Recently a post of mine describing attacks on homeopathy as “batty and arrogant” that I wrote last year was retweeted. This meant that again homeopathy’s hard-core detractors rushed out with lectures about the scientific method and the need for randomised trials (obvious) but yet again no attempt to actually deal with the issues I raised – that if you are worried about failing to follow the rules of evidence based medicine, homeopathy is not the place to point the finger.
So although I am, as I said, agnostic about homoeopathy, I think it’s worth coming back to the issue because the problems with evidence based medicine as practiced at the moment haven’t gone away, in fact they have become even clearer. For instance, Takeda Pharmaceutical and Eli Lilly & Co. (LLY) have just had to pay a combined $9 billion in punitive damages for hiding the cancer risks of their Actos diabetes drug. To me that seems far more dangerous and irresponsible than anything done by homeopaths.
The central charge against homeopathy is that there are no randomised trials showing its effective, so it’s worthless. My point is that even if that is true – both sides swap trial results – drug treatments with impressive RCT results, like Actos, can turn out to be deadly. Cause for much greater concern I’d argue. Drugs can also come trailing positive RCT results and be remarkably ineffective. The drug ezetimibe, according to RCTs, is very effective at lowering cholesterol and widely prescribed. However no RCT has ever shown that it cuts your risk of heart disease. There are also serious questionmarks over the benefit of prescribing cholesterol lowering statins to millions who don’t have heart disease.
Of course this doesn’t prove that homeopathy is any good. But the attacks on homeopathy aren’t just about a lack of evidence. The underlying message is that without RCT support a treatment is not just unproven but fraudulent. And since few non-drug treatments have RCTs all CAM (Complementary and Alternative Medicine) is fraudulent.
Beware of endarkenment
Some of the self-proclaimed sceptics attacking homeopathy then go even further and claim that this lack of evidence means that if CAM is allowed to flourish it could usher in a time of “endarkenment” – a reversal of the scientific principles established in the enlightenment. This lunatic claim is perfectly illustrated by the tag line on a blog by the vigorous homeopath basher “Skepticat”, which reads: “resisting the age of endarkenment”. The threat to the enlightenment from the multiple examples of drug companies worth billions of dollars playing fast and loose with the evidence is apparently as nothing compared to the destructive power of those homeopaths.
The “endarkenment” point, however, turns out to be very enlightening. It explains why those bashing homeopathy and other CAM practices are so rude and aggressive. They are engaged in a crusade. Armies of the light battling against forces of darkness. This, ironically, puts them in an ideological or even religious camp rather than a scientific one. In fact the reason the various forms of CAM don’t have trials backing them has nothing to do with a fear of the light of reason but simply because their treatment don’t involve patentable products.
However the endarkenment myth-making has been very effective in pushing non-drug treatments out to the fringes with, what I and others would argue, disastrous consequences for our health. We are faced with an epidemic of lifestyle disorders – diabetes, cancer, Alzheimer’s – and while putting more and more very expensive drugs through RCTs to target the symptoms will be very profitable, it will do little to affect the underlying causes.
That is because drugs are very good at doing one thing, such as shrinking a tumour or boosting insulin production, while these lifestyle disorders all involve a range of unhealthy changes in the way the body is functioning, all of which lifestyle treatments can reverse. However measuring the benefits of treatments designed to have a range of effects is not something that RCTs do well. They are good at measuring what drugs do – produce a single effect.
Why RCTs are like a one-legged stool
Seeing this as a problem doesn’t mean that you are rejecting science or in danger of reversing the enlightenment but it does mean rethinking what counts as scientific medicine. This is the argument put forward by a couple of researchers at the Alzheimer’s Drug Discovery Foundation in New York in JAMA (Journal of the American Medical Association) Neurology February 2014.
They start by remarking that relying solely on RCT’s is like: “resting all of health care evidence on a one-legged stool.” The effect, they say, has been to downgrade to relevance other equally valid forms of non-randomised treatments for chronic diseases, such as supplements and changes in diet and lifestyle..
The reason for this, they go on, is that: “RCT’s are usually reserved for profitable new drugs while non-drug treatments are usually tested with cheaper “observational” studies.” (These are studies which look at what happened to people getting a treatment rather than giving one group the real treatment and one a dummy. Something that is difficult to do with diet, for instance.)
At the moment observational studies are considered less reliable than RCTs but the way RCTs are usually done on non-drug treatments, claim the authors, means that they are more likely to produce negative results. That’s because they are: “frequently underfunded, short-term and underpowered” (don’t have enough people in them to detect some of the effects).
So our current system of evidence based medicine that allows both dangerous and ineffective drugs onto the market is used as a stick to beat such CAM treatments as homeopathy. The way it does test CAM treatments is poor and more likely to produce negative results. This still doesn’t prove homeopathy works but it does suggest the system used to evaluate it and other non-drug treatments is in need of a serious overhaul.