Oct 29 2007

My Day with the Homeopaths – Part II

As I discussed on Friday, last week I was part of a panel discussion on homeopathy hosted by UCONN. It was an interesting experience, as I knew it would be. In part I of my report from the conference I talked about the plausibility arguments against homeopathy and Dr. Rustom Roy’s unconvincing response. Today I will complete my report, discussing the clinical evidence.

Donald Marcus from Baylor did an excellent job of presenting a review of the clinical evidence for homeopathy, accurately conveying that the evidence is largely negative. Iris Bell, a protege of Andrew Weil from the University of Arizona, had the job of distorting and cherry picking the clinical evidence to make is seem as if it supports homeopathy. Her strategy was typical, standard fare for CAM proponents.

First, she argued that we should accept clinical observations as reliable evidence. These are open-label or uncontrolled case reports, essentially the clinical experience of homeopaths. This is all a fancy way of saying anecdotal evidence, which over a century of scientific medicine has taught us is completely unreliable. I think anecdotes are worse than unreliable – they tend to lead us to conclusions we wish to be true rather than those that are true, and they can cause a false sense of confidence in the unwary.

It is not a surprise that homeopaths think their treatments work. As unreliable as anecdotal experience is, it is especially so if it confirms the beliefs of an ideological group desperate for recognition and legitimacy, and further a group dedicated to one treatment modality. (I don’t trust the experience of cardiac surgeons with cardiac surgery.) And to put one more nail in this coffin, I especially don’t trust the subjective experience of a group of practitioners that decidedly lack a scientific tradition.

Only data that is controlled sufficiently to minimize the effects of bias should be even considered, and certainly should trump any uncontrolled observations. Here Dr. Bell had to admit that the results of double-blind studies in homeopathy are mixed and are insufficient to demonstrate that homeopathy works for any specific indication. Even this soft condemnation is too generous, however. If one looks at the entirety of homeopathy clinical literature, we see a clear pattern that the better the study the smaller the effect, and the best studies tend to be negative. This is the pattern of pure noise with no signal – in other words, homeopathy does not work.

Dr. Bell tries to rescue homeopathy from this negative data in two primary ways. The first is to falsely present negative data as if it were positive. She does this using the Texas sharpshooter fallacy – shooting the side of a barn at random then drawing a bull’s-eye around the bullet holes. In research, this translates to looking for anomalies in the noise of the data and then claiming after the fact that it is significant. Dr. Bell presents a study with homeopathic dust mites (slide 93 in the presentation), which was negative in that there was no significant difference in the clinical outcomes. However, the outcomes for the treatment arm showed more oscillations than the placebo arm – again, even though the total outcome showed no difference. Dr. Bell concludes, using post-hoc reasoning, that this indicates biological activity in the homeopathic treatment. Voila – a negative study shows biological activity.

The second strategy was to claim that the randomized controlled trials were not adequate, primarily because they did not allow the homeopathic treatment to be individualized to the subjects. Homeopathic treatment treats the whole person, not a disease or symptom, and without individualization the study is not a test of true homeopathic treatment. This is, of course, hogwash. If there is any biological activity in homeopathic treatment, that would produce an effect that can be measured. Further, the principle of “like cures like” contradicts this whole-person defense. An extreme dilution of a substance should treat the symptoms it causes in higher dose, according to homeopathic philosophy. If this has any truth, we should be seeing some signal in the studies done so far, but we aren’t.

These objections are similar to the ones we hear from CAM in general, such as acupuncture. Current studies are never good enough (once they are negative). Positive studies are still touted, despite the same limitations.

What is likely to happen is what is happening with acupuncture studies – the complaints of the advocates will be catered to in future studies. If these studies are well designed and executed, I predict they will be negative, and then homeopaths will find some excuse to dismiss them (while cherry picking and touting any that happen to be positive, regardless of their weaknesses).

All of this amounts to advocating allowing lower quality evidence that supports homeopathy while rejecting negative evidence as not being high quality enough. Simultaneously, I might add (especially during the Q&A) criticizing the standards of evidence in mainstream scientific medicine. It seems that homeopaths would like to apply whatever standard they wish ad hoc.

Far worse than Dr. Bell was Andre Saine N.D. from the Canadian Academy for Homeopathy. He presented the epidemiological evidence for homeopathy, which amounted to 150-year-old unverified anecdotes. He presented the reports of homeopaths from the mid-1800s claiming they cured cholera, pneumonia, and rabies as if it were reliable evidence. Dr. Saine would have us believe that we can verify such a cold trail of highly dubious self-serving reports. Again we see a desperate plea to lower the bar for scientific evidence so as to admit homeopathy.

D r. Saine’s presentation degenerated into a sales pitch for homeopathy that would make any sideshow barker proud. He assured us that homeopathy is more effective than standard medicine and can cure just about anything, magically free from any side effects. He even claims that homeopathy can cure rabies with 100% success. Rabies is almost 100% fatal, even with modern treatment, so this is quite an astounding claim. An audience member helpfully suggested that we can test this claim on animals that contract rabies, since they are just put to death in any case. I pointed out that if Dr. Saine’s claims are even remotely true it is amazing that such a simple study has not been done in the last two centuries, that we have been sitting on a cure for such a deadly disease all this time and yet homeopaths have never been able to silence critics with a controlled experiments. I also pointed out that homeopathically treating “rabies,” a disease, contradicts Dr. Bell’s “holistic” defense, but that’s a separate point.

I humbly suggested that we have not seen such a study – that would dramatically silence any skepticism about homeopathy – because homeopathy does not work, and Dr. Saine’s century and a half old anecdotes are perhaps not reliable. This prompted the audience member to ask me if such a study were done and cure rabies would I be converted to a believer in homeopathy. I responded in the affirmative, with the appropriate caveats about study design and transparency, but also turned the question around. If such a study is negative would the audience member then doubt the effectiveness of homeopathy.

I found it ironic that she felt she should ask me that question, definitely implying (and the audience generally agreed) that it is the proponents of scientific medicine who are closed-minded. Yet we are the ones who are constantly in a state of reevaluating our claims and treatments based upon new evidence, and actually change our practice. Homeopaths are clinging to a 200-year-old disproven system of medicine and refuse to change in the face of new evidence. But she did not feel it necessary to challenge the homeopaths with such a question, as I did.

I also pointed out that despite hundreds of millions of dollars spent by NCCAM on alternative modalities, despite numerous studies, there has yet to be a single alternative modality that is rejected by its proponents. Until one single CAM modality is rejected based upon evidence of lack of efficacy, they collectively have no claim to being scientific or evidence-based. All CAM research is a sham and a waste until this happens.

The audience was hopeful – hopeful for the promise of homeopathy, for collaboration with skeptical scientists, with ultimate vindication. They beamed with the hope that UFO enthusiasts had 40 years ago that proof was just around the corner (and each new generation finds and loses for themselves). They made all the arguments of the ESP researchers who want to prematurely declare their discipline legitimate, and who blame all the negativity on the closed-mindedness of skeptics.

It was very hard for me not to show the “been there, done that” reaction that I had sitting in that room, hearing all the tired excuses and logical fallacies over again. But I think I pulled it off. Even the dedicated homeopaths, by the end, seemed to at least think that I was an exception (and they said so every time I displayed a trait they thought absent in their ideological enemies). They clearly entered the forum thinking that homeopathy skeptics were closed-minded, dismissive, and practitioners of corporate, drug shilling medicine. What they met were a couple of academic physicians just trying to honestly defend the scientific standards of medicine. We weren’t the bogey men they imagined, so we must (in their minds) be exceptions to the rule.

While I don’t think I changed any minds on homeopathy (and the poll that was conducted on the live webcast indicates this; it was 90% pro-homeopathy before and after the conference) it was an interesting window into the current claims of its proponents. It also clearly showed the depth of the problem. The hardcore believers are buried beneath an increasingly sophisticated mound of nonsense. The “water memory” data were little more than a smoke screen behind which homeopaths can hide. The clinical data are negative, but clinical data are also complex enough to be easily twisted to the desires of ideologues.

I have as little hope that proponents will abandon homeopathy as creationists will accept evolution. The purpose of skeptical attention, however, is to be a watchdog on such anti-scientific or pseudoscientific ideologues, to keep them on the margins and to make sure that their false claims do not go unanswered.

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34 responses so far

34 Responses to “My Day with the Homeopaths – Part II”

  1. Nitpickingon 29 Oct 2007 at 8:34 am

    Thanks, Doctor.

    One point (I am, after all, nitpicking.com): you mean “fare” up in paragraph two of this essay. It certainly wasn’t “fair”.

    Was the woo-iest homeopath really named a homonym of “sane”? Was the event held in the Irony Auditorium?

  2. tvmodeon 29 Oct 2007 at 3:05 pm

    Steven,
    Great post. I have been dealing with homeopathy for years, both in my personal and scientific life. Even though you may not have convinced anyone at the conference, you may have introduced them to scientific thought and reasoning for the first time. Most homeopaths have little scientific background and are especially weak in spotting flaws in experimental design. Every little bit helps!

  3. Richardon 30 Oct 2007 at 1:00 am

    As a proponent of homeopathy, I would like to thank you for participating in this debate, Dr. Novella.

    I hope we agree on the importance of having the sharpest possible clash of ideas in the ongoing debate about homeopathy. In that spirit, I feel you will strengthen your position by speaking more clearly to the actual claims of the homeopaths, even if they don’t make sense to you.

    In particular, you don’t seem to understand the theory behind the homeopath’s search for a pattern of symptoms, as shown both in the debate, and in your statement above:

    “The second strategy was to claim that the randomized controlled trials were not adequate, primarily because they did not allow the homeopathic treatment to be individualized to the subjects. Homeopathic treatment treats the whole person, not a disease or symptom, and without individualization the study is not a test of true homeopathic treatment. This is, of course, hogwash. If there is any biological activity in homeopathic treatment, that would produce an effect that can be measured.”

    The whole point here is that homeopaths feel that the biological activity of a homeopathic treatment is only triggered under a specific set of conditions. You can belittle the claim, but you can only disprove it by testing it!

    Testing the remedies without reproducing the conditions specified in homeopathic theory may allow you to refute something, but not classical homeopathy.

  4. ellazimmon 30 Oct 2007 at 2:40 am

    Perhaps one day when one of the true believers in the audience is dealing with a serious illness of their own or a loved one they will remember what you said and “play it safe” and go with evidence based modalities. I have my suspicions that when the poo hits the fan many homeopathy fans jettison the woo.

    And, as usual, we should be asking why do they choose to believe. They don’t question or doubt the science behind their car or their television or an airplane or nuclear power or (insert nearly endless list here) even though many of those things are close to magic for the average person. Why doubt medicine? We need to address that issue first.

  5. Steven Novellaon 30 Oct 2007 at 9:11 am

    Richard,

    I did not misrepresent or fail to understand homeopathic theory. My point is that homeopathic theory makes no sense and is not even internally consistent. There is no basis for the notion that like cures like. I understand that what homeopaths say is, essentially, that like cure like, but only under certain conditions. This makes even less sense (if that’s possible). The “conditions” they talk about are superficial biological and personality traits. Further, there is no plausible theory for how these traits “trigger” the action of “like cures like” or what the biological basis of the “reaction” to the homeopathic treatment is.

    The bottom line is that homeopathy is a tangle of magical thinking, every element of which lacks a theoretical or empirical basis.

  6. JoHon 30 Oct 2007 at 11:28 am

    Steve, excellent pair of articles again. Once more to-the-point, comprehensive, comprehensible and totally convincing.

    You should REALLY write a book. A while ago you replied seemingly affirmative to someone who suggested this. Was this semi-joking or was it serious?

    The world deserves a book from you, and when you publish one I will personally deliver them to all public libraries within 100km of my town, lol.

    JoH

  7. gimpyon 30 Oct 2007 at 1:56 pm

    As well as rational discourse there is another route you can take to keep homeopathy on the sidelines of civilisation. Organisations set up by homeopaths to regulate homeopaths often breach their own code of ethics and indulge in deceitful and threatening practices. If you draw attention to the unethical conduct and idiocies of these practitioners then you can discredit them in ways understood by people who have no interest in science or medicine.

  8. Richardon 30 Oct 2007 at 2:30 pm

    Hi Steve,

    I can understand if you need a quiet place to “let your hair down.” So if this is either a bad place or an inappropriate time to continue this conversation, please let me know. But in the hopes that you can spare another few moments, I would like to mention a couple of things.

    Alternative medicine is achieving ever greater levels of acceptance among the public. By all indications, this growth is concentrated among people with higher levels of income and education. While it may not sway you personally, these people are often convinced to try alternative medicine based on successful treatments of people they know. In that context, Dr. Bell and Dr. Roy have attempted to come up with claims for homeopathy that are clear-cut and falsifiable.

    If you want to win over the intelligent consumer, you will have to speak clearly and directly to the claims of those who, like Drs. Roy and Bell, are attempting to validate homeopathy on a scientific basis. Otherwise, you have effectively ceded the field.

    It seems to me that it serves neither your own position nor the interests of science and scientific inquiry to do anything less but meet your opponents head on. I hope you will continue to do so.

    But in any case, I am very glad that you took the time to participate in the debate last week.

    Richard

  9. Schnackyon 30 Oct 2007 at 6:23 pm

    Dr. Novella,

    Thanks for another excellent post.

    I have a question regarding your statement, “This is all a fancy way of saying anecdotal evidence, which over a century of scientific medicine has taught us is completely unreliable.”

    Do you know of any resource on the web that gives examples from the history of medicine where anecdotal evidence supported a treatment, but careful research showed the treatment to be ineffective or even harmful? When discussing the unreliability of anecdotal evidence with woo-believing friends, it would be handy to be able to give a few good examples.

    Thanks,

    Robert

  10. daedalus2uon 31 Oct 2007 at 10:27 am

    Robert,

    One example that comes immediately to mind is the lobotomy, for which the developers won the Nobel Prize.

  11. Schnackyon 31 Oct 2007 at 12:34 pm

    Daedalus2u,

    Great example! Thanks,

    Robert

  12. happy humaniston 31 Oct 2007 at 5:03 pm

    Richard on 30 Oct 2007 at 2:30 pm:
    “Alternative medicine is achieving ever greater levels of acceptance among the public. By all indications, this growth is concentrated among people with higher levels of income and education. While it may not sway you personally, these people are often convinced to try alternative medicine based on successful treatments of people they know.”

    And desperation. When people have disposable income and an ache that doctors can’t fully treat, they seek out alternatives. The media has done a poor job of explaining that no alternative has been proven to do what it claims. The media is caught up in a “he-said-she-said” style of reporting, not in analyzing the merits of each claim. Woe the lack of good science reporters!

    Just because “alternative medicine is achieving ever greater levels of acceptance among the public”, doesn’t mean it works. I have a hunch that people try acupuncture or homeopathy or whatever for a while. When it doesn’t work, they stop using it. I would love to see the records of a homeopaths to see the pattern of attendance of his/her “patients.” I’d wager that more than half come for a while and stop. If I called them, they would admit that it didn’t work, or didn’t work as they hoped.

  13. Giladon 01 Nov 2007 at 3:21 am

    It seems that what concerns supporters of homeopathic medicine is that the treatment isn’t administered “correctly”. Unlike some other cases (such as surgery), we can actually have a double blind experiment that includes a practitioner giving homeopathic treatment in the traditional style. A sketch of the experiment follows:

    Recruit some certified homeopaths to treat people during the experiment. Every day for some period of time (depending on required confidence, budget, etc.) give each homeopath a “kit” containing all the required homeopathic preparations. 50% of the times the kit must contain the real preparations, in the other 50% it should contain distilled water (in each bottle). Now let the homeopaths do their job, and finally, ask the patients (you could just offer a “free homeopathic clinic”) to rate the improvement in their condition. If patients usually require more than one visit (I don’t know what standard practices are), match the “kit” to the patient and not the homeopath/day. Finally, if homeopathic medicine has an effect under these “natural” conditions, we can expect to find significantly more improvement in those patients treated with homeopathic preparations than in those treated with distilled water.

    My guess is that many patients will report an improvement, but no more in one group than in the other.

  14. superdaveon 01 Nov 2007 at 8:29 am

    I have a question for the homeopaths. How is it possible to have zero side effects? If you understand anything about how side effects work, you would understand that any drug with a degree of potency will virtually always have side effects. It is impossible* to cause a biological effect in a system that targets only what you want, because there are no parts of the body with entirely unique conditions. admitting there are no side effects is tantamount to admitting there are no main effects.

    *maybe one day advanced dielivery systems will allow this, but it is highly unlikley for anything orally administered

  15. daedalus2uon 01 Nov 2007 at 9:48 am

    Sole reliance on anecdotes as evidence of therapeutic benefit is inappropriate, particularly when there is no back-up theoretical mechanism that corresponds to physical reality as we understand it (as in homeopathy). Many times an anecdote is the first evidence of therapeutic effect and (with actual research, mechanistic understanding and clinical trials) actually leads to new therapies. Examples include lithium for bipolar disorder, a therapeutic benefit was first noticed in a patient using a salt-substitute that contained lithium. Tricyclic antidepressants were discovered from effects of antihistamines on people with depression. In some these, the detailed mechanism is still not understood. But the researchers involved maintained the intellectual honesty to admit the limits of their knowledge and not make up magical explanations and then generalize those magical explanations to develop other “treatments”, such as “like cures like”.

    No doubt the pharmacological properties of biological products, tobacco, opium, coffee, various roots and leaves were first “discovered” anecdotally. Some, such as opium, are pretty obvious, and even a very casual clinical trial will show effects. Some are no doubt mediated via the placebo effect and the difficulty of acquisition plays a large role, as in the erectile dysfunction therapeutic effects attributed to tiger penis and rhino horn (another application of “like cures like”). The marketing success of which depends more on the affluence of the gullible rather than on any demonstrable degree of efficacy beyond that of a placebo.

  16. daedalus2uon 03 Nov 2007 at 11:48 am

    Interesting that Richard has not responded to any of my questions or the other questions about homeopathy. I can only presume that either he doesn’t know the answer and doesn’t want to admit it, or does know the answer and doesn’t want to tell us because it puts homeopathy in a bad light.

    So much for “[agreeing] on the importance of having the sharpest possible clash of ideas in the ongoing debate about homeopathy”.

  17. Richardon 04 Nov 2007 at 4:45 pm

    @deadalus2u:

    Sorry for not getting back to you, but I don’t actually frequent this blog. I had a point to make to Dr. Novella, waited for a couple of days without hearing a response, and stopped checking.

    I’m only here now to email the link to someone. But since I am here, I’ll mention that your question about disposal of homeopathic remedies is an interesting one, and I would love to know the answer.

    Unfortunately, I’m not a homeopath or a medical researcher, so my guess would be just that. My own professional interest is primarily in the role of anomaly on scientific development and the effect on standards of proof when anomaly is involved in scientific controversy.

    If you want to discuss those kinds of questions, I would be happy to give you my own views on them, if I get the chance to stop by here again. In the meantime, I do hope those who are involved on both sides of the debate will make ever greater efforts to respond with rigor to the arguments of their opponents.

  18. kilroyon 04 Nov 2007 at 6:09 pm

    deadalus2u,

    The anecdotal “evidence” you speak of, is not evidence in it’s self, all though it may be a reason to look for evidence supporting or refuting the anecdotes. (The reason for a clinical trial is not part of the trial.)

  19. Richardon 04 Nov 2007 at 6:20 pm

    @Giladon

    I did a quick scan of the posts here after responding to deadalus2u, and I would feel remiss if I didn’t respond to you, since you are dealing with an issue that I have some familiarity with.

    I am under extreme deadline pressure this week, and once again, I am neither a homeopath nor a medical researcher. This will have to be quick, but I hope it speaks to what you raised, and if there is more discussion of this, I will make an attempt to respond either quickly during the week or at greater length next week.

    First of all, your suggestion is a really good step in the right direction. It is based on an attempt to come to terms with the actual claims of classical homeopathy. Dr. Iris Bell, who was one of the participants in last week’s debate has come up with suggestions along these lines. I believe she discussed this in the following paper (but, again, I don’t have time to check right this minute):

    Bell IR. All evidence is equal, but some evidence is more equal than others: can logic prevail over emotion in the homeopathy debate? J Altern Complement Med. 2005; 11 (5):763-9.

    (By they way, Bell has a list of papers on both sides of the debate at
    http://nationalcenterforhomeopathy.org/articles/view,173)

    In any case, as I recall, Bell outlined a similar procedure, whereby qualified homeopaths would screen participants for the study, to determine whether they were eligible for the use of a particular remedy. Once the participants were selected, the remaining trial would essentially be an ordinary randomized, controlled, double-blinded trial.

    Homeopathic remedies are generally administered in a somewhat different way than what you described, and the best test would be of a particular remedy, as I just mentioned, but I want to give you real credit for making a better effort than most people do to understand what it would actually take to refute classical homeopathy.

    And yes, if the right study or studies of this type, with design agreed to by representatives of the interested parties beforehand, and results verified afterwards under similar conditions, failed to show a significant difference between homeopathy and placebo (as you think they probably would), that would be a valid falsification of homeopathy in my book.

  20. Richardon 04 Nov 2007 at 6:25 pm

    Sorry, I meant @Gilad!

  21. daedalus2uon 04 Nov 2007 at 9:07 pm

    kilroy, a “case conference” is essentially an anecdote. It is “evidence”, but of a limited sort. It can’t be used to “prove” anything. It is the sort of evidence to justify further work. When Drs treat their patients, and those patients get better, the Drs get what is called experience. Not the same thing as a clinical trial, but something of value. Drs don’t treat a statistical sample, they treat individuals, and the results of an individual outcome is an anecdote.

    Not everything in medicine has been subjected to a clinical trial. There have been no clinical trials as to the use of sterile technique in surgery for example. But the germ theory of infection is so well established that it would be irresponsible to not use sterile technique in elective surgery, or to attempt a double blind trial of sterile technique in surgery. The times that sterile conditions have failed, and infections have ensued, are anecdotes that confirm that sterile technique is important.

  22. Richardon 05 Nov 2007 at 12:36 am

    @superdave

    Again, I am not a homeopath, and I am by no means an expert on homeopathic theory. But from what I do understand, homeopathic remedies work (if they work at all :) in a way that is quite different from the drugs most people are used to.

    To speak generally and simplistically, drugs are primarily used to suppress symptoms or kill pathogens. In doing so, they are delivered as a substitute for the body’s own mechanisms, and often are acting contrary to the workings of these mechanisms (which are often producing “symptoms” in an attempt to ward off disease, for example).

    On the other hand, a homeopathic remedy is based on a “symptom picture” that gives the practitioner an idea of the unique state of the entire organism at the time of illness. The remedy is essentially a way to give the body “missing information” that the body’s own mechanisms can then make use of as a guide in their own efforts to achieve cure.

    So if the remedy is the right one, it is only aiding the body in doing what it would do on its own, but for some reason hasn’t known how to. Because of that, there would not generally be any side effects, although it is apparently not uncommon for the symptoms to be mildly aggravated for a brief period.

    Where side effects, as the term is generally understood, are more likely to come into play is when a person is given the wrong remedy. Although this is apparently harmless in most cases, it is not unknown for someone to have serious symptoms from taking the wrong homeopathic remedy. Maybe it’s one of those malevolent placebos at work!

  23. pragmaticon 05 Nov 2007 at 10:51 am

    Steve (and all), I very well understand your feeling that “homeopathic theory makes no sense and is not even internally consistent.” I remember those feelings well from my early days (and years) as a homeopathic patient, and then as a homeopathy student. (I am now a friends-and-family practitioner.) But I persisted because over and over I saw it work, in some cases for conditions for which “everything else” had already failed. (Hay fever and other allergy; mental imbalance; behavior disorders; ADD; and a raft of more trivial complaints.)

    As to the (apparent) lack of internal consistency, that is similar to the (apparent) lack of internal consistency in the field of physics, where different rules, observations, outcomes and etc. apply under different circumstances, and to different purposes (e.g. Newtonian versus quantum laws). In other words, what first appears to be “lack of internal consistency” turns out instead to be complexity, and the difficulty of learning enough of “the whole picture” to give useful context. In both cases, tho the connections are not immediately apparent, they are learnable.

  24. daedalus2uon 05 Nov 2007 at 8:02 pm

    Persiflage, the wiki article on nocebos is quite bad.

    A nocebo is a pharmacologically inert substance said to exacerbate an illness or to worsen a symptom before it is administered. There is then the expectation on the part of the recipient that the symptoms will get worse. However this does not always happen. In my blog on placebo and nocebo effects,

    http://daedalus2u.blogspot.com/2007/04/placebo-and-nocebo-effects.html

    I cite a study where researchers studied the effects of placebos and nocebos on nausea. After administering the “treatment”, the same substance said to make nausea worse (nocebo), or better (placebo), they found that the nocebo actually reduced the symptoms of nausea (both subjectively and via gastromyograms) and the placebo made the symptoms worse.

    These effects of nocebos and placebos on the enteric nervous system can be explained by the placebo effect being mediated by neurogenic production of nitric oxide. The enteric nervous system is mostly nitrergic, so with increased NO (from the placebo effect), the enteric nervous system is more active. The nocebo effect is to lower NO levels, and so would reduce the activity of the enteric nervous system.

    A substance is a nocebo only when there is an expectation of adverse effects. If adverse effects are not expected, it is not a nocebo effect, it is a placebo effect.

    In general, the placebo effect changes an organisms state from the “fight or flight” state to the “rest and relaxation” state. The enhanced healing and reduced pain sometimes attributed to placebos is due to the diversion of greater metabolic resources to healing, rather than keeping them ready for fight or flight.

    The nocebo effect switches physiology from the “rest and relaxation” state to the “fight or flight” state. That is what coaches try to do before the ritualized combat of athletic events. That diverts resources away from cellular maintenance and readies them for consumption by skeletal muscle (mostly).

    It needs to be appreciated that there is a whole spectrum of different metabolic states between those extremes. No doubt they are different for different tissue compartments too.

    That is essentially what ischemic preconditioning does, turn off long time constant pathways to conserve ATP. That can be good in the short term, but bad in the long term. I think that is the main cause of ill health associated with chronic stress. The organism is kept perpetually in the fight or flight state, and not enough resources are devoted to cellular repair and so the cells deteriorate.

  25. daedalus2uon 05 Nov 2007 at 9:45 pm

    Actually, I just realized that a homeopathic preparation cannot work via a collective property of water, via a “water memory” held as information in a structure of water.

    Cells are encased in lipid membranes which are impermeable to water. Water only goes into and out of cells through pores or transporters, or attached to ions and other molecules. A hypothetical collective property of water is necessarily destroyed if that water is divided down into molecular sized units. Once water molecules are isolated, they become indistinguishable and any “memory” is necessarily lost.

    If you had a cd, and took it apart down to the individual bits, the collective information would be lost. Similarly if you took a book apart down to the individual letters, the collective information would be lost. If you take water apart down to individual molecules, any collective information that may have been present is lost.

    In order for water to get to cells, it has to be absorbed though the gut, which means traversing through multiple cell membranes. There is simply no way to deliver water to cells that has not been disassociated into molecular sized units which can’t carry any collective information.

    Homeopathy could still work via the placebo effect.

  26. TheBlackCaton 06 Nov 2007 at 1:23 pm

    @Richard

    What is the nature of this “missing information”, how does the body recognize it, and what are the mechanisms it uses to do “what it would do on its own”? And why would the missing information need for the body to fight, say, a cold and an allergy attack, which have the same symptoms but completely different biological causes, be the same? What is more, all of the known healing effects the body uses have their own side effects. For instance fighting off infection causes a fever. Repairing damaged tissue results in scar tissue formation. Fighting off respiratory pathogens causes excess mucous to be produced. Healing broken bones results in the formation of a temporary connective tissue covering and imperfect replacement bone replacement. And improving the body’s healing ability can have its own problem. Autoimmune diseases are a major and common problem. There is evidence that the reason the 1918 Spanish flu was so deadly was that it caused the immune system to destroy the lungs. Saying that the body is just healing itself does not eliminate the issue with side-effects at all.

    Practitioners of quack medicine love to throw around ideas of the body “healing itself” or “enhancing the body’s natural healing powers” or something like that, but they never explain why the body isn’t healing itself already, how exactly it would go about healing itself, why the particular quack treatment aids this process, why no conventional medicine can tap into this healing ability, why the healing ability itself has never been directly observed, why evolution would preserve these latent but unused healing abilities, why the normal side-effects from natural healing are not present, nor any of the numerous other questions that arise from these claims. It is just thrown around as a defense for using a treatment that cannot possibly have any physiological effect and only has positive effects.

  27. woodchopperon 07 Nov 2007 at 3:39 pm

    Good work again. Thought you might be interested in a comment from the other side of the hill. Here: http://otherhealth.com/showthread.php?t=9151

    I love this: “Second a material scientist, not interested in homeopathy but water structures, presenting the LATEST, like a few months ago, research on water patterns to support water has memory, organization, etc that in turn can support homeopathy claims. ”

    If people really think that is there any point debating with them?

  28. daijiyobuon 08 Nov 2007 at 10:13 pm

    As I write in “I Shot The Homeopath…”:

    ‘science has yet to see ‘beyond placebo effect,’

    Water’s memory just make their nipples erect.

    ‘Purposeful life spirit’ is a necessary belief [3],

    Kent followed Hahnemann, homeo.’s founder and chief.

    -r.c.

  29. Richardon 12 Nov 2007 at 10:39 pm

    @TheBlackCat

    (Not sure if you are still there. As I mentioned, I had extreme deadline pressure last week, and am just now catching up.)

    As I said before, I am not a homeopath or a medical researcher, so I can’t answer your questions directly. But I would like to point out a couple of things.

    First of all, these are great questions, and if homeopathy actually works as claimed, we should be able to find out more about them, once serious research efforts are underway. At this point, most of the researchers who could answer these questions either know nothing about homeopathy or don’t have the funding it would take to seriously pursue the answers.

    But first things first.

    Since we haven’t even established to everyone’s satisfaction whether homeopathy works or not, serious opponents of homeopathy should support research that can prove — one way or the other, once and for all — whether it does. That is, people on both sides of the controversy have to work together to get real answers to this most basic question. Anything less is just speculation, informed or otherwise.

    If it turns out that homeopathy does work, then give yourselves some time to let the facts sink in, as scientists generally have to when reality trumps theory. And once you have caught your breath, start digging into these questions, as well as the many others they will lead to.

    And if it turns out that homeopathy doesn’t work, hundreds of thousands, if not millions, of people will want to know what actually did cause them to have such profound results with homeopathy. And that, too, will be worthy of serious investigation.

  30. TheBlackCaton 14 Nov 2007 at 1:00 pm

    @Richard

    This is exactly the problem. Homeopathy is not some new, untested treatment. It has been around for 200 years. It predates modern medicine. It is not new. It has been thoroughly tested and found to not work. You are making it sound like nobody has seriously looked at the question of whether homeopathy actually works. They have, over and over again. You are making it sound like medical researchers oppose the idea of testing homeopathy. They don’t, they have done it countless times already. The ones who oppose the testing of homeopathy using legitimate methods are the homeopaths. They are the ones who always come up with excuses for why it can’t be tested, or why the most recent negative test failed to find any effect.

    You are painting a picture of the brave homeopaths being held down by the medical community that is blocking proper research into the subject, when the reality is it the homeopaths themselves are the ones that are hampering testing of their own field. If they were really that confident in their treatments they should be working to find ways to test it properly. As it stands they have refused to test it and refused to provide enough specific information that other people could test it. So it has been left to real medical researchers to come up with tests as best they can based on what the homeopaths say about how their treatments work. This of course leaves the homeopaths an easy out, they consistently say the test is flawed in some way. But they don’t make any attempt to fix the flaws in a reasonable manner. Serious opponents of homeopathy do support research into whether it works, and they have done the research over and over. It is the homeopaths who oppose the research. The ball is now in their court. If they want to show that their treatments actually work then they should develop scientifically-valid protocols to test them. They have been asked over and over, even begged by the medical community to do so. They have refused.

    And there is nothing that needs to be explained about why people think they feel better sometimes after homeopathic treatments. There is nothing profound at all. It can easily be explained by well-known effects such as the cyclical nature of disease, placebos, subjective validation, selective reporting, confirmation bias, lack of post-treatment monitoring, reliance on anecdotes, and spontaneous remission. There is no indication that there is anything out of the ordinary that needs to be explained. But if there is some effect then it is up to the homeopaths to show that it exists. Medical researchers have done all they can do to test it. It is clear that homeopaths will never accept any properly-controlled experiment that contradicts their position no matter how rigorous and valid the methodology. If they want to show that homeopathy works then they need to test it, or the very least explain how it can be tested. But they won’t do that.

  31. Richardon 15 Nov 2007 at 2:28 pm

    @TheBlackCat

    “Serious opponents of homeopathy do support research into whether it works, and they have done the research over and over. It is the homeopaths who oppose the research.”

    You mean like the Shang study, for example? (Shang A, Huwiler-Muntener K, Nartey L, Juni P, Dorig S, Sterne JA, Pewsner D, Egger M. Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy. Lancet. 2005; 366 (9487):726-32.)

    You know, the one that claims to compare 110 allopathic studies and 110 homeopathic studies, but actually compares only 6 allopathic studies and 8 homeopathic studies, without even saying which ones were used…

    Have you even read this paper? And if so, can you say with a straight face that you would give it a passing grade in an undergraduate medical research seminar? And can you explain why the editors of Lancet say this “study” heralds the end of homeopathy?

    On the other hand, have you read Bell Rheumatology study? (Bell IR, Lewis DA, 2nd, Brooks AJ et al. Improved clinical status in fibromyalgia patients treated with individualized homeopathic remedies versus placebo. Rheumatology 2004b; 43 (5):577-82.)

    The only criticisms I have seen of this one are that it wasn’t on a large enough scale to be definitive. So how are you working to get funding for a large-scale study that uses the same design — or alternatively, what should the authors do to make the study worthwhile, and if they do, will you be working to help them secure funding?

    Gilad was on the right track, as I mentioned above, but I don’t know of any study carried out by opponents of homeopathy that embodies the kind of design I mentioned in response to Gilad. And that kind of design is absolutely essential if you want to refute the actual claims of classical homeopathy.

    If you know of such a study, please send me the reference!

  32. TheBlackCaton 15 Nov 2007 at 2:41 pm

    Looks like Steve has already covered the points you brought up in his most recent post. You can continue the discussion there.

  33. zenoon 20 Dec 2008 at 2:52 pm

    Aaarrrggghhh! Just started watching the webcast of your talk. An excellent presentation Dr Novello, but my brain was exploding at the tripe Dr Roy was spouting!

    Just how can you bridge the abyss that separates these pseudo scientific quacks and real science? They wouldn’t know science if they tripped over it.

  34. zenoon 20 Dec 2008 at 2:52 pm

    Pity we can’t see his slides…

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