homeopathy performs no better than placebo. What is truly amazing to me is that despite the negative results of these meta-analyses, homeopaths have continued – right to the top of the profession – to claim that these same meta-analyses
Clinicians, pundits and researchers all like to say things like ‘There is a need for more research,’ because it sounds forward-thinking and open-minded. In fact that’s not always the case, and it’s a little-known fact that this very phrase has been effectively banned from the
There have been over a hundred randomised placebo-controlled trials of homeopathy, and the time has come to stop. Homeopathy pills work no better than placebo pills, we know that much. But there is room for more interesting research. People do experience that homeopathy is positive for them, but the action is likely to be in the whole process of going to see a homeopath, of being listened to, having some kind of explanation for your symptoms, and all the other collateral benefits of old-fashioned, paternalistic, reassuring medicine. (Oh, and regression to the mean.)
So we should measure that; and here is the final superb lesson in evidence-based medicine that homeopathy can teach us: sometimes you need to be imaginative about what kinds of research you do, compromise, and be driven by the questions that need answering, rather than the tools available to you.
It is very common for researchers to research the things which interest them, in all areas of medicine; but they can be interested in quite different things from patients. One study actually thought to ask people with osteoarthritis of the knee what kind of research they wanted to be carried out, and the responses were fascinating: they wanted rigorous real-world evaluations of the benefits from physiotherapy and surgery, from educational and coping strategy interventions, and other pragmatic things. They didn’t want yet another trial comparing one pill with another, or with placebo.
In the case of homeopathy, similarly, homeopaths want to believe that the power is in the pill, rather than in the whole process of going to visit a homeopath, having a chat and so on. It is crucially important to their professional identity. But I believe that going to see a homeopath is probably a helpful intervention, in some cases, for some people, even if the pills are just placebos. I think patients would agree, and I think it would be an interesting thing to measure. It would be easy, and you would do something called a pragmatic ‘waiting-list- controlled trial’.
You take two hundred patients, say, all suitable for homeopathic treatment, currently in a GP clinic, and all willing to be referred on for homeopathy, then you split them randomly into two groups of one hundred. One group gets treated by a homeopath as normal, pills, consultation, smoke and voodoo, on top of whatever other treatment they are having, just like in the real world. The other group just sits on the waiting list. They get treatment as usual, whether that is ‘neglect’, ‘GP treatment’ or whatever, but no homeopathy. Then you measure outcomes, and compare who gets better the most.
You could argue that it would be a trivial positive finding, and that it’s obvious the homeopathy group would do better; but it’s the only piece of research really waiting to be done. This is a ‘pragmatic trial’. The groups aren’t blinded, but they couldn’t possibly be in this kind of trial, and sometimes we have to accept compromises in experimental methodology. It would be a legitimate use of public money (or perhaps money from Boiron, the homeopathic pill company valued at $500 million), but there’s nothing to stop homeopaths from just cracking on and doing it for themselves: because despite the homeopaths’ fantasies, born out of a lack of knowledge, that research is difficult, magical and expensive, in fact such a trial would be very cheap to conduct.
In fact, it’s not really money that’s missing from the alternative therapy research community, especially in Britain: it’s knowledge of evidence-based medicine, and expertise in how to do a trial. Their literature and debates drip with ignorance, and vitriolic anger at anyone who dares to appraise the trials. Their university courses, as far as they ever even dare to admit what they teach on them (it’s all suspiciously hidden away), seem to skirt around such explosive and threatening questions. I’ve suggested in various places, including at academic conferences, that the single thing that would most improve the quality of evidence in CAM would be funding for a simple, evidence- based medicine hotline, which anyone thinking about running a trial in their clinic could phone up and get advice on how to do it properly, to avoid wasting effort on an ‘unfair test’ that will rightly be regarded with contempt by all outsiders.
In my pipe dream (I’m completely serious, if you’ve got the money) you’d need a handout, maybe a short course that people did to cover the basics, so they weren’t asking stupid questions, and phone support. In the meantime, if you’re a sensible homeopath and you want to do a GP-controlled trial, you could maybe try the badscience website forums, where there are people who might be able to give some pointers (among the childish fighters and trolls …).
But would the homeopaths buy it? I think it would offend their sense of professionalism. You often see homeopaths trying to nuance their way through this tricky area, and they can’t quite make their minds up. Here, for example, is a Radio 4 interview, archived in full online, where Dr Elizabeth Thompson (consultant homeopathic physician, and honorary senior lecturer at the Department of Palliative Medicine at the University of Bristol) has a go.
She starts off with some sensible stuff: homeopathy does work, but through non-specific effects, the cultural meaning of the process, the therapeutic relationship, it’s not about the pills, and so on. She practically comes out and says that homeopathy is all about cultural meaning and the placebo effect. ‘People have wanted to say homeopathy is like a pharmaceutical compound,’ she says, ‘and it isn’t, it is a complex intervention.’
Then the interviewer asks: ‘What would you say to people who go along to their high street pharmacy, where you can buy homeopathic remedies, they have hay fever and they pick out a hay-fever remedy, I mean presumably that’s not the way it works?’ There is a moment of tension. Forgive me, Dr Thompson, but I felt you didn’t want to say that the pills work, as pills, in isolation, when you buy them in a shop: apart from anything else, you’d already said that they don’t.
But she doesn’t want to break ranks and say the pills don’t work, either. I’m holding my breath. How will she do it? Is there a linguistic structure complex enough, passive enough, to negotiate through this? If there is, Dr Thompson doesn’t find it: ‘They might flick through and they might just be spot-on … [but] you’ve got to be very lucky to walk in and just get the right remedy.’ So the power is, and is not, in the pill: ‘P, and not-P’, as philosophers of logic would say.
If they can’t finesse it with the ‘power is not in the pill’ paradox, how else do the homeopaths get around all this negative data? Dr Thompson – from what I have seen – is a fairly clear-thinking and civilised homeopath. She is, in many respects, alone. Homeopaths have been careful to keep themselves outside of the civilising environment of the university, where the influence and questioning of colleagues can help to refine ideas, and weed out the bad ones. In their rare forays, they enter them secretively, walling themselves and their ideas off from criticism or review, refusing to share even what is in their exam papers with outsiders.
It is rare to find a homeopath engaging on the issue of the evidence, but what happens when they do? I can tell you. They get angry, they threaten to sue, they scream and shout at you at meetings, they complain spuriously and with ludicrous misrepresentations – time-consuming to expose, of course, but that’s the point of harassment – to the Press Complaints Commission and your editor, they send hate mail, and accuse you repeatedly of somehow being in the pocket of big pharma (falsely, although you start to wonder why you bother having principles when faced with this kind of behaviour). They bully, they smear, to the absolute top of the profession, and they do anything they can in a desperate bid to
I’m not saying I don’t enjoy a bit of banter. I’m just pointing out that you don’t get anything quite like this in most other fields, and homeopaths, among all the people in this book, with the exception of the odd nutritionist, seem to me to be a uniquely angry breed. Experiment for yourself by chatting with them about evidence, and let me
