Friday, February 19, 2010

Benefits and risks of Homoeopathy: a rejoinder to the article published in the Lancet

Prof. Chaturbhuja Nayak
Central Council for Research in Homoeopathy
New Delhi, INDIA

The Lancet has recently published a comment entitled “Benefits and risks of
homoeopathy”1. The commentator Ben Goldacre has denigrated Homoeopathy by citing
the results of five studies2-6 which have not produced statistically significant benefit over placebo. But, he has taken a partial view of the results of some of the studies, referred by him, where the authors have not totally branded homoeopathy as placebo response. Rather the authors have admitted that there was some evidence that homoeopathic treatments are more effective than placebo, that the evidence of clinical trials is positive.
However, they have suggested to undertake further high quality studies to confirm these results. While many high quality trials with proven efficacy of homoeopathy have been done, Ben Goldacre has cherry-picked five only to suit his own conclusions.

ii. Goldacre has rightly cited that during the Cholera epidemic in the 19th century, death rate at London Homoeopathic Hospital was three times lower than those at Middlesex hospital. While admitting that the then contemporary treatments were harmful, he is not ready to accept the credibility of London Homoeopathic Hospital, where the mortality rate was three times less than an allopathic hospital. On the other hand, he jokes, “the homoeopathic treatments were at least inert”. How could the inert homoeopathic medicines result in 3 times less mortality than the conventional medicine?

iii. The homoeopathic doctor knows that the medicine he is administering to his patient is surely more effective than placebo. As such, the question of violating the informed consent and autonomy of the patient, as stated by Goldacre, does not arise.
iv. Goldacre’s comment that “ a routine feature of homoeopathy marketing practice is to denigrate mainstream medicine” is quite malicious and aims at widening the rift between the Allopathy and Homoeopathy practitioners. Most of the qualified homoeopathic doctors usually do not criticise the Allopathic treatment, nor do they advocate against the established prophylactic programmes, as alleged by the commentator. Rather, most of the Indian qualified homoeopathic doctors advise the patients to follow the immunization programmes which are universally accepted. They also do not undermine public health campaign, do not leave their patients exposed to fatal diseases, nor disregard fatal diagnoses, as commented. To the chronic patients who have been under Allopathy treatment for a long time, whenever switch over to homoeopathy for the reasons best known to them, the conscientious and qualified homoeopathic doctors usually do not advise to stop the previous treatment abruptly, particularly in conditions like Diabetes Mellitus, Bronchial Asthma, Epilepsy, High BP, mental illnesses etc. Rather they advise to continue the previous therapy along with the homoeopathic treatment, for certain period. On the basis of further response, the patient is advised either to continue the previous one as such or in tapering doses or to stop. Goldacre should remember that, there are negligent, incompetent and irresponsible doctors in every medical stream. If a surgeon leaves an instrument inside the chest or abdomen, after completing the operation, should we undermine Surgery or Allopathy? For the fault of a few homoeopathic doctors, the entire system should not be crucified.

v. Ben Goldacre has opined that publication bias in alternative therapy journals is high. But he has referred to an article7 where the authors have observed that the publication bias in alternative medicine has come down in 2000 when compared to 1995. The commentator’s criticism of ‘lack of a culture of critical self-appraisal in alternative medicine’ is quite unfortunate and far from reality.

vi. Goldacre has referred to the article6 published in the Lancet (2005, vol-366) which denigrated homoeopathy as placebo response. In the said article, the authors have analysed 110 homoeopathy trials and 110 matched conventional medicine trials. Table-2 of the article shows that they have screened 21 (19%) Homoeopathy trials and 9 (8%)Allopathy trials as the high quality trials (double blind, with adequate generation of allocation sequence and adequate concealment of allocation). In reality, they have framed their opinion by analyzing the outcomes of 08 homoeopathic trials and 06 conventional medicine trials, on the plea of considering large trials of higher quality. Instead of identifying 12 more allopathy trials of high quality to match 21 homoeopathic trials, it is not known, why they have come down to the unmatching ratio of 8:6. Did the authors fail to procure the additional high quality Allopathy trials to match the homoeopathic numbers?

vii. Homoeopaths never routinely respond to negative meta-analyses by cherry-picking
positive studies, as alleged by the author. But, if the meta-analysis is designed to serve the malicious intention of the votaries of a particular system to belittle others and is not based on actual facts and truth, then the best option is to ignore it.
It is established beyond doubt that randomized placebo control trial (RCT) is not a fitting
research tool to test homoeopathy, where the medicine is tailored to each individual
patient, but not to the medical diagnosis. Besides considering the complaints of each
patient and their variation at different times and under varying circumstances, his/her
physical attributes and mental state are also taken into account to choose the most
appropriate medicine. It is therefore, difficult to conduct double blind placebo control
trials with homoeopathic medicines. Masking the therapeutic intervention from the
therapists can not be conceived for in-vivo trials in homoeopathy and if done, results in
inappropriate conclusions in outcome assessments. But the authors of the most of the
meta-analyses whose results went against Homoeopathy, have wrongly come to
conclusion by advocating that homoeopathy trials were of poor/low quality, on the
pretext that those did not follow the tenets of RCT. Is it not irrational to judge a therapy by the bench mark which is not appropriate to that system, and compare two medical streams which are based on quite distinct and different doctrines and philosophies?

viii. The homoeopaths do not promote the only observational study8, as cited by Goldacre.There are a large number of human9-13 clinical trials, in vitro and in vivo studies on animal14-22 and plant23-27 models, which have been published in the internationally reputed journals and have been authored by the scientists of other disciplines. How could the diseased plants and animals respond favourably to homoeopathic treatment, had it been a placebo response!

ix. It is derogatory on the part of the Goldacre to comment that “Homoeopaths can
misrepresent scientific evidence freely to an unsuspecting and scientifically illiterate public”. The people have been attracted towards homoeopathy, not by the advertisements made by a few homoeopaths, but by its effectiveness, absence of side effects, simple way of application of medicines and cost-effectiveness. The author’s criticism of “society’s eagerness to endorse the healing claims of homoeopaths” has no base since the society is bound to acknowledge the people’s satisfaction obtained through homoeopathic treatment. The Govt.’s recognition of homoeopathy, particularly in India, is based on the demand of the people owing to the success of homoeopathy in addressing the health problems of the people, but certainly not due to the healing claims of homoeopaths. Rather, the Govt. of India has enacted ‘Drugs and Magic Remedies (Objectionable Advertisements)’ Act, 1995 which prevents the practitioners from making unethical claims.

x. Goldacre’s observation that “homoeopaths have worked themselves off from academic
medicine and critique has been all too often met with avoidance rather than argument”
might be his own experience in his own country, but certainly does not hold good for all places, particularly for India. The reputed institutions and research scholars have their own portals and people can easily access to their academic and research activities. If his comment that “placebo could have a clinical role” is true, then the effect of medicine of any system could be told as placebo effect? Why is Homoeopathy alone targeted?

Homoeopathy has thrived on the basis of patients’ benefit and public acceptance due to its efficacy. It will never perish by the heinous propaganda of a few critics having bias and jaundiced views against Homoeopathy.

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