The most recent "Anonymous" comment to my kefir post raised some interesting points that I felt required a more formal response.  Here is the text of the comment, without edit:

Anonymous said...

It is condescending attitudes like this that are driving patients away from mainstream medicine and toward charlatans. Just because medical labs have not adequately tested a treatment methodology does not mean there is no evidence for its efficacy.

What difference does it make whether the anecdotal self-reports are being published in medical journals or on amateur hobby websites? In either case you still have to take the patients' word when they say they feel better. And who cares if it's a placebo? Do they feel better or not?

By all means, critique foodsellers making untested medical claims. But don't mock the self-reports of patients who are proving more successful at treating their own illnesses than you are--especially when the treatment they have found has centuries of traditional use.

If they are saying that it works, then get in your lab and start testing.

I have been experimenting with kefir for the last two weeks. Despite the fact that I am a natural skeptic AND I hate plain yogurt, there is no question that my Crohn's, my ADHD, my chronic anxiety, and my restless limb symptoms are significantly improving, with a marked improvement in my bowel regularity. And the stuff tastes and smells absolutely delicious

I am indeed contemptuous and condescending regarding of the expounders of nonsense.  Nothing else seems to work as well when my goal requires drawing attention to quackery.  Besides that, its fun!

One of the important points raised in the Anonymous comment relates to "lack of evidence is not evidence of lack."  This appears to constitute the main point of Anonymous's first paragraph.  Great.  I get that.  But, understand that simply being ignorant is not an argument in favor of anything!  The fact that I don't know, simply means that I don't know!  It doesn't mean that I have to err in favor of this week's favorite quackery.  That would be an argument from ignorance--something that a skeptic, like Anonymous claims to be in his last paragraph, would understand.  The burden of proof regarding the efficacy of a treatment modality lies  with the purveyor.  Just because some crackpot claims he has a cure form an illness does not mean I need to break out the lab equipment.  The research dollars wasted by Anonymous's approach would be astounding.

Anonymous's second paragraph addresses, first, anecdotal evidence.  He implies that anecdotal evidence is an accepted, and even trustworthy, part of scientific research.  Medical and, more generally, science researchers, understand exactly the opposite to be true.  They understand that human beings are excellent at pattern recognition, but phenomenally terrible at statistics.  Anecdotal evidence is astoundingly error-prone.  That means that anecdotal evidence is considered untrustworthy.  In fact, one of the principle goals of a researcher in science is to bias-proof the research as much as possible.  In other words, the researchers work hard to eliminate sources of personal opinion and belief from their studies.

The second point in the same paragraph, regarding placebos, is more complicated.  I believe Anonymous means, essentially, that the "end justifies the means."  Hey, if a placebo works, what's the harm, right?  I believe this is a particularly paternalistic and dangerous approach to healthcare.  How would you feel if your physician recommended a treatment for you that he or she absolutely knew, worked no better than fake treatment, in other words, was just a placebo.  Worse yet, how would you feel if your physician, billed you, and your insurance, $130 for something he or she knew worked no better than that fake treatment?  In other economic areas like retail and auto repair, obtaining money by lying to customers is called fraud.

Patients have a right to expect that their physicians will tell them the truth about risks and benefits for tests and treatments, and that their physicians will not bill for services or treatments that the physicians know provide no benefit beyond that obtained by fake therapy.

Anonymous's last paragraph is just more anecdotal evidence.  "The plural of anecdote is anecdotes, not data."

Not here too!

I fly 3000 miles to further my medical education, in San Diego. $620 for the classes. In the exhibit hall, I find a booth hawking homeopathic remedies!


Can I not escape this blithering nonsense?! This quackery forces me to question why I bother paying dues to the AOA. Are they really so desperate for funds that they are willing to sell their collective souls for the price of a stinking booth on the exhibit floor? Homeopathic physicians are quacks! They promote nonsense that hurts our patients directly and indirectly. It doesn't belong anywhere near physicians who give a damn about their patients.
- Posted using BlogPress from my iPhone

Homeopathy: Part 3

Homeopathy: Part 3

Magical energy

Why do homeopaths bother going through such time-consuming machinations?  What possible benefit could there be to diluting a solution billions of times beyond the “nothing’s left” point?  Fantastically, homeopaths claim that the more dilute the remedy, the more powerful it is: "less is more."  They claim that a process they call “potentizing by succussion,” transfers healing energy to the, now, non-existent ingredient.[i]  Succussion involves ritualistic tapping of the remedy with each dilution.  This “healing energy” supposedly increases in concentration with each dilution.  The more dilutions performed, the more agitated the remedy, and therefore, the more potent the cure.

I have several objections to this rubbish.  No solution or solvent has ever demonstrated any type of objectively measurable memory.  Wouldn’t this theoretical basis for potency mean that the solution would remember anything it had ever met, no matter how insanely dilute?  In fact, wouldn’t the tiniest impurities in the solvent get “potentized” to insanely powerful and unpredictable degrees?  Wouldn’t that render the remedy worthless--or perhaps even more potent?

The concept of increasing potency with lowering concentrations simply makes no sense.  It contradicts the laws of chemistry and physics.  The intended concentrations are so low that any real effect identified likely reflects a previously unknown property of the alcohol or water solvent.[ii] 

Legislated ignorance and sacred cows

In 2003, over three thousand homeopathic physicians practiced in the United States, with thousands more in Europe.  If homeopathy is such nonsense, why does this industry generate hundreds of millions of dollars in annual revenue for homeopathic practitioners and remedy manufacturers?[iii] The answer is complex.  Let’s first look at why it is legal to sell this garbage at all.  This makes for an excellent case study in American special-interests politics. 

In 1938, Royal Copeland, a Senator for the State of New York, sponsored a piece of legislation, the Food, Drug, and Cosmetic Act, to protect the American public from dangerous or worthless drugs and patent medicines.  Senator Royal Copeland also happened to be Dr. Royal Copeland, a homeopathic physician.  He managed to carve out an exemption in the new law for his homeopathic remedies by legislating that any product listed in the Homeopathic Pharmacopoeia would automatically receive full recognition as a drug without having to meet most of the rigorous standards that conventional prescription drugs must meet.  The new law exempted manufacturers of homeopathic remedies from proving their products contained the labeled ingredient, proving that the strength of the remedy as listed was accurate, and proving that the remedy effectively treats any medical condition at all.  Homeopathic products also do not have to carry expiration dates, and can legally contain far more alcohol than the ten percent usually allowed in standard medications.8 

However, homeopathic products must comply with some FDA regulations.  Over-the-counter preparations can only be marketed to treat self-limited disorders, in other words, disorders that would go away on their own if not treated at all.  As such, homeopathic remedies occupy a protected niche created by special interests. 

Drawing back the magic curtain

Some, like Dharma, ask, “Well, it must do something, right, even if they don’t understand it?”  On the contrary, the data so far shows that homeopathy works no better than placebo.[iv]  Virtually all of the studies purporting to show benefit from homeopathic treatments are fatally flawed.[v], [vi],[vii], [viii], [ix], [x]  No adequately designed, sufficiently powered study has ever demonstrated that any specific homeopathic remedy works better than a placebo for treating any specific disorder.11

In one study, the effects of homeopathic remedies on hot flash severity and frequency in menopausal women clearly revealed no statistically significant benefit for menopausal symptoms.[xi]  Unfortunately, the authors of the study went on to crunch the numbers from one angle after another until they found a way to present a positive result about the research. “If you can’t find something good to say about something, don’t say anything at all.”  In this case, they noted that the overall health of patients was better a year after initiation of the study protocol in the treated group than the placebo group.

A well-publicized and controversial analysis of 186 studies of homeopathy published in The Lancet, a well-respected medical journal, in 1997, concluded that a “trend existed for homeopathy to be more effective than placebo.”[xii]  However, a thorough review of the data conducted by the editors of the journal revealed that, of those 186 studies, not even one showed a significant benefit for any homeopathic remedy over a placebo.  The analysis also revealed a strong inverse relationship between study quality and homeopathic benefit: the better the study design, the poorer homeopathy fared.[xiii]  

I suspect any appearance of success for homeopathy is likely due to the placebo effect.  A more recent article published in the 27 August 2005 issue of The Lancet seems to confirm that notion.[xiv]  The authors matched over a hundred studies on homeopathy with comparable studies on traditional medications.  They found bias colored many of the studies.  Taking that bias out of the equation they found that traditional medications work considerably better than placebo while homeopathic remedies performed no better than placebo.

So tempting, the Ring of Power

If the benefit of homeopathy is all placebo, so what?  What’s wrong with that?  Why not prescribe homeopathic remedies with the knowledge that they are placebos?  After all, the patient feels better.  Isn’t that the final objective, anyway?  Is that not why patients seek out doctors in the first place?  This is the single most dangerous and insidious aspect of this phenomenon.  In this particular case, the ends absolutely do not justify these fraudulent means.  The ideal of patient autonomy that drives me to defend a patient’s right to choose some treatment other than what I perceive as rational, makes this choice impossible for me. 

To pass on to my patient, under false pretenses, something I know has no intrinsic therapeutic merit would be paternalistic, unethical, and personally abhorrent.  Homeopaths are not generally in the habit of informing their patients that the treatment being offered is a placebo.  To smilingly lie as I hand Dharma a bee’s wax pellet that I know contains nothing that will help her, robs her of her autonomy.  Dharma has a right to make well-informed decisions about her own care, drawn from the best possible information.  Remember, Dharma pays to get my medical advice.  Dharma has the right to expect she is getting her money’s worth in the form of my considered medical opinion, not intentional deception.  Otherwise, Dharma’s autonomy is meaningless. 

The magic mirror

The quackery that is homeopathy exists because of the quackery found in conventional medicine.  Healthcare has too many special interests feeding on the trillions of dollars in the healthcare budget.  The same defective reasoning that causes patients to accept homeopathy also causes many more patients and physicians to use questionable practices in conventional medicine.  The modern equivalents to leeching, purging and mercury poisoning still exist.  New medications and interventions get far more exposure, and aggressive direct marketing than their 19th century counterparts did.  The recent withdrawal of several high-profile drugs from the market, probably with thousands of deaths to their credit, reinforces the wary public’s opinion that medications are dangerous things.

Inherent in the use of homeopathy is the search for something safer than what modern medicine has to offer.  That being said, the problems in the current system do beg for changes, but do not justify fraud.  The trend towards science-based medicine promises slow, but steady improvement in treatment.  One could argue that not treating is better than treating with many of the medications currently in use. With homeopathy, that is precisely what patients get: nothing, in the guise of treatment.

People pay a lot of money for homeopathic therapy.  Our collective tax dollars find their way into government-funded research programs on this codswallop to the tune of tens of millions of dollars each year.  Not all claims to therapeutic benefit have equal standing. Homeopathy is based entirely on extraordinary, magical reasoning.  Extraordinary claims require extraordinary evidence. Therapeutic modalities based on extraordinary claims should meet the extraordinary evidence standard before qualifying for large research grants—and especially before they see the light of day as treatment for adults and children.

---

[i] Davenas E, Beauvais F, Amara J, Oberbaum M, Robinzon B, Miadonna A, Tedeschi A, Pomeranz B, Fortner P, Belon P, et al.; Human basophil degranulation triggered by very dilute antiserum against IgE.

Nature. 1988 Jun 30;333(6176):816-8.

[ii] Shealy CN, Thomlinson RP, Cox RH, Borgmeyer V; Osteoarthritic Pain: A Comparison of Homeopathy and Acetaminophen;American Journal of Pain Management; 1998 Jul; 8(3): 89-91

[iii] Stelin I; Homeopathy: Real Medicine or Empty Promises?; FDA Consumer Magazine. 1996 Dec

[iv] Shipley M, Berry H, Broster G, JenkinsM, Clover A, Williams I; Controlled Trial of Homeopathic Treatment of osteoarthritis; 1983 Jan 15; 1(83160:97-8

[v] McCarney R, Warner J, Fisher P, Van Haselen R; Homeopathy for dementia; Cochrane Database Syst Rev. 2003;(1):CD003803

[vi] Walach H, Haeusler W, Lowes T, Mussbach D, Schamell U, Springer W, Stritzl G, Gaus W, Haag G; Classical Homeopathic Treatment of Crhonic Headaches; Cephalalgia. 1997 Apr;17(2):119-26

[vii] Reilly DT, Taylor MA, McSharry C, Aitchison T; Is Homeopathy a Placebo Response?; Lancet. 1986 Oct 18; 2(8512); 881-6

[viii] Reilly D, Taylor MA, Beattie NG; Campbell JH, McSharry C, Aitchison RC, Stevenson RD; Is Homeopathy Reproducible?; Lancet.; 1994 Dec 10; 344(8937); 1601-6

[ix] Jacobs J, Jimenez M, Gloyd SS, Gale JL, Crothers D; Treatment of Acute Childhood Diarrhea with Homeopathic Medicine: A Randomized Clinical Trial in Nicaragua; Pediatrics. 1994 May; 93(5):719-25

[x] Hill C, Doyon F; Review of Randomized Trials of Homeopathy; Rev Epidemiol Sante Publique. 1990; 38(2):139-47

[xi] Jacobs J, Herman P, Heron K, Olsen S, Vaughters L; Homeopathy for Menopausal Symptoms in Breast Cancer Survivors: A Preliminary Randomized Controlled Trial; J Altern Complement Med.; 2005 Feb; 11(1):21-7

[xii] Linde K, Clausius N, Ramirez G, Melchart D, Eitel F, Hedges LV, Jonas WB; Are the Clinical Effects of Homoeopathy placebo effects? A meta-analysis of placebo-controlled tirals. Lancet. 1997 Sep 20; 350: 834-43

[xiii] Linde K, Scholz M, Ramirez G, Clausius N, Melchart D, Jonas WB; J Clin Epidemiol. 1999 Jul;52(7):631-6

[xiv] Shang A, Juwiler-Muntener K, Nartney L, Juni P, Dorig S, Sterne J, Pewsner D; Are the clinical effects of homoeopathy placebo effects?  Comparative study of placebo-controlled trials of homoeopathy and allopathy. Lancet 2005 Aug 27;366(9487):726-32

Homeopathy: Part 2

Guinea pigs and “provings”

The Homeopathic Pharmacopoeia, at least the classical homeopathic remedies, derives from homeopathic “provings.”  A proving is research, homeopathy-style.  It sounds very scientific, couched in the jargon of science, but what exactly is a proving?  Homeopathic experimenters conduct provings by studying a potential ingredient‘s effects on healthy individuals.  The human guinea pig consumes a quantifiable amount of the substance, then takes copious notes on symptoms he or she experiences, including physical symptoms, state of mind, and feeling warm or cold, etc.  Hahnemann, himself, took cynchona extract, the source of quinine, to which he had a profound reaction:

I took by way of experiment, twice a day, four drams of good China (Cinchona).  My feet, finger ends, etc., at first became cold; I grew languid and drowsy, then my heart began to palpitate, and my pulse grew hard and small; intolerable anxiety, trembling, prostration, throughout all my limbs; then pulsation in the head, redness of my cheeks, thirst, and in short, all these symptoms which are ordinarily characteristic of intermittent fever, made their appearance, one after the other, yet without the peculiar chilly, shivering rigor, briefly, even those symptoms which are of regular occurrence and especially characteristic - as the dullness of mind, the kind of rigidity in all the limbs, but above all the numb, disagreeable sensation, which seems to have its seed in the periosteum, over every bone in the body - all these made their appearance. This paroxysm lasted two or three hours each time, and recurred if I repeated this dose, not otherwise; I discontinued it, and was in good health.[i]

In Dharma’s case, with her back and hip pain, I asked why and how she takes Arnica.  She didn’t directly answer that question.  Instead, she made a blanket statement about wanting something to treat the cause of her disease, not just the symptoms.  She boldly declared that homeopathic remedies do that, implying that traditional medications ignore the cause of a disease.  Homeopathic practitioners often echo this belief, criticizing traditional physicians for “just treating symptoms.”  They accuse traditional doctors of ignoring the underlying cause of an illness, and of not treating the “whole patient.”  In contrast, they claim their own approach is more holistic, which, in this context, means all encompassing.

This really couldn’t be further from the truth.  Homeopathy centers precisely on treating symptoms, with complete disregard for the underlying causes of those symptoms. The “proving“ process described above focuses solely on symptoms.  The Law of Similars guides the choice of remedy for the practitioner based only upon the extensive history of the patient’s symptoms, regardless of the cause. 

For example, a study from 1998, published in the prestigious Archives of Otolaryngology—Head & Neck Surgery reviewed a commercially available homeopathic remedy for vertigo.[ii]  Vertigo is the subjective sensation of spinning when no spinning actually exists.  It has literally dozens of potential causes, including stroke, brain tumor, ear infection, and migraine.  The study designers chose one homeopathic remedy to treat all vertigo, without regard for the cause.  Unfortunately for the authors, the study suffered from weaknesses common in the literature supporting alternative and complementary treatments: it had a small population size, and had no placebo control.  Instead, the authors compared the performance of the homeopathic formulation against the performance of beta-histine, a drug marginally effective in treating a few specific types of vertigo, but not nearly the variety of causes for vertigo included in this study.  The authors also excluded from the study anyone with vertigo lasting longer than six months, and patients rating their vertigo as a five-out-of-five on a severity scale.  Apparently, even homeopathic researchers believe homeopathy only works for moderate symptoms, that don’t last very long.

Ducks and quacks

Homeopathy’s second commandment is Hahnemann’s Law of Infinitesimals.  This law, which homeopaths summarize as “less is more,” is even more absurd than “like cures like.”  While the concept of “like cures like” might occasionally stumble upon a useful remedy by chance, “less is more” is just plain idiocy.  It turns out that Dharma’s homeopathic remedy consist of an extremely dilute potion of the ingredient listed on the bottle. The remedy, in fact, is so dilute that not even one molecule of the original ingredient remains in the remedy--more magic.  Dharma gaped at me disbelievingly when I explained this.

Arnica Montana is an herb commonly used by homeopaths to treat inflammation and pain, such as Dharma’s backache.[iii]  The homeopathic formulation I encountered most frequently while researching arnica bears the label: “30 C.”  The instructions state: “Take 2 pellets by mouth every 4 hours as needed.”  What does “30 C” represent?  Well, hold on to your calculators!  Astonishingly, it means that the remedy has been through thirty serial dilutions, each dilution being 1-in-100. 

Let’s take a closer look at what this means.  Starting with one milliliter (a milliliter is abbreviated “ml,” and equals about fifteen drops, or about one-fifth of a teaspoon) of pure arnica extract, I would dilute that with ninety-nine ml of water to get my first dilution.  I would then remove one ml of the resulting solution, place it in a new bottle, and add ninety-nine ml more water to the solution.  Yet again, I would remove one ml of the newest solution, again placing it in a new container, and again adding ninety-nine ml of water.

At the end of just three dilutions, I would have a solution that is now only one-millionth (1/1,000,000^th) the concentration of the original extract.  To get the final desired concentration of “30 C” as indicated on the bottle, I must repeat this diluting process twenty-seven more times.  That is not a trivial fact.  Each dilution adds two more zeroes to the denominator.  The final, miniscule concentration is 10^-60.  How dilute is this? 

Assume, for the sake of argument, that I began with one milliliter of the pure arnica extract and desired to make the same “30 C” dilution without throwing any of the extract or water away.  In order to end up with a “30 C” solution I would have to add my one ml of extract to 10⁵⁷ liters of water.

Proxima Centauri, the nearest star to our Sun, lies only four light-years away.  It takes light just over four years to reach us from that distance.  If you filled that entire distance with an enormous sphere of water that touched Earth on one edge and Proxima Centauri on the other, it would only contain 2.84 x 10⁵² liters of water.  My solution would have to contain 100,000 times that much water to reach the “30 C” dilution!  Such extraordinary amounts of water being unavailable in this end of the known universe, the manufacturers of homeopathic remedies concoct their “30 C” remedies by throwing out 99% of the extract and solvent at each of the thirty steps in the process.

When I discuss this subject with people, I can’t help but think of Mr. Gould, the gray-haired, tired looking man with slightly pink-tinted glasses who taught me high school chemistry in California.  Picture Jackie Gleason on a grumpy day, standing in front of a periodic table of elements.  Though he seemed bereft of a sense of humor, I have no doubt these remedies would have wrested a chuckle from him.  It turns out that these dilutions to concentrations less than 10^-23 are meaningless.  At that concentration, there is only a fifty percent chance that any of the original substance, even one molecule, persists in the solution. 

Imagine, for a moment, that I give you 100 marbles and 100 small boxes.  After I instruct you to divide the marbles evenly among the boxes, you end up with 100 boxes, each containing a marble.  Now, I hand you a huge pile of additional boxes, giving you 1,000 boxes.  I ask you to divide your one hundred marbles evenly among the thousand boxes.  Clearly, you cannot do this while keeping the marbles whole.  You’ll end up with one hundred boxes, each containing a marble, and nine hundred empty boxes. 

The same thing happens with molecules.  There comes a point in serial dilutions when the number of medicine bottles being filled vastly exceeds the number of molecules of the original medicine.  Most of the bottles are empty.  The “30 C” dilution of Arnica far exceeds that point, as do the dilutions of many homeopathic remedies.

How do homeopaths respond to this seemingly irrefutable point, when confronted with it?  Well, to quote George Carlin, “…it was heavy mystery time.”  Homeopaths who actually understand the math agree that the original ingredient no longer exists in the remedy.  In other words, they know the bottle of arnica contains no arnica.  Incredibly, they claim that the solvent has some kind of magical memory that remembers what had been dissolved in it, and that this memory constitutes the active ingredient in the remedy.  Now, that is magic.  It also explains the complete lack of side effects attributable to homeopathic remedies: there’s nothing in them.  Imagine if oil companies could make gasoline this way.

Another remedy, called Oscillococcinum, comes from freeze-dried duck liver and heart.  The product bears a label touting an astounding 200 C dilution.  That equals one part duck out of a number with 400 zeroes behind it.  At this dilution, it would be harder to find a molecule of this duck’s liver in the remedy than finding one molecule of this duck’s liver in the rest of the entire universe!  At the time of this writing, six doses of lactose pellets carrying a fond, but extremely distant memory of duck liver and heart could be purchased on-line for a mere $24.95.  An article in the February 17, 1997 issue of U.S. News and World Report referred to the single miserable duck whose organs comprise the entire world supply of this remedy as “the  $20 million duck,” when it was learned that the sales of this product for 1996 approximated that amount.[iv]

Much more to come...

---

[i] Cullen, W.: 'Abhandlung uber die Materia Medica. Ubersetzt und mit Anmerkungen versehen von Samuel Hahnemann.' 2 Bande. Im Schwickertschen Verlag. Leipzig 1790.

[ii] Wieser M, Strosser W, Klein P; Homeopathic vs Conventional Treatment of Vertigo; Arch Otolaryngol Head Neck Surg. 1998 Aug; 124(8): 879-85

[iii] Vickers AJ, Fisher P, Smith C Wyllie SE, Rees R; Homeopathic Arnica 30X is Ineffective for Muscle Soreness After Long-Distance Running: A Randomized, Double Blind, Placebo-Controlled Study; Clinical Journal Pain;1998 Apr 15; 14(3): 227-31

[iv] Barrett S; Homeopathy: The Ultimate Fake; http://www.quackwatch.org/01QuackeryRelatedTopics/homeo.html

Homeopathy: Part 1

 “There are no greater liars in the world than quacks—except for their patients.”

--Ben Franklin

Potions and pellets

Dharma recently transferred to my care from another practice.  At her first appointment, Dharma complained of back and hip pain.  She had overdone it a bit during an ice skating lesson the previous day.  Dharma presented me an empty, tiny, paper envelope, and asked me to replenish her supply of Arnica. 

Arnica is a homeopathic “remedy”  That is what homeopathic physicians call their potions and pellets.  Traditional homeopathic remedies consist of supposedly therapeutic agents dissolved in a liquid such as water or alcohol, or mixed into pellets of bee’s wax or lactose (milk sugar).

The Homeopathic approach to medicine dates back to the late 1700s, when Dr. Samuel C. F. Hahnemann (1755-1843), its founder, practiced medicine in Germany.  A memorial in Washington, D.C. commemorates his life and accomplishments in bronze on marble.  Hahnemann became disenchanted with the medical practices popular in his day--leeching, purging, and treatment using mercury compounds—which seemed just as likely to harm a sick patient, as help them.  In his quest for a different path, he developed the precepts of homeopathic medicine, rooting them firmly in pseudoscience and mysticism.  Homeopathy, as I will explain, requires near-lethal doses of magical-thinking on the part of its practitioners and patients.

Homeopathy is not merely a dead limb on the evolutionary tree of medicine, like other rotting branches such as phrenology (reading lumps and boney landmarks on the head).  For several complex reasons, homeopathy and a few related treatment modalities are enjoying resurgent popularity.  The number of practicing homeopathic physicians in this country grew from 200 in the 1970s to over 3,000 in 1996.

Many of my colleagues fault homeopathy for having roots in 18th century mysticism and relying upon unscientific concepts like good and evil humors and spirits.  Those criticisms, though accurate, miss the point.  I do not criticize homeopathy for the primitive ideals it once espoused and has since discarded any more than I criticize a thirty year old man for having believed in Santa Claus as a child.  I criticize homeopathy and homeopathic providers for the misinformation they expound now.  Homeopaths spout absolute blarney right now, every day, about their practices and their remedies.

Healing magic

Dr. Hahnemann erected his edifice upon three scientifically unsound and discredited foundations.  I will discuss each concept in turn, the first being the “Law of Similars.”  Paraphrasing: “like cures like.” 

Homeopaths claim that a substance known to cause a certain symptom in a normal person can cure a sick person with similar symptoms.  For example, suppose Dharma had presented to my office on this occasion with vomiting from food poisoning.  A homeopathic-practitioner would prescribe Dharma an extract derived from a plant or animal product capable of causing vomiting in normal people.  A facet of this at first glance, seems plausible.  Eating a rancid piece of meat can certainly result in vomiting.  The act of removing that piece of meat from the stomach by vomiting, or from the intestine through diarrhea, allows the body to protect itself to some degree by ridding itself of the rancid meat before it can do serious damage.  In fact, traditional medicine often uses syrup of ipecac for this very purpose: as a cathartic, to induce vomiting after poisoning. 

When examined more closely, however, this analogy falls short of explaining the homeopathic approach.  The homeopathic remedy, though it’s derived from a chemical believed to cause vomiting, is not given with the intention of causing vomiting; it’s intended to cure vomiting without causing vomiting.  In other words, a homeopath does not intend to cure vomiting by giving a remedy to provoke vomiting and get it over with; he gives a remedy capable of causing vomiting, but expects there will be no vomiting.  This defies reason.  I have yet to find a way to reconcile this apparent paradox without relying on the supernatural or magical.

Homeopaths have built an entire system of treatment upon this implausible, paradoxical premise.  It’s like saying that I painted my room red in order to make it blue.  The homeopathic approach differs markedly from standard medical and pharmacological practice, in which a physician prescribes a medication known to cause a certain effect in order to obtain that effect, not its opposite.  Modern medications base their mechanisms of action upon the receptor model, in which a medication interacts with a specific receptor to provide some therapeutic benefit.  The medication’s ability to interact with other, untargeted receptors, accounts for some of its side effects. 

The evidence supporting the receptor model is overwhelming and very reproducible.  Many of the receptors targeted by modern medications have been specifically identified--the ability of various medications to bind to those receptors having been well demonstrated.  Credence in homeopathy, on the other hand, requires us to accept fanciful, magical concepts that come completely without credible supporting evidence, and to abandon well-established, reliable, science.

Homeopathy preaches that a remedy interacts with a body’s vital forces to affect a cure.  So far, no credible research has succeeded in demonstrating the existence of any such forces, let alone the ability of homeopathic remedies to interact with them.  The efficacy of homeopathy—and the health of those who pay good money for this preposterous treatment—rests upon an immense and untenable leap of faith.  And that's just the beginning.

More to come...

Kefir Mythology

Kefir is a yogurt-like product made by fermenting milk with cultures of several bacteria and yeast. Frankly, until recently, I had never heard of it (nor--to my short-lived, blissful ignorance--smelled the pungent stuff). However, fad, alternative remedies usually cross my path in exactly this manner; I initially catch a rumor of some new uber-cure, then see it spread, much like a virus among unvaccinated children, over weeks to years.  I had the privilege of smelling Kefir in the hands of a patient who was using it to treat abdominal pain she had suffered from for several months.  She noted if she stopped using the Kefir for even a day, she started feeling worse.

I did a little research and found a company called Body Ecology that markets a Kefir Culture Starter kit. The website touting the benefits of Kefir claims all the usual nonsense about "strengthening the immune system" and such, but goes on to specifically claim that Kefir helps patients with ADHD, flatulence, herpes, cancer, colon "strengthening," chronic fatigue syndrome, and "cleansing the whole body."  What exactly does that mean?

Another website, this one for Lifeway Foods, claims that Kefir helps with Crohn's disease and Ulcerative Colitis (UC) because those diseases are "similar to Irritable Bowel Syndrome."  In fact, Crohn's and UC are not related to Irritable Bowel Syndrome at all (other than the fact that they all affect the bowel).   Without descending too deeply into technical details, Crohn's disease and Ulcerative Colitis are inflammatory conditions of the gut that, when present, effectively rule out Irritable Bowel Syndrome as a cause of abdominal pain.

Two clicks more on my Mac took me to PubMed, the web portal of the National Library of Medicine, where I found absolutely no randomized, controlled trials supporting any of these claims. It appears, then, that Kefir is a yogurt-like food that may have some as yet poorly established benefits of a "probiotic" nature, now being promoted--with no reliable research support--as a cure-all for all sorts of symptoms and diseases.

What's the harm, one might ask. Well, in this case, Kefir is not being promoted simply as a nutritious food (which it might very well be), like cheese or yogurt. Purveyors are making health claims about this product. Some patients suffering from symptoms like chronic abdominal pain, Crohn's disease, ulcerative colitis, nausea, fatigue, colon cancer, herpes, and ADHD are listening in, and buying it. This can cause unsafe delays in actually working up, diagnosing, and treating potentially dangerous illnesses. It can also foster a false sense of security in a patient who believes he is adequately protecting himself or others from the effects of a serious infection when in fact it isn't true.

In summary, there is no reliable evidence that Kefir is anything more than a (moderately disgusting) food.  The patient with the Kefir turned out to have a Helicobacter pylori infection which I treated with antibiotics and an acid reducing medication.

Alternative medicine: to what, exactly is it an alternative?

I recently read an article from the February 23, 2010 edition of the journal, Depression and Anxiety, that left me pondering what, exactly, is meant by "Alternative Medicine." The study in question looked at the efficacy of therapeutic massage for treating Generalized Anxiety Disorder. Not surprisingly, it apparently works. So did several of the other types of relaxation techniques presumably used as a sort of control in the study, namely relaxing in a quiet room, and thermotherapy (the application heat to body).

Fine. So be it; to the degree that the study was performed reliably by competent researchers, using rigorous, well conceived and implemented protocols, it may be provisionally accepted. My question is this: how is massage alternative medicine? We're talking real, hands-on-the-skin, rubbing of the soft tissues here. This is not mystical energy manipulation, Reiki, chakra balancing, or psychic surgery. Soft tissue massage is a well established therapeutic modality generally accepted as treatment for certain medical problems. The notion that massage would promote relaxation is certainly plausible--perhaps even common sense. The notion that relaxation helps relieve the symptoms of generalized anxiety is also generally well established.

By definition, alternative medicine is an alternative to something else. In this case, it is an alternative to this vague concept of "established medicine." For the purposes of this post, I am defining established medicine as the practice of medicine using an evidence-based (or science-based, using the phrase coined by Dr. Steven Novella) approach to patient care. Mainstream medicine is a continuously transforming thing; it morphs to accommodate ever-increasing knowledge and understanding. As diseases, prevention, and treatment become better understood, the practice of medicine changes to reflect that understanding. In essence, modern medicine reflects the scientific method.

Sometimes, treatments that were initially considered "alternative" become mainstream by passing scientific muster. In this sense, alternative simply means unproven. Once a treatment is adequately proven to work, it becomes mainstream, not alternative. Great! That's a system that is self-correcting and always improving.

So, really, alternative medicine is just an alternative to a scientific approach to diagnosis and treatment. If its not based on science, what is alternative medicine based on? Probably crap. Is that what you want to be treated with? Not me.

TAM 6: Just amazing!

So, I'm in my hotel room at the Imperial Palace Hotel and Casino in Las Vegas basking in the afterglow of TAM 6.  For the uninitiated, TAM 6 is the sixth full installment of The Amazing Meeting.  This is the brainchild of the extraordinary magician, and skepticism activist, James "The Amazing" Randi.  http://www.randi.org/  Its a place for all those interested in reality, skepticism, science, and public education about those subjects, to come together and learn, share, celebrate and, most importantly, plan to take over the world!  Ha, ha, ha!  (Think evil sounding laugh, here.)  Yes, plan!  That's what we did, here.  We skeptics refueled our batteries.  We had lots of really good laughsat the expense of all the charlatans and con-artists, at all the crap and woo out there.  We made new important contacts.  We plotted and schemed about new ways to organize our thinking and activities.  Oh, what a glorious weekend!

This year's meeting was at the Flamingo Hotel, right next door.  The speakers were fantastic!  The keynote speaker, Dr. Neil deGrasse Tyson, was outstanding. He brings an energy and passion to his speaking that I would like to clone for my use, and to lend to all the science teachers in this country.

Adam Savage, of MythBusters, gave an excellent talk on his particular neuroses, and obsessive compulsive disorder, and then, he showed us a really cool video of things having the snot blown out of them.  I mean real KABOOMS!  What a rush!  My kids can't wait to get their hands on a couple of the ping pong balls used to raise a sunken ship in an episode.  If only Buster could have been there.

I bought a copy of Flim Flam, by Randi himself and asked him to sign it.  Of course, I used the moment as a photo opportunity.  I realized afterwards that ever picture of me at this thing features me grinning like a three-year old on Santa's lap.  I have to admit, I was very star-struck.

I think my favorite moment from the entire meeting, though, actually happened after 

hours.  A bunch of fans of the Skeptics' Guide to the Universe podcast (see the link in the links section) got together at a local restaurant for a wonderful evening of wine, and talk, and skepticism.  I have never felt so thoroughly a part of an extended family as I did that night.  Rebecca Watson, one of the Skeptical Rogues in the podcast, did a wonderful job setting that up.  It was so much fun to talk to Bob, and Steve, and Jay, as well.  I love to be around people who fight the good fight, and do it with passion!

So, now, I go back to Maine.  I'm already working on my list of topics for this blog...

Pass the cream and sugar, then shove it!

Ok, people.  I love my morning cup of coffee as much as anybody does.  It goes back to residency.  I could drink a half pot of tar-like coffee back then and go to sleep without a problem.  Caffeine dependency is glorious.  But, why would anyone want to waste a perfectly good cup of Trader Joe's 100% Kona (in my opinion, the best coffee in the world) by forcing it up his anus into his colon?  Coffee enemas?  Come on!  Who comes up with this crap!  Totally wrong route of administration if you ask me.

So, ok, there has to be a logical explanation, right?  It must make some medical sense, right?  Why else would all these people be spending all this money on coffee for their wazoos, right?  Absolutely not!  A Google search for the phrase "coffee enema" returns 61,700 hits.  Maybe Freud was right about the whole "anal fixation" thing.  A Medline search for "coffee enema"--using the extremely powerful, very user-friendly search engine relied upon by scientists all over the world--returned only fourteen hits, none of which were clinical trials on this subject.  Two were unabstracted reviews criticizing the use of coffee enemas.  

Overall, I'd have to say that is extremely compelling evidence against sticking a hose containing coffee up your own, or your friend's anus.  It is my medical opinion that only a well trained provider of evidence-based medicine should ever have a crack (no pun intended) at inserting any thing in any ones' anus under almost any foreseeable circumstances.  And even then, make them explain it to you twice, OK?  Its your anus!

Now, having effectively ruled out the well-informed, "I've got logic and reason on my side" approach to this, we are left with trying to understand the other motivations for filling the colon with some quantity of Folgers, or Yuban, etc.  If I could insert the sound of chirping crickets at this point, I would.  It conveys absence, or silence really well.  Close your eyes and picture it.  Poignant, yes?  Like most of this nonsense, coffee enemas are about money: profit margin.  None of this is real science.  Absolutely all of it is crap and belongs in the septic system with the usual contents of our collective colons.  

Sites touting the use of coffee enemas often recommend them for daily use prior to other types of alternative medical treatments, such as liver "detoxifications," calling them safe and more effective than drinking coffee.  http://home.bluegrass.net/~jclark/coffee_enema2.htm  That's great.  "Heres some nonsense to do that will keep you busy flushing coffee up you arse for a month prior to getting to the real stupidity."

The plural of anecdote is anecdotes, not data.  No number of personal testimonials should be enough to convince a prudent, well reasoned person to flush coffee up his or her anus.  Always hold any person who wants you to try something for your health to the same skeptical scrutiny that you would use when listening to your doctor describe the potential side effects of your prescription medications.

Iridology

I was out for dinner with some friends yesterday when someone mentioned a new "medical specialist" had moved to town, setting up shop in a local family practitioner's office.  Apparently that practice has hired an iridologist.  Now, you would think that iridology refers pretty generically to the study of the iris--the colored part of the eye; in fact, that is what the latin and greek roots for this word mean, "the study of the iris."  Perhaps a subspecialty of ophthamology, one that deals only with diseases of the iris, would use this term to describe it's clinical focus.  Unfortunately, not so.  Iridology is completely bogus, absolutely discredited quackery.

Iridologists believe--or at least they say they believe it--that they can diagnose all sorts of physical and mental illnesses by studying the appearance and location of features on the iris of the eye.  The claim that the iris can be directly mapped to various organs and regions of the human body, and that certain features can signify specific illnesses in the mapped regions.  For example, they claim the part of the iris near the six o'clock position correlates to the kidney.  Features located in this area denote illness or disease of the kidney.  

Iridology generally limits it's scope of malpractice to diagnosing illness.  I suspect this explains why all manner of alternative medicine crackpots use it as a launch pad to sell their various  incarnation of "treatment."  Anybody looking for a way to justify their particular brand of nonsense can diagnose some malady using iridology.  After that, guess what, they have the perfect cure!  They might be selling natural supplements, magnets, homeopathic remedies, or whatever--iridology makes a great segway into all of them.

Lest there be any doubt, this particular field of idiocy has been the subject of many wasted research dollars.  Taken as a whole, which is the way medical literature should always be taken, the research confirms that iridolgy is worthless.  There are certain recurring patterns seen in the scientific literature surrounding subjects like this:

• The better the quality of the study, the worse the quackery performs.
  
• The pseudoscience always seems to yield results that are just barely beyond the border of significance, even with increasingly rigorous protocols.  This is often used to justify provisional acceptance while "awaiting further study."
  
• Quacks support their quackery with vague, feel-good rhetoric that boils down to nothing of substance.
  
• The quacks try to use an imperfect understanding of a disease or condition as evidence in support of their quackery.  This is really a poorly-veiled argument from ignorance ("I don't understand what is happening here, therefore it must be due to my snickelfritz").  
  

The literature on iridology uses all of these.  The bottom line: absolutely no decent evidence supports the premises, or the practice of iridology.  The best studies that have been done on the subject prove it is crap.  But, crap is a subject for another post...