of whether people felt they had got better. You may well have taken baseline scores, and measured other objective outcomes, as you say on the radio and in the methods section of the paper: but you did not report that data.

    Here are my questions:

    Is it true, as I say, that you collected but did not report the data?

    Why withhold that data?

    Why did you refer to this data today, as if they were reported outcomes in the study which I had ignored, when they were not reported at all, in the one paragraph results section?

    What is the “totally untrue statement” that I make?

    As you say, “Absolutely again totally untrue statement by Dr Goldacre”: what is the previous totally untrue statement that I make?

    For your convenience I attach the text of my contribution below.

    I look forward to hearing from you soon,

    Ben

    Dr Ben Goldacre

    From: Spence, David
    To: ben@goldacre.net
    Date: Dec 19, 2005 7:23 AM
    Subject: RE: dr spence

    Dear Ben

    Thanks for your message – I am afraid I did not hear You and Yours (busy doing hospital outpatient clinic) – so cannot comment
    As we spoke for about 15 – 20 minutes, no doubt many things were edited out and some things will have been snippets from longer statements – always a problem with media interviews!

    Regards
    David

  38. Ben Goldacre said,

    December 19, 2005 at 9:32 am

    To: David.Spence@ubht.swest.nhs.uk
    Date: Dec 16, 2005 5:25 PM
    Subject: one quick last question

    one quick last question:

    in what sense was this a “straight longitudinal clinical observation study” if the only outcome is a single snapshot piece of data from each patient on whether they felt they had improved? in what sense was it a longitudinal study?

    b

    Spence, David to ben

    Dear Ben

    I think both of us know what longitudinal observational studies are – it really does not require explanation!

    Regards
    David

  39. Delster said,

    December 19, 2005 at 10:46 am

    I see what people are saying about lack of control group and non use of baseline information etc but there is another point to mention.

    Lets face it. the time people go to see a doctor, homeopath or whatever form of treamment they seek is when they are feeling really really bad, or is this just me?

    So given that then any period of waiting, with or without treatment, will produce an improvement in most patients, excepting of course those who drop dead of whatever it was in the meantime.

    So, asking the survivors if they feel better will pretty much get a yes answer overall except for those with conditions that tend to remain constant due to the very nature of the problem.

    Derek

  40. Paul said,

    December 19, 2005 at 12:16 pm

    Yes – this is a very good point and is related to that mentioned above (Mojo). It is also strongly related to Regression to the Mean (Ben above).

    We all fluctuate about a mean of wellness. If you get me on a day when I’m at the lower end of my distribution then it’s highly probable that I’ll have moved closer to the mean if you ask me how well I am on another day. If we introduce this to the design of our study as a systematic confound i.e. we ask people how they’re feeling when circumstances strongly suggest that they’re at a low ebb (i.e. they’ve got so low that they’ve pitched up at a hospital out-patients’ dept) then it’s highly probable that the next time they’re asked, they’ll feel better .

    This regression to the mean is fatal unless it is either controlled for (by taking a distribution of individual’s scores and computing a mean which becomes the standard level for that person) or, much simpler, take two samples from the same population (i.e. people who’ve pitched up at the same department ion the same day), treat one group but not the other and compare them. Duh.

    I know that I’m restating much of what’s been said above, but I am slightly deranged by the arrogant evasiveness of Dr. Spence and this is helping me to release my anger. Please forgive me.

    (“Dear Ben
    I think both of us know what longitudinal observational studies are – it really does not require explanation!
    Regards
    David ” – that’s what really got my goat. Breathtaking…)

  41. BSM said,

    December 19, 2005 at 12:45 pm

    Guess what, Paul. I hadn’t read to the ned of your post, but look what I copied to my clipboard on the way down;

    “I think both of us know what longitudinal observational studies are – it really does not require explanation!”

    He bloody knows you’ve got him Ben and is hoping he can bluster it away.

    Misrepresenting his data like this is beginning to hover around the territory of an ethical offence.

    Formal complaint time? His woo hospital is part of a conventional NHS trust so he has bosses.

  42. BSM said,

    December 19, 2005 at 1:04 pm

    “One thing I don’t understand about homeopathy is, if each patient is different and needs a lengthy consultation to arrive at a ‘diagnosis’ and the right remedy, how come you can go into any chemist or health food store and buy ready-made remedies for specific problems off the shelf?”

    Consider the following facts. Please do not try to make a coherent narrative from them unless you include the fact that homeopaths are shifty liars.

    1. Homeopathy is highly individualised and every patient’s totality is prescribed for from a range of thousands of remedies in dozens of potencies.

    2. The same few remedies are prescribed to multipe patients with all sorts of problems.

    3. Homeopathic ‘first aid’ kits will contain between 10 and 20 remedies.

    4. You will rarely find anything other than a limited range of potencies in use.

    5. Homeopathy does not treat ‘allopathic’ disease entities.

    6. Homeopathic remedies are sold with specific diseases mentioned on the bottles.

    7. Homeopaths are happy to claim cure for a range of specific ‘allopathic’ diseases from asthma to ‘flu.

    8. It is completely unhomeopathic to pick on a single remedy as the base for a therapeutic trial.

    9. Arnica will almost always be the first thing a homeopath mentions when asked to prescribe in a case of injury.

    10. No valid trial of homeopathy can be run without the involvement of homeopathy.

    11. There are many positive trials of homeopathy. They involved homeopaths.

    12. There are many more and better trials of homeopathy with negative outcomes. They involved homeopaths.

    13. Homeopathy is an effective powerful and reliable remedy that can cure real physical diseases of all types.

    14. Homeopathy is such a shrinking violet that it can never be expected to work under the restrictions of a controlled trial.

    15. Of course homeopathy will show it works in controlled trials.

    16. Surveying patients and collecting ‘clinical observations’ is a superior method for collecting outcome data for homeopathy.

    17. Trials of homeopathy often produce negative outcomes because subjects have continued to drink alcohol or coffee, smoke, wear perfume or take prescription medicines

    18. Homeopathy can reliably cure patients whatever their lifestyle.

    19. Homeopathy is appropriately used complementarily alongside a conventional medicine

    20. Homeopathy’s paradigm is fundamentally opposed to that of conventional medicine, which either ‘suppresses’ the real disease, or at least confuses the patient’s symptoms.

  43. Tessa K said,

    December 19, 2005 at 1:06 pm

    Ah, claiming the editor dunnit. I thought it was a live programme? Whether it is or not, Ben could send him the link to listen to the programme again online.

  44. Cap'n Bob said,

    December 19, 2005 at 1:06 pm

    There is no mention of ethical clearance, or consent, anywhere in the paper. That’s unheard of. It’s at the top of the tedious tick list, for editors, peer reviewers, and paper authors. If they didn’t get clearance, and cannot demonstrate informed consent, for a study in an NHS hospital, that really is quite serious stuff, much more serious than what type of study you claim to be doing, or seeming slippery about what data you collected and reported, we’ve all got to respect our patients first and foremost, after all.

    Anyway. They must have got it. I just can’t imagine they didn’t. That would be truly truly extraordinary. It can’t be possible.

  45. Paul said,

    December 19, 2005 at 1:58 pm

    Hmmm good point Cap’n Bob.

    I’ve searched the journal website and there’s no mention (unusually for a clinical journal) that all submitted work must have been ethically approved.

    I must say that I find it difficult to believe that this caring clinician (“I am afraid I did not hear You and Yours (busy doing hospital outpatient clinic)”) would have neglected such a thing.

    Wouldn’t it be funny if they were brought to book on this tangential issue – after all, the homeopaths usually try to assume the moral/ethical high ground even when their science crumbles under the most gentle scrutiny.

  46. Michael P. said,

    December 19, 2005 at 5:17 pm

    The ethical point is very important here. Is the ethical approval of a study (presumably conducted using public money) available publicly? Freedom of information?

    On top of this, is it ethical to justify the use of public money sustaining ‘hospitals’ on the basis of fudged numbers and evasive answers to criticism?

    I suspect shenanigans – time to call in the regulators?

  47. Morag said,

    December 19, 2005 at 10:25 pm

    Regarding the use of a tiny range of remedies, and a total lack of individualisation, do have a look at this ridiculous apologia, by a veterinary homoeopath. vetpath.co.uk/voodoo/carpentr.html

    The salient passage is:
    “I went [on an introductory course at the London Homoeopathic Hospital] for four days in October 1991.

    “I arrived back at my practice armed with a free remedy kit given on the course, bursting with useless knowledge! Okay, I thought, let’s put this junk to the test. We had been told about the 10 remedies in the box; the only things I could remember was that one of them was meant to be good for anticipatory anxiety, and one was for panic and shock. We were heading for bonfire night, and the annual drugging of anxious dogs which I was convinced made the anxiety worse, not better, and which I hated doing.

    “So I decided to run my own mini trial, and around 10 willing owners opted to give their dogs argentum nitricum 30c pre-5th November, and aconite 30c if they started to get into their expected state of panic during any fireworks. I waited to get my proof that these were nothing more than sugar pills, convinced that I would see no response. ….

    “When I saw the results, my heart sank. I cannot remember the exact figures, so excuse me for this, but around seven out of 10 dogs had shown improvement on previous years, some marked, and a couple had not even needed any of the panic remedy on the night as they seemed totally unconcerned.

    “This was not meant to happen! I did not want to have to learn any more about this stuff, but this was too unexpected to be ignored! I decided that I owed it to my curiosity to find out more, ….”

    So, he’s been on a course lasting four days. He seems to have absorbed nothing about individualisation, just that of the ten remedies in the freebie handout, one was “for anticipatory anxiety, and one was for panic and shock”. OK, no individualisation, the two conditions mentioned both psychological, not a huge proportion of veterinary practice I have to say, and gosh, it worked.

    Funny that, 14 years later we’re still having the annual debate about how to handle firework phobias, and the homoeopaths aren’t coming forward in their droves to tell us that they ahve the answer. He can’t remember the exact figures, because it’s been 14 years – what Mr. Carpenter, aren’t you using the same regimen successfully every year?

    This is the sort of drivel used to support the repeated assertion that homoeopathy “works in animals”. It only works in animals because people like Mr. Carpenter repeatedly assert that it does. Juat as in man, show it a control group and this remarkably robust method, that even works for a cack-handed amateur after a four-day course with no individualisation, goes all shy and retires to the boundaries of statistical noise.

    And while I’m on a roll, David Spence’s reaction seemed strangely familiar. I’ve got it – though this is really BSM’s story, to be fair. vetpath.co.uk/voodoo/case2.html

    This one is also a homoeopath challenged on what he’d said on a radio programme – this one couldn’t even remember having been on the programme at all!

    “Subject: Re: Radio 4 with Graham Easton

    “apologies for delay
    “been away 18 days and returned last night to 500+ e-mails.
    “Please can you help me to recall the case you mention.
    “To discuss a case on radio seems a tricky thing to do, at the best of
    times.
    “Besides which, I am not one to go around ‘claiming success’.
    “I look forward to hearing from you.”

    They must go to special classes….

  48. Ben Goldacre said,

    December 20, 2005 at 8:16 pm

    just for completeness, i got this today. i’m quite happy with it, although i am a bit worried that they replaced recall bias with another more concerning source of bias: the homeopath in the room with their patient reminding them from the notes how unwell they were and then asking them if they feel any better.

    i’m also uneasy about that process being considered as making the study “longitudinal”, and it’s rather a long way from the collection and comparison of baseline data. i’m also not sure that this unusual measurement scenario was entirely clear from the paper.

    Dear Ben

    Thanks for your further message – I have now listened to the link.

    It transpires that the two instances that I said you had said something untrue concerned the following:

    1. Not comparing how unwell patients felt at the start with how unwell they felt later and that patients had to remember, on the spot, how unwell they were in the past.
    2. That the patients had all chosen homeopathy.

    I think (I hope) the first point is clear in the paper – it was a point that was raised in the peer review process and the wording clarified thereafter, as a result, to the satisfaction of the peer reviewers – careful detailed medical baseline assessment with as many quantifiable parameters as possible and then any health change at subsequent follow-ups rated as change from that initial baseline assessment i.e. a direct comparison with how unwell they felt at the start with how unwell they felt at each subsequent follow-up. The patients do not have to remember, on the spot, they can see what was recorded at the outset.

    As to all the patients choosing homeopathy – this is not a valid statement in that many patients are referred here who know nothing about it and may not even have heard of it – the referral having been the suggestion of their consultant or GP. The interviewer intervened to say that they still chose it because they attended! Well that’s an interesting point but then it actually applies to us all in NHS secondary care.

    On reflection, I think I can see how such a ‘problem’ has arisen – which is a product of the “media design” of how these things seem to be done. 3 players – recorder, interviewer, interviewee. The recorder is able to prepare their piece and get it balanced, just as they want it to be (no problem with that): the interviewer is able to study the recorder’s piece and decide which parts they wish to quiz the interviewee about (again, no problem): the interviewee, however, is sat down in a studio, played the recorder’s piece, which they are informed is very scathing, and then immediately asked a series of questions. The problem with this is that there is no time to digest the recorder’s points (it is difficult enough to remember them and impossible to remember the exact wording) or to consider what other facets the recorder might be intending to examine.
    Being given a transcript of the recorder’s piece half an hour before would avoid such misunderstandings.

    Causing upset is not the way I go about things, so I apologise for any upset I have caused by these statements.

    I thought your comment that the results from hospital outpatients were “interesting” summed it up very well.

    Regards
    David

  49. Psychodynamic Interpretations Ltd said,

    December 20, 2005 at 9:04 pm

    I particularly enjoy the way he projects “being upset” into you.

  50. BSM said,

    December 20, 2005 at 9:36 pm

    ” to the satisfaction of the peer reviewers”

    And his peers are?
    Hilarious.

    ” The interviewer intervened to say that they still chose it because they attended! Well that’s an interesting point but then it actually applies to us all in NHS secondary care”

    Which doesn’t invalidate the point that they were almost guaranteed to be positively biased as a cohort towards homeopathy.

    ” The patients do not have to remember, on the spot, they can see what was recorded at the outset.”

    And tune their responses accordingly.

    “The problem with this is that there is no time to digest the recorder’s points (it is difficult enough to remember them and impossible to remember the exact wording) or to consider what other facets the recorder might be intending to examine.”

    I’ve listened again to the rest of his responses. The questions may have quoted Ben’s comments but the answers should have been self-contained based on the many valid defences of a properly run study. That fact that he now bleats that he didn’t have a transcript of Ben’s words is pathetic.
    e.g.
    Interviewer: “did he agree with the broad point that the research was little more than a customer satisfaction survey?”
    Spence: “it is not a customer satisfaction survey…this was a straight longitudinal clinical observation study”

    He opens his own mouth. He inserts his own foot. Neither Ben nor the interviewer made him give stupid answers to easy questions.

    What next, Ben?

  51. BSM said,

    December 20, 2005 at 9:45 pm

    Here’s a good example of an advocate of homeopathy just not ‘getting it’, very much like Spence.

    www.hpathy.com/homeopathyforums/forum_posts.asp?TID=3680&TPN=8

    “my new recommendation for a protocol of homeopathic treatment:  maybe something like this:  pick a diagnosis or chief complaint – chronic complaint preferred, to avoid the vagaries of acute prescribing.  enroll the next 200 patients with that complaint in the trial.  ignore your randomization and blinding thing.  pre-test all participants with lab tests that are specific to their compaint, and also a general series of lab tests to sample a broad range of physiological function.  repeat the series of lab tests at the conclusion of each treatment episode.  no time limit.  no mongrelizing of methodologies.  classical homeopaths only need apply.  use statistical analysis with a comparison of outcomes to established “normal” course of illness in untreated subjects.”

    The last 150 years of routine scientific experimentation has just passed these guys by.

  52. Morag said,

    December 20, 2005 at 10:18 pm

    Have you asked him yet where he’s going to get his comparator data, what analytes he’s proposing to measure and why, and what he would classify as an improvement?

  53. Morag said,

    December 20, 2005 at 10:20 pm

    “I think (I hope) the first point is clear in the paper – it was a point that was raised in the peer review process and the wording clarified thereafter, as a result, to the satisfaction of the peer reviewers…” You mean it was even worse in the original version as submitted?

    Come on, the paucity of actual recorded and reported results in this “study” is a joke.

  54. Rachel Findlay said,

    December 20, 2005 at 10:20 pm

    Marvellous commentary all you scientists (I pressume?) Ben now has a copy of a letter Dr Spence wrote me. My initial letter to Dr Spence was strongly worded (not impolite or abusive). I feel very strongly my father was denied treatment for rheumatoid arthritis for years while homeopathic clinics are funded by the NHS. Without my having mentioned my father in my critique of his Today programme effort Dr Spence suggested I had a “deep seated emotional issue” in his response to me. Too right I do. Does not make his pseudo science right though and the shameful thing is the bad choices made for scarce resouces in our health system based on bad science. But you all know this already. Am so grateful there are proper scientists out there who can challenge this medieval nonsense. Quote away Ben.

  55. Morag said,

    December 20, 2005 at 10:35 pm

    It’s very common for homoeopaths to attribute “emotion” – and “spite” and so on – to their critics even when faced with simple factual arguments.

  56. Morag said,

    December 20, 2005 at 10:36 pm

    Er, meant to mention this link in that context.
    vetpath.co.uk/voodoo/vettimes.html#gregory1

  57. Tessa K said,

    December 20, 2005 at 11:47 pm

    Morag: well, of course, anyone disagreeing with homeopathy must have an ulterior motive or be over-emotional. No sane person could possibly doubt its efficacy.

  58. Ben Goldacre said,

    December 21, 2005 at 12:12 am

    btw i made a quick call to elizabeth grice from the daily telegraph (v charming on phone). as you might remember, she mentioned prof matthias egger in her piece, the internationally respected epidemiologist who did the big lancet meta-analysis recently that showed homeopathy was no better than placebo.

    the relevance to this thread is that in her article, she said prof egger was known as “eggy”, and i wondered, who on earth could have given her this extraordinary piece of information? and it was, of course, dr spence. apparently he kept calling him “eggy” throughout the interview.

    so pause for a moment:

    he actually called a professor of epidemiology who disagrees with him… “eggy”.

    i am half david spence’s age, with a pretty solid reputation for childish jibes, and i feel totally outclassed. i can only hope that when i’m sixty i, too, will be calling respected academics who disagree with me “eggy”.

    except i’ll dance around the room when i do it, shouting eeegggggyyyy eeeeeeeeggggggyyyyyy.

    and if they get all eggy about it, i’ll do it even more.

    i mean really…

  59. Michael P. said,

    December 21, 2005 at 9:01 am

    “…the referral having been the suggestion of their consultant or GP. The interviewer intervened to say that they still chose it because they attended! Well that’s an interesting point but then it actually applies to us all in NHS secondary care.”

    Well, yes, but you have to include them in the follow-up of the study!!!!! The drop-outs are also your data, you dolt!

    I really really want to know, who are these people accountable to? GMC? Can they be struck off like normal doctors?? Can they be suspended whilst being investigated for making it up as they go along?!?!?!

  60. Paul said,

    December 21, 2005 at 9:04 am

    I think that BSM has hit the nail on the head – they just “don’t get it”. The fact that Specky Spence (I don’t know if he wears glasses, but if he does, that’s what I’m going to call him) wrote a reasonably detailed explanatory note is probably testimony to the fact that he doesn’t want to be simply a fly-by-night huckster. But the content of his explanation quite simply shows that he doesn’t understand the issues. (My suspicion is that this paper probably went somewhere like the BMJ (which actually lets some pretty ropey stuff through), got the mauling it deserved and thence plummeted down the impact factor ladder to where it currently resides).

    If I were an advocate of CAM who had a genuine desire to determine, scientifically, the efficacy of the treatments (pace Edzard Ernst) I would be horrified that Specky Spence was clouding the water with this drivel.

  61. rachel findlay said,

    December 21, 2005 at 11:03 am

    Hilarious Ben. And Morag thanks for your comments. I think you are right when you say there is a theme with these guys. Very reassuring when one doubts oneself in the face of Dr Spence’s honeyed words on posh Bristol NHS paper. I can admit to being a bit emotional (on account of growing up with knackered rhumatoid infested pa – who is a star by the way). I do know however I’m not an airy fairy twit and can see the emperor (or rather Dr Spence) is buffo when he’s left his tweeds at home. He has outclassed me also in evasive arguments and yes, “eggy”, does get the gold prize. I wouldn’t even try to compete.

  62. RS said,

    December 21, 2005 at 11:16 am

    “The interviewer intervened to say that they still chose it because they attended! Well that’s an interesting point but then it actually applies to us all in NHS secondary care”

    Except of course that most other branches of medicine are actually based on evidence rather than voodoo. Being referred to a homeopathic hospital is not like being referred to the dermatology department, or even to psychiatry, it’s more like being referred to your local New Age book shop, or Dr & Herbs. Most people would never even be referred because they wouldn’t go, and quite a few others wouldn’t go even when they are referred – because people are not quite as stupid as we think.

  63. RS said,

    December 21, 2005 at 11:19 am

    “I can admit to being a bit emotional (on account of growing up with knackered rhumatoid infested pa”

    Was it the Glasgow Homeopathic Hospital where, because of budget cust, they wanted to close it? In the end, after a campaign by society’s fans of pseudoscience, it was retained, meaning that the budgets of actually effective evidence based real medicine departments will have to be cut instead.

  64. rachel said,

    December 21, 2005 at 11:27 am

    Dad was treated ititially by specialists in Glasgow. They were excellent he was lucky enough to get on a trial when the “new” anti tnt drugs were trialed on NHS. Imagine his surprise when he found out most other european countries health systems had licensed these ages ago (and USA also) while the NHS was still dragging its feet. It took ages for NICE to ratify these drugs and we watched dad in hospital, surrounded by much younger sufferers whose joints were also being destroyed, being denied this. Of course the underlying reason for NHS not having these drugs as quickly as other countries is funding. They are there now but only after a fight with our local health board and I know, from an insider on the Board in Edinburgh, it was a funding problem to get these drugs. And yet, Dad could always have gone to Glasgow for some arnica do address his knackered joints pain of course. Darn wish we’d known that at the time!

  65. Delster said,

    December 21, 2005 at 12:30 pm

    RS,

    you shouldn’t dismiss herbs so easily (Dr & Herbs). many plants do have medicinal properties and many common drugs have been devoloped from them.

    The main difrence between herb / plant remedies and homeopathy is that the plants contain more than just water and so can actually do something (other than rehydrate!)

  66. lecanardnoir said,

    December 21, 2005 at 12:36 pm

    I’m feeling rather frustrated here. It is clear that our Health Service has been hijacked by self-serving irrationalists with the result that resources that could deliver real improvements in peoples lives are being diverted into mumbo-jumb.

    To me, finding out that the NHS funds homeopaths is like discovering that our courts still practice trial by fire if evidence of witch craft cannot be obtained in other ways, or that our schools are teaching that evolution is ‘not proven’ and that there must be an ‘Intelligent Designer’.

    It is not like more research into Homeopathy could show that it is effective. To find out that diluting a substance to the point where it is, to all effect, no longer there and then saying the water can cure you would overthrow pretty much all the physics and chemistry we know. Such a discovery would not be like finding the Loch Ness Monster – this is at least, theoretically possible – it is more like finding fairies at the bottom of my garden, or (more seasoanlly) finding Father Christmas squeezing down my chimney in a few days time.

    So what can we do? At the very least should we not be shuffling of a letter to our MPs? Thoughts?

  67. Tessa K said,

    December 21, 2005 at 12:40 pm

    Delster: you’re right, plant medicine should not be lumped in with homeopathy. It certainly helped a lot of people when there was no alternative. However, these days, I’d rather take a measured dose with known side-effects and no impurities than gamble on getting the right active amount of leaf or root without any bird poo or mould in it. Plant-derived medicine is good, herbal medicine is a lottery.

  68. Michael P. said,

    December 21, 2005 at 12:46 pm

    I quite agree lecanardnoir, someone’s accountable for this. I would like to know who it is. If any other sector of the NHS used smoke and mirrors to create numbers justify themselves there would be a national outcry and a formal investigation!

  69. RS said,

    December 21, 2005 at 12:51 pm

    “you shouldn’t dismiss herbs so easily (Dr & Herbs). many plants do have medicinal properties and many common drugs have been devoloped from them.”

    Yes, thank you, I am well aware that some herbs can have medicinal properties, and that many drugs have been developed from them, and also many poisons. I am also aware that most people pushing herbal remedies haven’t got a clue what they’re doing, for instance Dr & Herbs promoted Ban Lan Gen tea to stop bird flu.

    www.bbc.co.uk/watchdog/reports/personal/personal_20051122.shtml

  70. RS said,

    December 21, 2005 at 12:53 pm

    “The main difrence between herb / plant remedies and homeopathy is that the plants contain more than just water and so can actually do something (other than rehydrate!)”

    But the main similarity is the almost complete lack of any evidence base. At least homeopathy works via placebo, I’m not sure I want some untested active ingredient fucking me up and counteracting my placebo effect.

  71. Morag said,

    December 21, 2005 at 1:04 pm

    Tessa K makes a very valid point. Of course many plants have active ingredients – but remember that they also have active poisons. The fact is that “big pharma” has practically mined out the known botanical sources of useful pharmaceuticals, identified the active principles, purified and (usually) managed to set up an artificial synthesis, just as well or the world’s plant resources would never stand the strain. Thus we have standardised, purified and licensed medicines.

    This leaves the herbalists with the ineffective plants, the poisonous ones, and the crude unpurified extracts which could contain practically anything. Which would you rather take?

    Yes, herbal preparations can be biologically active, but you don’t know what you’re taking, and always remember that biological activity might not be in the form you wanted. Think deadly nightshade, giant hemlock, yew, laburnum, foxglove and so on – several of these do give rise to useful pharmaceuticals but you’d be mad to take a crude extract. Frankly, if a herbal preparation really does have a useful therapeutic effect, that has probably already been exploited in the form of a nice safe and tested pill. If no such pill exists, one has to ask why not?

    Homoeopathy is one of a small group of alternative medicines which absolutely *can’t* do anything, and deserves to be laughed out of court until such times as its proponents have successfully persuaded the basic sciences to rewrite their textbooks to include magical effects. However, this shouldn’t lead us into being too readily accepting of the claims of other branches of alternative medicine, just because in these cases they *might* work.

  72. rachel said,

    December 21, 2005 at 1:39 pm

    lecanardnoir – you are quite correct. Enough mumping and time for a letter to one’s MP (or MSP here in Scotland as health is devolved issue). In fact I think I’ll write to the health minister. The Glasgow clinic noted above means we have a homeopathic NHS funded centre here in Scotland as well as in Bristol. Also, I wonder if the practitioners at these clinics (seemingly qualified doctors) have private clinics of their own ……….? If this is the case no wonder they are so keen to maintain the veneer of respectability.

  73. rachel said,

    December 21, 2005 at 1:46 pm

    Oh my lord….not the usual run of the mill NHS hospital. And I thought the NHS was short of funds.

    www.adhom.org.uk/welcome.htm

  74. Morag said,

    December 21, 2005 at 2:55 pm

    This is the big issue, of course. What homoeopaths like David Spence are desperately afraid of is being locked out of the NHS gravy train. Hence these dishonest studies, designed to show their methods in as good a light as possible, in the hope of being able to stave of the consequences of the negative results coming from properly designed trials.

    One common assertion (a favourite of the Southampton-based bunch) is that since patients want it (“demand” it), then homoeopathy must be made available. Since when? What about the breast cancer patients who want herceptin? What about Rachel’s father, who wanted proven treatments available in other countries? “Wanting” doesn’t get you anything until NICE have spoken. Except isn’t it strange the way NICE always seems to be sidestepped in favour of consumer satisfaction studies as soon as it’s homoeopathy we’re talking about?

    The use of scarce NHS resources for quack therapies is a public scandal. Not just homoeopathy but acupuncture, reflexology, and several other nutball approaches. If people are really helped by a long consultation, an hour or two one-to-one attention, having their feet massaged with a nice smell in the air, then come clean and offer this as relaxationaids or even psychotherapy. And evaluate the cost-effectiveness in these terms. But spare us all from subsidising the telling of barefaced lies to patients.

  75. Michael P. said,

    December 21, 2005 at 3:42 pm

    Hmmm, I’m not sure about all this. When you look for information, you go round and round in circles.

    I tried to find info on the Glasgow centre. Thanks for that link you gave us Rachel. It shows that it’s a very nice building indeed. Nice garden too. Costs no more than a ‘normal’ hospital apparently.

    Anyway, it tells you sod all about what they do. Or who does it. A quick look on the Scottish Executive website gets you the National Panel of Specialists from May 2005 as a PDF. In there for homeopathy is listed Dr. Thomas Edward Whitmarsh at the Glasgow joint. But, alarm bells ringing – I don’t think he’s NHS. On their system, I mean. His email address is tom.whitmarsh@virgin.net Very professional. And here I was expecting scot.nhs.uk. How silly!

    So, funded by the NHS. Referred to by the NHS. Regulated by….

    Answers on the back of a postcard.

    (hint – ‘themselves’)

  76. Peter Evans said,

    December 21, 2005 at 7:27 pm

    Just been to the NICE site ( google it ). You can put in a request that they do some research into any aspect of current or planned treatment. I am not qualified. Perhaps someone who knows how to complete the technical sections would do a much better job ( I completed the form as a memeber of the public ). Worth a shot?

  77. Rachel said,

    December 21, 2005 at 10:44 pm

    One could always drop NICE a letter. That’s the next one for me. Today I wrote Andy Kerr our illustrious health minister in Scotland and the chair of “Health Scotland” the Rt Hon Lesley Hinds who is the Provost of Edinburgh in her other life (that’s mayoress to any non Scots). Not sure where this will get me but one must try. Starfish and all that.

  78. Delster said,

    December 22, 2005 at 9:58 am

    RS,

    was not aware that Dr & Herbs had been promoting that tea for bird flu. having said that, one of the ingredients for Tamiflu is, or is derived from, Star Anise. So rather than put down Ban Lan Gen tea out of hand, what i’d say is ask who’s done an analysis of the tea and what it contains, then test the active ingredients to see if there is any provable benefit…. who knows they may actually have something…. stranger things and all that.

    Also as for “But the main similarity is the almost complete lack of any evidence base” i’d have to say that there is evidence in plenty. After all if there was no evidence for medicinal properties then why were medicines developed from them?

    Yes there are problems in herbal medicine as both Tessa and Morag pointed out along with your self is that there is a quality control problem. Different batches of the plants will contain differing levels of the active ingredients and may also contain impurities depending on the soil it was grown in. So yes the pill form is much more practical and a good bit safer to boot.

    Morag also said “This leaves the herbalists with the ineffective plants, the poisonous ones, and the crude unpurified extracts which could contain practically anything. Which would you rather take?” Sorry but i’d have to disagree with this. Herbalists are not left with the ineffective plants, they are left with exactly the same plants as they have always used.

    Also “Big Pharma” are not even coming close to discovering all the medicinal properties of plants, fungi etc let alone being able to synth the active ingredients. There are still plant species being discovered and as long as thats the case then the posabilities, let alone the actual benefits, are nowhere near tapped out.

    I’ve just had a thought….. you all remember the water that could draw the sharpness out of lemon juice? well if it works the way it say’s then we could sort out the problem of nuclear waste by burying it surrounded by bottles of water…. and people said it would be a problem for centuries!!

  79. Morag said,

    December 22, 2005 at 12:55 pm

    Dr & Herbs were crucified on “Watchdog” about that flu promotion. One of their top brass was actually lured into the studio and put on the spot. All he could say was, “why can’t we advertise it for flu, the Chinese have been using it for flu for hundreds of years.” Nothing at all about any evidence they were *successfully* using it for flu, or that it might contain anything with an active ingredient.

    I should point out that while they were looking for the antimalarial that eventually became artimisinin, they tested over 300 herbs the Chinese “had been using for” malaria “for hundreds of yeards”. All but one was found to have no efficacy at all. The remaining one was the jackpot. I think there’s a lesson there somewhere.

    I didn’t just say the herbalists were left only with the ineffective plants, please don’t use selective quoting. I said “This leaves the herbalists with the ineffective plants, the poisonous ones, and the crude unpurified extracts which could contain practically anything.” Which is pretty much what they had in the beginning, right enough. My point was that such has been the interest in purifying and exploiting useful compounds from herbs, pretty much everything in common use has already been looked at in that respect. So, if there really is useful activity in the herb, there is almost certainly a purified and standardised and tested and licensed version of the compound. If no such pill exists in relation to any herbal claim, you really have to ask yourself, why not?

  80. Delster said,

    December 22, 2005 at 3:06 pm

    I have to admit to not watching much TV these’s days (result of enforced exposure to daytime tv) so missed that watchdog… still begs the question has anybody analysed and tested the stuff?

    as for selective quoting it was just pointing out they have what they have always had. As for the poisonous etc it just means never cross an apothacary! :-)

    As for all commonly used “medicinal” herbs having been researched etc….. does anybody know of a database or some central knowledge base that lists what has been researched along with results? After all i’ve not seen any Vetiver sleeping tablets and it’s a damn fine soporific (in my own experience that is, sample size one, no control group)

  81. Delster said,

    December 22, 2005 at 3:35 pm

    just as an aside, if medicinal drugs have to pass stringent tests to get a licence, then how exactly did homeopathic treatments, which are after all taken internally, get approved? If that is they are actually approved?

    And what basis were they approved on… that fact thay they are just unlikely to kill someone? (or do anything to them for that matter)

    And if they are not approved then what on earth are we doing paying for these things on the NHS for….. and thats apart from the whole matter that these things don’t bloody work anyway.

    If the effect is only as good as placebo then why don;t we have the normal GP do a consultation and (if warrented) then send them down the chemist with a prescription for a bunch of sugar coated sugar pills? It would be cheaper than the tapwater merchants

  82. rachel said,

    December 22, 2005 at 3:37 pm

    www.ucl.ac.uk/Pharmacology/dc-bits/quack.html

    Here’s another webpage that’s got a nice cartoon and articles on dodgey scients/medicine including references to Dr Spence’s dodgey homeopathy trials.

  83. Morag said,

    December 22, 2005 at 8:36 pm

    Delster, homoeopathic remedies have a special licensing system all to themselves which excludes any requirement to prove efficacy. Don’t ask me why, I don’t know, exvept that it’s politics.

  84. Morag said,

    December 22, 2005 at 8:41 pm

    Here’s the relevant page on the MHRA web site.
    www.mhra.gov.uk/home/idcplg?IdcService=SS_GET_PAGE&nodeId=98

    Background to the legislation on licensing of homoeopathic products
    Until the introduction of the Homoeopathic Registration Scheme in 1994 the only homoeopathic medicines available on the market were those granted product licences of right (PLRs) when the Medicines Act came into force in 1971. Attempts to acquire marketing authorisations for new homoeopathic medicines were unsuccessful owing to difficulties in proving efficacy in conventional clinical trials.

    Current legislation for homoeopathic medicines
    The Homoeopathic Registration Scheme, implemented under a European Directive 92/73 EEC, is a simplified regulatory procedure, whereby products are assessed for their quality and safety and can then be marketed without specific medical claims. The simplified registration scheme thus enables a rapid introduction of new homoeopathic medicines onto the UK market.

    Fantastic, isn’t it?

  85. Michael P. said,

    December 23, 2005 at 9:09 am

    Delster: “does anybody know of a database or some central knowledge base that lists what has been researched along with results?”

    I doubt it. These things are usually done on massive scale screening projects, sometimes by the academics but usually by pharma. The results of the millions of compounds that bring no leads in the pharma screens are more than likely trashed and they move on to the next set of compounds.

    So it’s interesting what you say Morag: “pretty much everything in common use has already been looked at in that respect.” There’s a change in the way pharma are looking at this. Historically the chemists and the informaticists got together and thought up criteria for compound-types to screen for a particular application and the biologists screened it. Or, alternatively the chemists screened them themselves using modelling techniques and other clever stuff. But now they are turning more to screening theme and variations on ‘natural’ compounds as their starting points. i.e. start with a compound type from a plant etc. and make progressive changes to it’s structure then screen them all against your target. But it’s a monumental task – screen every imaginable substance with every known medical condition. It will never all be known.

  86. Michael P. said,

    December 23, 2005 at 9:15 am

    OMG Morag! The best bit is right at the bottom…

    Registration criteria –
    In order to qualify for registration the products must:
    1. Be for oral or external use – this includes all methods of administration with the exception of injections;
    2. Be sufficiently dilute to guarantee their safety;
    3. Make no therapeutic claims.

    So they stopped the introduction of new ‘treatments’ because they couldn’t prove it. But now they can sell what they like, as long as it’s quackery!

  87. rachel said,

    December 23, 2005 at 9:55 am

    Michael and Morag: Brilliant. Thank goodness there are people who know the detail of this and can analyse it. It’s also good the NHS sponsored homeopaths know you are out there too.

  88. Deetee said,

    December 28, 2005 at 2:47 pm

    Thanks for the links to the Glasgow Homeopathic Hospital. I was entranced by the views of its marvellous new facilities. The concept of a creative, healing environment with artistically designed areas of space, gardens, water features and lighting effects will do much to promote “wellness” in itself.

    [Quote from grateful patient: “Thank you so much for everything you have created at the hospital. I wonder if you realise how important it is for those of us who depend upon it’s environment to calm us, strengthen us, and then send us out into the world to cope for another while.”]

    One must ask, why bother with homeopathy at all when the environment does all the healing for you? And, how wonderful to find that they imagine this could all be provided within the usual constraints of the NHS budgeting process!

    I would suggest a little trial which could help resolve the issue as to whether homeopathy works……

    Get a homeopath to run outpatient consultations in a draughty portacabin in the middle of a car park next to a building site, at least 100 yards from the main hospital building with all its ancilliary services, and at least 500 yards away from the pharmacy and 800 yards from the laboratory (I was in this situation until very recently). Give the patients 10 minutes per visit.

    Give a conventional hospital consultant the opportunity to work from the facilities of the Glasgow Homeopathic Hospital site, and give him 45m – 1 hour per consultation.

    After 6 months, compare patient outcomes using a similar “customer satisfaction” survey as did Dr Spence at Bristol. Publish the results on the front page of the the Daily Mail.

  89. Rachel said,

    December 30, 2005 at 8:01 pm

    Yes indeed and thanks for the clever observation Deetee. Dr Reilly certainly gives himself a lot of coverage. As you point out, should I everI have an illness then I’ll go straight to the Glasgow homeopathy clinic with a view to the calming, strengthening environment healing me. Won’t bother with the “normal” doctors….they don’t work in calming, strengthening environments so surely can’t be as good.

  90. Kimpatsu said,

    January 10, 2006 at 8:28 am

    One observation about animals and the placebo effect: there are respectable studies by veterinarians that show white coat hypertension in animals. That being the case, animals should also certainly respond to placebos.

  91. Gilles said,

    January 26, 2006 at 9:57 pm

    Here’s a link to the audio of David Spence’s reply.
    www.bbc.co.uk/radio4/youandyours/items/01/2005_50_fri.shtml

  92. Ben Goldacre said,

    January 29, 2006 at 12:29 pm

    In October 2004, Peter Fisher, ubersenior homeopath, appeared on the BBC Radio 4 programme, “The Other Medicine”. He said ” . . . pool them [clinical trials] using a statistical technique called metanalysis. Everybody who’s done that concludes that the evidence says homeopathy really does work compared to placebo, it is not a placebo effect.”

    What is it with these guys denying the existence of all meta-analyses except the one early flawed one that benefits them?

  93. ‘Medical apartheid’ (at wongaBlog) said,

    May 23, 2006 at 10:37 pm

    […] See here, too. The Department of Health isn’t terribly helpful: A spokeswoman for the Department of Health (DoH) said it was up to clinicians and trusts to decide on the best treatment for a patient. […]

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