Homoeopathy: the effective promotion of ineffective remedies?

Abstract

In this issue Ross et al. [1] demonstrate that homoeopathy is alive and kicking. In Scotland, about 12% of general practitioners (GPs) use homoeopathic medicines and 60% of all GP practices prescribe them. Considering that many patients buy these remedies over the counter, the true usage is likely to be much higher. The Scottish situation is perhaps special, but there is little doubt that homoeopathy is again gaining in popularity How can we explain this increasing usage of homoeopathy? One reason could be that it is effective. Homoeopaths use highly dilute remedies devoid of meaningful pharmacological effects and believe their treatments rely on undefined, nonpharmacological effects. However, not understanding how it works does not mean that it does not work. So what do systematic reviews and meta-analyses of rigorous clinical trials tell us? In 1997, Linde and colleagues published a meta-analysis of 89 controlled clinical trials, which concluded that the ‘clinical effects of homeopathy are not completely due to placebo’ [2]. Since then, more than 20 further systematic reviews or meta-analyses have become available [3–8]. Collectively they fail to demonstrate convincingly that homoeopathic remedies differ from placebos. As science cannot prove a negative, we are not able to state categorically that homoeopathy is ineffective, but we can be certain of one thing: its clinical effectiveness has not been established. Of course, our doubts are significantly increased by the absence of a plausible mechanism of action. Another explanation for homoeopathy’s increasing popularity could be effective promotion. In the UK, Royal protection has always been important for homoeopathy. The Prince of Wales’s Foundation for Integrated Medicine is a lobby group which has produced many documents that favour homoeopathy. Its (government-funded) patient guide on complementary medicine advertised homoeopathy as ‘most often used to treat chronic conditions such as asthma …’ [9] (no other ‘evidence’ on the subject was provided). The quote is in accordance with a previous (also publicly funded) pamphlet designed to give primary care groups ‘a basic source of reference on complementary and alternative therapies’ [10]. In relation to homoeopathy, it stated that ‘specific conditions for which there is the best evidence of effectiveness are those where there is an allergic component, e.g. asthma …’ [10]. The recent Smallwood Report [11] (commissioned by Prince Charles and funded by Dame Porter) was specifically aimed at UK politicians [11]. It claimed that ‘the best evidence for homeopathy … is associated with its use as an alternative to conventional medicine in relation to a number of everyday conditions in general care, particularly asthma’ [11]. Despite the lack of reliable data [12], it also asserted that the National Health Service (NHS) could save £16 million each year if only 4% of British GPs were to use homoeopathy more extensively. The Scottish data [1] imply that this type of lobbying, combined with commercial promotion, is effective in popularizing homoeopathy. A third reason for the increasing use of homoeopathy could be that patients do find it useful after all. The best evidence fails to demonstrate that homoeopathic remedies differ from placebos [3, 4, 6–8]. However, this does not necessarily mean that patients do not perceive benefit which could originate from a placebo effect, or from the homoeopathic encounter, or both. Observational studies regularly show that patients profit from seeing a homoeopath, e.g. [13]. The homoeopathic remedy may therefore be a placebo but (unsurprisingly) the homoeopathic encounter with its abundance of time and empathy seems to work for many patients. So is the current rise of homoeopathy a good or a bad thing? The answer obviously depends on the perspective. Prince Charles was recently quoted saying that he did not support alternative medicine ‘because of some self-indulgent pet projects, or because of some half-baked obsession with quackery’ [14]. Richard Horton, editor of the Lancet, seems to see things differently: ‘Let’s be clear: this report [the Smallwood report][11] contains dangerous nonsense’ [15]. Others have also argued that the rise of homoeopathy is ‘just another worrying example of the growth of irrational dogmas’. Vis-a-vis the increasing importance of patient choice in the NHS, this raises an intriguing question: do we condone treatments because of their popularity or their effectiveness? The Scottish data [1] make me wonder.