Skepticblog

The Huffington Post, an online news source, from its creation has embraced anti-scientific pseudomedicine. It has been a home for a number of anti-vaccine cranks, as well as promoters of all kinds of medical nonsense. Occasionally there appears a brief flower of reason (token efforts at best) – for example our own Michael Shermer recently publicly called out Bill Maher on his anti-vaccine nonsense in the HuffPo. Here’s the money quote:

As well, Bill, your comments about not wanting to “trust the government” to inject us with a potentially deadly virus, along with many comments you have made about “big pharma” being in cahoots with the AMA and the CDC to keep us sick in the name of corporate profits is, in every way that matters, indistinguishable from 9/11 conspiracy mongering.

But these brief incursions of reason aside, the HuffPo has been in continual free fall into medical woo since its inception. Although in retrospect it has been hopeless for a long time, for me it crossed the veil into complete an utter advocacy of woo when it hired Dana Ullman as a regular blogger.

Ullman is notorious as a homeopath and internet lurker, spreading undiluted nonsense as far and wide as his typing fingers can manage.  I will have to resist the urge to deconstruct every bit of medical misdirection he will spread with his new forum – that would be a full time job for one blogger. But as I have already received numerous requests to take a look at his latest post, I will give him some deserved skeptical attention.

Some Background on Homeopathy

First, some obligatory background on homeopathy. If you’ve already heard this one, you can skip to the next section. There is also a more thorough overview of homeopathy at sciencebasedmedicine.org.

Homeopathy is a two hundred year old belief system invented out of whole cloth by Samuel Christian Hahnemann- it never was a legitimate science in its methods or ideas. It is based upon several magical pre-scientific ideas (wrongly called “laws” by proponents). The first is a manifestation of sympathetic magic – the law of similars, or the notion that like cures like. This is a common superstitious belief, but not based upon scientific reality.

So the first law of homeopathy says that you use small doses of a substance to treat symptoms created by that substance. The second law of homeopathy says that you don’t do that. (This is actually one of my favorite quips of James Randi from his lecture on homeopathy.) The second law, the law of infinitessimals, says that as you dilute the substance it becomes more potent – in direct violation of the very real laws of physics and chemistry. Homeopathic remedies are often diluted beyond the point where there is even a single molecule of active ingredient left (or basically, there is the background chemicals that are already present in the water being used).

Homeopathic remedies are therefore nothing but water, and no one has been able to demonstrate the ability to reliably distinguish ordinary water from a heavily diluted homeopathic “remedy.” Modern homeopaths try to rescue their outdated nonsense by saying that water has “memory.” Of course, you can’t rescue nonsense with more nonsense. No one has demonstrated that water can retain complex chemical information for any significant duration – certainly nothing close to what would need to happen for the information to be retained all the way through ingestion and transport through the blood to the site of action.

In short, from an historical and basic science point of view, homeopathy is bunk. From a clinical science point of view, it does not work. But there is a lot of noise in the clinical literature, and this is where Ullman performs his best legerdemain.

Homeopathy is not equivalent to allergy shots

One of the mental misdirections that homeopaths like Ullman like to use to confuse the public is to make an analogy between homeopathy and allergy shots. Ullman writes:

Allergy is the medical specialty that commonly uses small doses of an allergen in order to desensitize a person to that allergen.  This concept of using small doses of what might cause a problem in order to help prevent or heal the person is an ancient observation of healers/physicians all over the world, and it is the basis for a type of natural medicine called homeopathy.

I take down this claim more thoroughly here. Allergy shots exploit a very specific biological function. An allergic reaction occurs when a specific kind of antibody, IgE, binds to an allergen and triggers an allergic immune response. Allergy shots expose the patient to an initially very small (but not homeopathic) dose of allergen so that the body will form a different kind of antibody, IgG, that does not trigger an immune response. Then the doses slowly increase, forming more and more so-called blocking antibodies of IgG. Eventually the patient can receive a full exposure to the allergen, and the circulating IgG antibodies they built up will bind to the allergen, blocking the allergy causing IgE.

This is a very specific mechanism that derives from our basic science understanding of the immune system. Homeopathic remedies do not work by this mechanism (they don’t work at all) – they do not provoke the production of IgG, or any other physiological response that we can tell. There is therefore no legitimate analogy between homeopathy and allergy shots – except in the most superficial and intellectually lazy manner.

The allergy shot analogy is nothing but a hand-waving misdirection to give a false sense of legitimacy to discredited magic.

The Cherry Picker 2000

Ullman’s well-known modus operandi is to cherry pick those studies that seem to support the use of homeopathy, and to ignore or dismiss those that show that homeopathy does not work. Again – this is just intellectually lazy and biased. As I teach my medical students – you cannot come to any sort of reliable conclusion based upon a single study. And further, there is enough noise in the clinical literature that if you allow yourself to cherry pick only certain studies, you could support just about any conclusion you wish.

It is only meaningful to interpret the literature as a whole, with a sophisticated understanding of the nature of the literature. The literature, for example, has some meta-structure, such as the file-drawer effect – the tendency to publish positive studies more than negative studies.

And, I and others contend, that the clinical literature needs to be put into the context of the basic science literature as well, so that all available scientific information is brought to bear on any medical question (and this is precisely where science-based medicine differs from evidence-based medicine).

Ullman writes:

Respiratory allergies represent the condition for which there is a relatively strong research base for efficacious treatment with homeopathic medicines. A group of researchers at the University of Glasgow published four studies, three of which were published in the BMJ (British Medical Journal) and the Lancet, two highly respected medical journals. Each study was randomized, double-blind, and placebo-controlled. Each trial used an oral 30C homeopathic preparation. The first two trials involved patients with hay fever, [4] [5] where patients were either give a placebo or homeopathic doses of 12 common flowers to which people are allergic.

The emphasis is in the original – Ullman is trying to impress his audience with the prestige of the journals in which these results were published. Journal prestige does matter, and these are legitimate journals. But Ullman is using them as shiny objects to beguile his audience.

First, Ullman glosses over the messy results of these trials, focusing the most positive results. Here is the actual results and conclusion from the study:

Fifty patients completed the study. The homoeopathy group had a significant objective improvement in nasal airflow compared with the placebo group (mean difference 19.8 l/min, 95% confidence interval 10.4 to 29.1, P=0.0001). Both groups reported improvement in symptoms, with patients taking homoeopathy reporting more improvement in all but one of the centres, which had more patients with aggravations. On average no significant difference between the groups was seen on visual analogue scale scores. Initial aggravations of rhinitis symptoms were more common with homoeopathy than placebo (7 (30%) v 2 (7%), P=0.04). Addition of these results to those of three previous trials (n=253) showed a mean symptom reduction on visual analogue scores of 28% (10.9 mm) for homoeopathy compared with 3% (1.1 mm) for placebo (95% confidence interval 4.2 to 15.4, P=0.0007).
Conclusion: The objective results reinforce earlier evidence that homoeopathic dilutions differ from placebo.

The conclusion is odd – “homeopathic dilutions differ from placebo.” The authors did not conclude that homeopathy was superior to placebo – perhaps because some of the outcome measures were worse, such as initial aggravations. The authors seemed desperate just to conclude that the homeopathic “remedy” was different from placebo, to argue against the counter claim that homeopathic remedies are nothing but placebo.

But the parsimonious conclusion from these four trials is that they involved a small number of overall subjects (253 – that is small for four trials) and the results were predictably mixed. And it must also be realized that what gets published is often a very sanitized version of what actually happened during a study. That is why independent replication is needed – there are just so many ways for subtle biases to creep into these studies, especially when subjective outcomes (like the visual analogue score) are being used. Even nasal airflow is very tricky, as the measurement is very technique and effort dependent.

Ullman calls this a “relatively strong research base.” Rather, this is extremely thin, especially for such an implausible treatment.

But it gets worse, because these were the best studies that Ullman could cherry pick. A 2006 systematic review concluded:

Some positive results were described with homeopathy in good-quality trials in rhinitis, but a number of negative studies were also found. Therefore it is not possible to provide evidence-based recommendations for homeopathy in the treatment of allergic rhinitis, and further trials are needed.

Hmmm – a number of negative studies. Ullman did not happen to mention those. Also, here is a tip on reading such reviews – “further trials are needed” is a polite way of saying that the evidence is negative or equivocal. These authors looked at the evidence and found it too wanting to make any firm conclusions. Ullman looked at the evidence and found it to be a relatively strong research base. Maybe he meant “for homeopathy,” in which case he would be correct. This is the best homeopathy can do – equivocal.

Incidentally, the same is true of homeopathy and other respiratory illnesses. Here is a recent review of homeopathy and asthma:

There is not enough evidence to reliably assess the possible role of homeopathy in the treatment of asthma. Further studies could assess whether individuals respond to a “package of care” rather than the homeopathic intervention alone.

I love the reference to the “package of care” – that is code for all the non-specific and placebo effects that go along with getting therapeutic attention. It’s like saying that this jelly doughnut is “part of this complete breakfast.” Of course, the breakfast is already complete without the doughnut. But in this case is more like saying a drawing of a doughnut is part of this complete breakfast – you don’t actually get to eat a doughnut.

In other words – homeopathic remedies add nothing to the treatment of respiratory illness.

Conclusion

A fair and scientific assessment of homeopathy for allergic rhinitis can only lead to the conclusion that homeopathy is extremely implausible, and the evidence for efficacy is weak and inconclusive. Dana Ullman, however, is telling his readers that homeopathy is on the forefront of science and there is a stong evidence base for its effectiveness.

That is the kind of responsible reporting that the Huffington Post was apparently looking for.