Discouraging News from the Review of Allergy and Intolerance: Homeopathy Means We Need to Rewrite Textbooks

When people want you to consider rewriting "textbooks in physics, pharmacology and chemistry", you hope that they have good evidence behind it and some workable hypotheses with which to replace these erroneous and out-moded doctrines that have maintained a stranglehold in scientific and medical education. Sadly, it doesn't seem as if either the evidence or workable replacement mechanisms of action will be available any time soon so 'we mun dree oor wyrd' and hope for a paradigm shift to happen before error leads us into catastrophe.

The House of Lords has appointed a committee to investigate allergy and intolerance in the UK. The Committee is investigating some important issues with implications for public health and public policy so I was hopeful that the written submissions and oral hearings would involve robust explorations of the science and associated issues.

Unsurprisingly, most of the experts and bodies that submitted evidence concentrated on their own niche of expertise and mentioned technologies, techniques, treatments or dubious techniques with which they disagreed in passing rather than reviewing them. Both The Society of Homeopaths (pdf) and the Faculty of Homeopathy (pdf). offered written evidence.

[T]he Society [of Homeopaths] calls on the Government to send a stronger signal to primary care organisations that homeopathy has an excellent evidence-base in [allergy and allergic diseases] and to give them permission to refer patients to registered homeopaths (RSHom) for treatment.

I was interested to read about the "excellent evidence-base" but the submission only contained references to a handful of studies and did not mention any of the meta-analyses that found no benefit for homeopathy. According to The Society of Homeopaths:

Homeopaths believe the incidence of allergy and allergic diseases is rising owing to a lower immune function in more individuals. This is probably brought about by a variety of factors that could be considered 'triggers', toxins in the environment; diets poor in unrefined foodstuffs and rich in additives; and possibly the over-vaccination of very young children before inherent immunity has developed.

Unfortunately, although it sounds science-y and related to medicine, the document does not expand on what is meant by a "lower immune function", "toxins in the environment", what sort of food additives they are complaining about, or "the over-vaccination of very young children". The complaint about vaccination stands in contrast to Dr. Peter Fisher's claim that 'respectable' homeopaths support vaccination. There are no figures or references to substantiate the claims that:

[i]n addition to being a safe, effective, and cheap method of treatment, homeopathy helps patients and their carers to feel more involved in their progress to health.

Similarly, although The Society refers to financial benefits to using homeopathic treatment and alludes to case-studies and pilot projects, there are no references.

The Faculty of Homeopathy (pdf) written report does explain that homeopaths have 3 different approaches to treating allergies and allergic disease.

In homepathy there are a number of therapeutic strategies for the treatment of allergic disorders. These are commonly termed "local", "constitutional" or "miasmatic" strategies. Local prescribing is a strategy based on the patient's actual allergic symptoms. The advantage of this strategy is that it can be achieved in a standard GP appointment or even through self-prescribing. Constitutional prescribing is based on a more in-depth consultation which takes into consideration the patient's allergic symptoms and, additionally, their unique patterns of coping with any disease. Miasmatic prescribing is based on an elaboration of the patterns of allergic disease which can be seen to run certin whole families. This approach can be particularly appropriate in complex allergic conditions...Isopathy is similar to homeopathy but the main difference is that the treatment is selected solely on the basis of the patient's proven allergies (as shown, for example, by skin testing). It involves giving a patient a substance to which they are allergic in a homeopathic potency, usually orally, for a short course of a few days in order to reduce the allergic response.

The Faculty of Homeopathy refers to the treatment that is available in the Homeopathic Hospitals within the NHS.

Patients often find it easier to accept advice about allergy from the homeopathic hospital, which can steer them away from the more extreme (and expensive) fringes of untested alternative treatments. This can be of particular benefit with food sensitivities and allergies or multiple sensitivities.

However, it seems as if the Royal London Homeopathic Hospital (RLHH) blends a number of techniques and modalities in its approach to allergies and allergic diseases which must make it difficult to attribute success to various interventions.

Classical allergic diseases are managed with avoidance advice, conventional treatment where appropriate, dietary advice, homeopathic medication, Western Herbal Medicine, and also (uniquely in the NHS) with a form of desensitisation treatment called enzyme-potentiated desensitisation (EPD). The clinic is also one of the very few centres able to effectively manage patients with 'food intolerance' in all its manifestations.

Infuriatingly, there are no references or follow-up information for any of these claims about the work of the hospitals. However, the RLHH does declare itself

fortunate to have a dietician who is expert in food allergy and intolerance, a rarity in such services. This enables patients to be treated who have adopted an unnecessarily restricted diet on the basis of spurious 'food allergy tests' available on the high street, gradually broadening such diets, offering authoritative advice, checking nutritional status and advising on supplements.

The Faculty of Homeopathy does provide an overview of their claim for an "evidence base for homeopathy in the treatment and management of allergic conditions" although I can not comment on the literature because I haven't seen it yet.

I have read a number of explorations of homeopathy, including Oliver Wendell Holmes' Homeopathy and Its Kindred Delusions and a further exploration of what the practice of homeopathic dilution of remedies means in reality.

Take a grain of rice. Cut it in half. Cut it in half again. That is the amount of your original solution.

Now, take the distance from where you live to the south pole. Now think about the distance around the earth. Now think about the distance from the earth to the sun. Ok, now think about the distance from the sun to Pluto. Pretty big, huh? Ok, now think about the distance from here to the nearest star. It takes light 4.3 years (light that came from our sun when Bush was re-elected will reach that star 4 months after he leaves office) to reach that star, Proxima Centauri.

Got that? Ok now imagine a cube with each side the length of that distance. I am going to hide that crumb of rice in that cube. Try to find it...

So, I was looking forward to a rigorous examination of some of the claims of homeopathy by some of the committee members during oral evidence 21 February 2007 (unapproved, draft transcript of testimony). The session started off in quite a lively manner when the homeopath, and representative for The Society of Homeopaths, Kate Chatfield said:

In homeopathy, as far as I am aware, we do not have any significant evidence for the treatment of asthma but we do with allergic rhinitis, with hay fever and a lot of clinical evidence...evidence suggests that homeopathy could be of great benefit in eczema as well

Prof. Ernst (Director, Complementary Medicine, Peninsula Medical School) then refers to his book which summarises many complementary therapies and the trials in which they have been evaluated and declares:

For no treatment modality is there good evidence that it is clinically effective in asthma, isotopic eczema or hay fever.

Later, committee member Lord Taverne asked Ms Chatfield to explain the difference between homeopathy and isopathy and asked her to compare them with "conventional treatments in efficacy and cost". Despite the assertions about the comparative costs in the written evidence, Ms Chatfield says that she doesn't have enough information to speak about the comparative costs. Ms Chatfield presents her explanation about homeopathy and isopathy and then, rather charmingly, adds:

I think homeopaths would consider homeopathy more effective than isopathy but I do not think we have any evidence to show that.

She is a lecturer in homeopathy, a research ethics adviser and representative for The Society of Homeopaths but is unable to make a simple declaration on the matter. This is the more remarkable because she later responds to Lord Taverne's enquiry about the meta-analysis of 110 homeopathy trials that reported "no evidence whatsoever that homeopathy performed better than placebos" with the criticism that it was 8 trials, not 110 because the authors excluded most studies on the grounds of insufficient quality:

What they did was single out what they called the high quality homeopathy trials and narrowed them down to ten trials of homeopathy which were not homeopathy when you looked at them. They were isopathy, not homeopathy. It was unbelievable that they could draw that conclusion from eight trials of isopathy.

Although, from her own words, there is no evidence to show that homeopathy is more effective than isopathy. Ms Chatfield's later attempt to clarify the matter does not help me although it may be more meaningful to others:

The major problem with meta-analyses and homeopathy is that they incorporate lots of different kinds of prescribing and it would be prescribing for the whole person, prescribing for the disease, using isopathy, comparing them all, lumping them all in together as if they are one thing when they are not.

I am assuming that Ms Chatfield will have an opportunity to clarify what she mean in follow-up submissions because I am flummoxed at this point. Lord Taverne initiated one of the most entertaining exchanges in the session.

Lord Taverne: In a recent debate in the House of Lords the president of the Royal Society said that if medicines can really work even if only a single molecule is left this would entail some entirely new scientific principle with amazingly broad ramifications and fundamental implications for experiment over the whole of science. Could you explain how the mechanism is supposed to work that achieves these astonishing results?

Ms Chatfield: I think you know very well that I will not be able to because we
have not discovered that yet. I am of the opinion-and I think a lot of homeopaths are who were initially sceptical when they came in and, for a number of reasons, are convinced by the evidence-that science is not a static thing. It changes all the time and just because we do not have an explanation currently we do have a lot of people proposing different theories about how it may work. Just because we can not explain it now does not mean it does not work. Yes, it will mean that science is revolutionised and I do not see that as a bad thing.

Prof. Ernst: There is a fundamental difference in saying we have not discovered the mechanism yet. 50 years ago, we did not know exactly how Aspirin worked but we always knew that there would be a mechanism there because it is pharmacology. With homeopathy, this is fundamentally different. Science tells us there is no mechanism by which it can work and that is an important difference. If we find the mechanism, then we have to rewrite our textbooks of physics, pharmacology and chemistry.

Prof. Brostoff: I do not think there is a problem with rewriting any textbook if new facts arise...

There are several dispiriting exchanges in the session as it seems that both VEGA testing and kinesiology are being treated with more credulity than their mechanism of action or plausibility would merit. However, the low-point is possibly when Lord Colwyn seems to disregard much of what has been said previously and mis-summarises that and tops it off with a personal anecdote:

I am sure the panel would agree that, despite the criticism, there is no doubt that these techniques-we can go back to kinesiology and Vega testing and also homeopathy-have succeses. I have referred patients to a kinesiologist for 30 years and I do not think he has ever got one wrong.

Exercising the level of diplomacy that is expected when responding to the latest outburst of an embarrassing relative during a fraught family gathering, Prof. Corrigan responded:

I am afraid that is the sort of anecdotal report we have to be very careful of. Such observations mean nothing outside a properly controlled trial. Anybody can convince themselves they have benefited, particularly the person who recommended them, but I am afraid that does not constitute scientific evidence.

Prof. Corrigan's patience is being tried very high during the later exchange on appropriate standards of proof which enable medications to be licensed for use or prescription within the UK. For various reasons, homeopathic and herbal medicines were licensed last year and can be prescribed on the NHS; however, allergen immunotherapy is not licensed.

Prof. Corrigan: I am afraid this is appalling nonsense. We have been campaigning as allergists to get allergen immunotherapy licensed by the MHRA for years. This is a very scientifically validated treatment which is of great benefit to thousands of sufferers with hay fever and still the MHRA turned us down because some patients have reactions to the injections. It is very frustrating that they then condone the use of these untried, uncharacterised and untested concoctions on the basis of no evidence at all. It is completely impossible to understand and very frustrating for the practise of a proper, scientifically conducted allergy.

With an unerring lack of clarity, Ms Chatfield responds:

Of course, I do not think it should be taken in isolation as a form of evidence but it is still a kind of evidence. I think the Chinese would be horrified by what you have just said, that because their medicine has not been scientifically proven it should not be used.

Prof. Ernst supports Prof. Corrigan in his use of the nonsense word:

It is a nonsense and it is very regrettable because it sets a double standard for the first time in medicine regulation...We are freezing our knowledge of potentially beneficial herbal treatments if we do not ask for proof of efficacy.

Later, when asked if there is any advantage to be gained by enforcing regulation of the practitioners of complemetary and alternative therapies, Prof. Ernst expanded upon his opinion that there is little to be gained from it:

if you regulate traditional herbalists and there is no shred of positive evidence for their individualised approach, you regulate in my view nonsense and that will result in nonsense.

Lord Taverne tried to take the temperature of the panel of experts as to whether it would be useful to issue guidance about alternative therapies to the public. Prof. Brostoff responded in a manner that may have sounded more germane, responsive or humorous in the session than it reads in the transcript:

It might be interesting to issue a health warning against going into hospital these days. If you take malpractice, if you take 10 per cent of hospital admissions being due to drug reactions plus MRSA, plus clostridium dificil, that would be more appropriate at the moment and it is also a much larger problem.

Prof. Ernst summarises the matter in a typically robust and clear fashion:

From my perspective, guidance against complementary, alternative therapies is nonsensical. Guidance against unproven or disproven treatments, yes. Many treatments in complementary medicine are unproven or disproven, but not all. Some have very good evidence, not in the area of allergy, I am afraid...It is not about a label, complementary versus mainstream; it is about proof of efficacy and safety.

Given the lack of support for homeopathy and other CAM modalities in the diagnosis and management of allergies and allergic diseases, and the heavy use of the nonsense word by Profs Corrigan and Ernst, I have to assume that the Earl of Selborne was asking a faux naif question:

There are currently five NHS homeopathic hospitals which offer homeopathic and other complementary treatments such as acupuncture. Should we have more on the National Health Service and should the range of treatments alongside conventional treatments be extended to such therapies as Vega testing and kinesiology on the National Health Service?

Prof. Corrigan responds admirably:

I could not condone expansion of homeopathic hospitals or any other alternative therapy to the deteriment of setting up a well accessible, conventional allergy service within the NHS.

I am, again, indebted to Ms Chatfield for some light relief when she has an exchange with Lord Broers.

Lord Broers: I have a simple, technical question about homeopathy and drugs. Is it possible to distinguish between homeopathic drugs after they have been diluted? Is there any means of distinguishing one from the other?

Ms Chatfield: Only by the label.

This exchange went some way to mitigating the depression caused by Prof. Brostoff's contribution to the discussion about whether the "present expenditure on [the] five homeopathic hospitals is justified or can be justified":

If you take general surgery or most surgical operations, probably 90 per cent have not been put to a true double blind clinical study and we are using empirical methods which sometimes work better than others. If homeopathy is satisfactory to the patient and adds something to their quality of life and keeps them away from the NHS, I would support it fully.

It is distressing that a supporter of homeopathy can only produce negative rather than positive evidence to support it but a little odd that he has not noticed that the question was about NHS support for homeopathy.

Neither the written nor oral evidence has made the case for homeopathy in the treatment of allergy or allergic diseases: despite the assertions, there is no evidence that it is cheaper than conventional treatments. I am unconvinced of the need to pulp the current range of textbooks for physics, pharmacology or chemistry, and don't consider it necessary to include footnotes or caveats in current editions.

Flickr artist Tom Morris offers a skit of Prince Charles talking about complementary and alternative medicine.