In Parts I and II of this series* we saw that from 2000 to 2002, key members of the Harvard Medical School “CAM” program, including the Director, had promoted quackery to the legislature of the Commonwealth of Massachusetts. We also saw other explicit or tacit promotions by Harvard institutions and professors, and embarrassing examples of such promotions on InteliHealth, a consumer health website ostensibly committed to “providing credible information from the most trusted sources, including Harvard Medical School….”
Those points were made in an essay that I sent in the spring of 2002 to Daniel Federman, the Senior Dean for Alumni Relations and Clinical Teaching at Harvard Medical School (HMS). I also sent Dr. Federman a treatise on homeopathy, including several examples of credulous Harvard professors and misrepresentations aimed at students, patients, and the public. Much of the content of that treatise has been covered by the series on homeopathy† with which I began my stint here on SBM, so here I’ll post only the parts relevant to promotions by academic physicians, including those at Harvard. There is a bit of redundancy involving InteliHealth, but please bear with me if you’ve made it this far; the discussion will be meatier than the short summary in Part II.
Modern Academic Promotions of Homeopathy
Dr. Holmes must be rolling in his grave. Homeopathy is now being given credence by mainstream academic ‘CAM’ programs of the best pedigrees, including Harvard’s. The National Center for Complementary and Alternative Medicine (NCCAM) even takes homeopathy seriously: the former Director, Wayne Jonas, is a practicing homeopath and continues to receive public funding from the NCCAM for homeopathic “research.” At a hearing of Rep. Dan Burton’s House Committee on Governmental Reform in November 2001, Jonas called for homeopathic solutions to bioterrorism threats, praising Jacques Beneviste in his prepared statement. Current Director Stephen Straus cautioned that such remedies should not be substituted for proven measures, even as he bowed to what now seems to be the polite way of discussing quackery:
The prophylactic benefits of exceedingly dilute substances are more in doubt than those of conventional vaccines.”
And, a bit later:
Even though there is some doubt that these products could be effective, we cannot prove the claims to be entirely specious….Exploration of such approaches should first involve careful studies in animals using contemporary methodologies to discern whether they hold any promise against diseases associated with biological weapons.”
Harvard Medical School
Harvard Medical School now presides over several promotions of homeopathy, both as a clinical method and as a subject of uncritical education and research. Descriptions of the practice and its basis are frequently erroneous in Harvard-based literature, as the following examples attest.
From 1997 until March 2002 InteliHealth, a joint effort of HMS and Aetna to provide web-based health information, had this to say about homeopathy:
One of the basic principles of homeopathy is that when a substance in large doses causes certain symptoms, in small doses it can help heal a person suffering from an illness that has those same symptoms. Some treatments in conventional medicine rely on this like-cures-like principle: vaccines, for instance, introduce small doses of an illness-causing agent to cure or prevent disease.
Conditions that respond well to homeopathic treatment include arthritis, migraines, asthma, eczema, attention-deficit disorder, depression, anxiety, ulcerative colitis, Crohn’s disease, chronic-fatigue syndrome, fibromyalgia, multiple sclerosis, back pain, gastritis, peptic-ulcer disease, ear infections, and strep infections.
To receive an information package and a directory that lists trained homeopaths in your area, send $10 to the National Center for Homeopathy, 801 North Fairfax Street, Suite 306, Alexandria, VA 22314, or use the center’s free searchable directory online at www.homeopathic.org. Contact the American Association of Naturopathic Physicians at 206-298-0125 to find a qualified naturopath in your area.
The vaccine analogy is, of course, erroneous. Vaccines do not “introduce small doses of an illness-causing agent,” since what they actually introduce are non-virulent, attenuated, or non-viable variants of such agents. Furthermore, the dose of the agent in a vaccine is substantial and determined by rational dose-response curves. The dose of the purported active agent in a homeopathic preparation is miniscule or nonexistent, and determined by homeopathic “provings,” which are invalid as a basis for therapeutic decisions.
There is no evidence for any of the therapeutic claims made in the second quoted paragraph. The “supportive research” section of the article may look impressive to the naïve reader. In fact, some of the references support the non-efficacy of homeopathy and the others are hopelessly flawed.
The third quoted paragraph consists of two advertisements.
Homeopathy, “Integrative Medicine,” and Ethics
The new InteliHealth homeopathy article is more circumspect, but still misleading. It is a good example of what now passes for a “balanced” treatment of the subject:
While homeopathy is relatively safe, it should be a complement to, not a substitute for, standard medical care.
This is a well meaning but naïve attempt, by advocates of “integrative medicine,” to coax pseudoscientific methods into the fold of rational practice. An example of the futility of this approach has already been offered above, in the case of licensed homeopaths advising parents against having their children immunized. It turns out that “standard medical care” is specifically proscribed by the most influential of all homeopathic treatises, Hahnemann’s Organon of Medicine:
§ 52 Sixth Edition
There are but two principle methods of cure: the one based only on accurate observation of nature, on careful experimentation and pure experience, the homœopathic (before we never designedly used) and a second which does not do this, the heteropathic or allopathic. Each opposes the other, and only he who does not know either can hold the delusion that they can ever approach each other or even become united, or to make himself so ridiculous as to practice at one time homœopathically at another allopathically, according to the pleasure of the patient; a practice which may be called criminal treason against divine homœopathy.
So much for homeopathy and “integrative medicine.” There is plenty of evidence that Hahnemann’s stern admonition is taken seriously by contemporary homeopaths (available upon request). Even if some disagree with his stance, it does not follow that homeopathy is thus rendered an acceptable practice. To paraphrase physicist John Farley, homeopathy is no more “complementary” to rational medicine than is alchemy to chemistry, astrology to astronomy, or creationism to evolution. It is theoretically true that if all practitioners of homeopathy also practiced, or referred patients for, rational medicine, and if no patients were seduced into substituting homeopathic preparations for rational treatment, there would be no medical disasters referable to homeopathy per se. After all, homeopathic “remedies,” at least those that are unadulterated, are inert. In reality, such contingencies can never be assured: on the contrary, they are undermined by endorsements, however well intended, from bastions of modern medicine and science.
Here is an example. The aforementioned Dana Ullman is among the most well known homeopaths in the United States today, and certainly one of the most influential in “Integrative Medicine” circles. His several popular books and his website, Homeopathic Educational Services, are recommended by many academic CAM programs, including the Rosenthal Center for Complementary and Alternative Medicine at Columbia University and the Zakim Center for Integrated Therapies at the Dana-Farber Cancer Institute in Boston. One of his books was recommended in the first Intelihealth article reviewed above. On his website, Ullman identifies himself as “an instructor in a course on homeopathy at the University of California at San Francisco” and states that he “serves on advisory boards of alternative medicine institutes at Harvard and Columbia schools of medicine.” Ullman is listed as a member of the advisory board of Integrative Medicine: the Worldwide Authority on Integrated Care, a position he shares with four representatives of the Harvard Medical School CAM project along with representatives of the medical schools of Johns Hopkins, George Washington University, SUNY Stony Brook, and the Universities of Arizona, Colorado, Hawaii, Maryland, and Minnesota. If the “integrative medicine” movement has embraced any homeopath, it has embraced Dana Ullman.
Yet it is difficult to imagine that his medical school patrons have read Mr. Ullman’s writings, even as they recommend them to the public. If they had, they would know that Ullman issues dire warnings to parents about “dangerous conventional medicines” and that for strep throat, for example, “you should start with homeopathic treatment” and “it is reasonable to forego antibiotics even for children since rheumatic fever is so rare today.” They might also have noticed an article in last October’s Utne Reader, for which Ullman lists himself as the “health book reviewer,” in which he recommended homeopathic “nosodes” for the prevention of anthrax (Ullman also offers an Anthrax Nosode and Accompanied Remedies Kit, for $33, on his website). Are these recommendations indicative of the benefits of “integrative medicine?” One can only hope that Harvard and the other medical schools that endorse Ullman do so out of ignorance, because the alternative explanation is even more troubling.
Another argument frequently given for the acceptance of homeopathy is the popular demand for a practice that is not intrinsically unsafe, wholly apart from its capacity to divert patients from rational medicine. If for whatever reason it makes some people feel better, the argument goes, why not welcome it? There are several answers to this. The first is that this essay addresses the appropriate role of trusted societal institutions such as medical schools and government, not the choices of a free citizenry. These institutions should be providing education, and doing so with the utmost integrity. At least some of the current demand is due to the very sorts of misleading promotions described here. The second answer is that those who seek homeopathy will always be able to find it, as they have in the past. In the U.S. it has been a tiny, fringe practice for almost 100 years, and it would behoove the public health for it to remain as such. The recent bandwagon-style
promotion of this and other CAM methods, to a large extent fueled by the misleading hyping of Dr. Eisenberg’s telephone surveys, has only served to move homeopathy closer to the popular mainstream—even as the evidence for it remains nonexistent.
Homeopathy was quackery in 1980 and nothing, other than “spin,” has changed. In any case, its capacity to appear to make some patients feel better cannot be divorced from its capacity to divert them from effective therapies. How many children reporting that their sore throats feel better after swallowing homeopathic belladonna or arsenicum, for example, would it take to justify each excess case of rheumatic heart disease?
Mainstream endorsements of irrational claims are also damaging in other ways: they are confusing to a scientifically challenged public, they waste research dollars, they help line the pockets of quacks, and they are embarrassing to the work of the great majority of physicians and medical scientists and to the reputations of the medical schools that feature “CAM” programs. Finally, if practicing homeopathy to the exclusion of rational medicine is unethical, it does not follow that “integrating” it with rational practice would make it any less so, even if it were to become technically safer. A lie is still a lie.
More Harvard Homeopathy Hype
Back to the new Intelihealth article:
It is also a highly controversial form of medicine because it lacks a scientific explanation for why its treatments might work.
Well, not exactly. Rational medical doctors know that it is a classic example of a popular delusion, and that there are perfectly good explanations for why its treatments might, at times, appear to work.
Homeopathic remedies consist of highly diluted preparations of natural ingredients. The ingredient may be diluted 30 to 50 times, sometimes to the point where no molecules of active ingredient remain.
The ingredients are actually diluted far more than 30-50 times, as correctly suggested by the second part of the sentence. Typical dilutions are 10^12-10^60 fold. There is no rational, repeatable basis for determining what might be the “correct” dilution for a given “remedy.”
But an analysis of 89 clinical trials published in a major medical journal, The Lancet, in 1997 found that the clinical effects of homeopathy are not entirely due to placebo effect.
A 1991 analysis of 105 clinical trials published in the British Medical Journal found that 81 of the studies showed positive clinical results while 24 found no positive effect from homeopathic treatment. The researchers concluded that the evidence was positive but insufficient to draw any conclusion regarding the efficacy of homeopathic treatment, and they recommended that additional well-designed studies be undertaken.
These are the kinds of equivocal reviews invariably cited by proponents of homeopathy and of further homeopathy research. Not stated in the InteliHealth article is that all such reviews find that the studies showing “positive effect” tend to be among the most methodologically flawed, whereas the better studies are more likely to show no effect. For this and other reasons such reviews actually support the non-efficacy of homeopathy, and further homeopathy research can be predicted to yield an endless cycle of equivocal results. In the meantime, the conclusions cited in the passages above—that there is some “positive” evidence and that homeopathy therefore needs further research—merely serve to give the practice an unearned appearance of legitimacy. Hence this sort of article—typical among modern, medical school based “CAM” treatises—is not really “balanced,” but implicitly promotional.
The Family Education and Resource Program of Children’s Hospital promotes homeopathy in a brochure aimed at patients and parents. Highlights of the brochure include a misleading definition of “alternative treatment” (“a kind of treatment you don’t usually receive at a regular doctor’s office or clinic”); a sub-heading (“How does homeopathy work?”) that presumes homeopathy to be effective; a misleading suggestion that homeopaths are astute clinicians (“Homeopathic practitioners wish to understand their patients well. Homeopathic remedies are very specific to the patient’s particular symptoms, daily routines and personality”) that is actually an allusion to the nosy, largely irrelevant “symptom” gathering previously described; and spurious suggestions of efficacy: “homeopathy may be helpful for people suffering from allergies, bruises and sprains and for children with diarrhea.” The brochure invites its readers to call the Center for Holistic Pediatric Education and Research at Children’s Hospital, whose national advisory board includes the president of the American Institute of Homeopathy, for “a list of pediatric homeopaths in the Boston area.”
The “information resources for consumers” webpage of the Caregroup/Harvard Medical School Center for Alternative Medicine Research and Education (CAMRE) promotes homeopathy indirectly by the following advice:
Please consult your local telephone yellow pages under these categories:
Massage – Therapeutic
Homeopathy is an integral part of the practice of “naturopathic physicians,” as documented elsewhere in these materials, and is also frequently offered by others on the list.
Homeopathy Research and Education at Harvard
Modern homeopathy research is taken seriously at Harvard but, like the endorsement of Dana Ullman, it is shrouded in a veil of ignorance. After Drs. Reilly and Eisenberg had chastised the conventional straw-man at the 2001 Harvard CIM conference, Reilly likened the concept of ultra-dilute homeopathic preparations to examples of small quantities of substances known to exert a biological effect: pheromones, vitamins, and pollen desensitization regimens. These analogies are false, but Reilly was not challenged. In his own syllabus Dr. Eisenberg listed three homeopathy articles under the heading, “Articles/Consensus Reports Suggesting Efficacy,” but none under the heading, “Articles/Studies Suggesting Lack of Efficacy.” Of the three listed articles, two actually support the lack of homeopathic efficacy, and the third is misleading and uninterpretable.
The Faculty Development and Fellowship Program in Complementary and Alternative Medicine at Harvard Medical School lists a homeopath among its faculty members. Here is a quotation attributed to this homeopath:
Quoting from Edward H. Chapman, M.D., Dht, President of the American Institute of Homeopathy, and Clinical Instructor at the Harvard University School of Medicine: “For those who need support in their struggle with Attention Deficit Hyperactivity Disorder … they can be assured from two hundred years experience using homeopathic medicines that they are safe. Your conventional doctor may be skeptical if you choose to use homeopathy. Don’t let that stop you. Seek assistance from well-trained homeopathic providers who are willing to work with you and your doctors.”
Is Harvard Medical School developing more faculty members with views such as this? Are fellows, in addition to patients, now being encouraged to think that homeopathy is a valid clinical practice or, at the very least, worthy of research? The Course Description for “Complementary, Alternative, Integrative Medicine” at HMS, which includes homeopathy on its list of covered topics, is hardly reassuring. It defines “CAM” as “refer[ring] to medical techniques not in conformity with the beliefs or standards of the conventional medical community…,” as if to suggest that knowledge has nothing to do with it. What distinguish modern medicine from homeopathy and most CAM claims are not “conventional beliefs” or even standards, but reason and facts. Isn’t this what should be stressed to medical students, fellows, and patients?
An Example of Homeopathy Research and More Ethical Mischief
Harvard’s Dr. Chapman also “uses homeopathy as the primary treatment for AOM” (acute otitis media) in children, according to a recent paper authored by himself and Dr. Eisenberg, among others. This paper is a useful example of modern “homeopathy research” in Boston and another illustration of the mischief that can result from misleading promotions of “CAM” popularity. It is a “pilot study” of homeopathic treatments of AOM in children. The authors justify this by stating that “homeopathy is a frequently used alternative therapy for AOM,” citing Dr. Eisenberg’s first telephone survey as evidence. That survey, however, involved only adults and reported that 1% of the 1539 adults queried, or about 15, had used homeopathy for any reason in the past 12 months; of these about 1/3, or a total of five, had seen a “provider.” The survey mentioned neither AOM nor any other disease in relation to homeopathy.
The homeopathy paper refers to the “principle of similars” as an “observation,” and states as fact the very claim that would seem to be at issue:
Choosing the appropriate medication for an individual patient is time-consuming and challenging, and it depends on the skill and experience of the homeopathic practitioner.”
As discussed earlier, homeopathic “symptom” gathering and “provings” are not valid clinical tools. Most troubling of all, 22 out of the 24 children in the study received nothing but homeopathic “remedies” for a disease that calls for antibiotics† (the other two received antibiotics only after 13 and 28 days, respectively). This appears to be a violation of the Declaration of Helsinki of the World Health Organization, which states, in part:
In any medical study, every patient — including those of a control group, if any — should be assured of the best proven diagnostic and therapeutic method.”
Nevertheless, the study was “approved by the Human Studies Committee at Boston Medical Center.” It would seem that “CAM” has spawned a new era in medical ethics together with its redefining of medical science.
Dr. Eisenberg, who has promised that the HMS “CAM” project will be guided by scientific integrity, seems to use science selectively when considering homeopathy. In testimony to the White House Commission on Complementary and Alternative Medicine Policy (WHCCAMP) in May 2001, he said:
I have given in your handout examples of I think the best examples we have to date, most of them from the last five years, where the evidence suggests that there is some efficacy of CAM therapies for particular conditions…Two studies, meta-analyses suggesting homeopathy as distinct from placebo… You are aware of these. These are sort of the examples of good research suggesting positive effectiveness.
Well, no. These are examples of research that is poor but nevertheless good enough, in the face of a vanishingly unlikely 200 year-old claim, to put the matter to rest once and for all. At the 2001 Harvard CIM conference Dr. Eisenberg, (mis-)quoting Carl Sagan, had declared that “exceptional claims require exceptional evidence.” Here, he seemed to have forgotten that truth.
Later in his WHCCAMP testimony Dr. Eisenberg offered a curious view of science, as it pertains to homeopathy, in responding to a question from homeopath and former NCCAM Director Jonas:
Wayne, I completely agree and I put up this slide to really humbly reflect on how the trajectory has gotten rather cockeyed, that in the absence of a robust basic science program, certainly the scientists in the medical community will continue to be irritated… So, I am agreeing with you.
I would say it a little differently, though. I think my suggestion in a positive, in a way to give a friendly amendment to what has happened, I think it has happened because it has happened. I mean, you know, if the first study was a basic science study of the mechanism of homeopathy, we would have a very different trajectory, but that didn’t happen.
Except that basic science did happen, as irritated scientists know. They might remind Dr. Eisenberg that there is an abundance of basic science pertaining to the “mechanism” of homeopathy: physics (the second law of the universe and no basis for “water memory”); chemistry (molecular theory and Avogadro’s number); biochemistry, physiology and pharmacology (pharmacokinetics, dose-response curves, the law of mass action, molecular receptors); pathology and pathophysiology (the natural history of disease and the classification of diseases according to real biological phenomena, as opposed to treatments based on irreproducible, subjective interpretations of “symptoms”).
A scientific study of the “mechanism” of homeopathy must also consider psychology and experimental design and interpretation for an appreciation of bias, cueing, selective attention, practitioner expectation, patient expectation, confirmation bias, the “Stockholm effect,” cultural predilections, the placebo effect, inadequate controls, error, fraud, chance, statistical pitfalls, publication bias, and more. These are the myriad reasons, i.e., “mechanisms,” by which any dogmatic therapeutic claim with little or no basis in nature can be expected, when subjected to clinical trials, to yield equivocal—as opposed to consistently negative—results.
As for the naïve assertion that even wholly negative results would dissuade true believers of homeopathy or any other magical healing “system,” which is the standard highbrow justification for the existence of the NCCAM, the HMS CAM project, and for the collective acquiescence of all who should know better, the last word must go to the good Dr. Holmes:
… it is impossible not to realize the entire futility of attempting to silence this asserted science by the flattest and most peremptory results of experiment. Were all the hospital physicians of Europe and America to devote themselves, for the requisite period, to this sole pursuit, and were their results to be unanimous as to the total worthlessness of the whole system in practice, this slippery delusion would slide through their fingers without the slightest discomposure, when, as they supposed, they had crushed every joint in its tortuous and trailing body.
† American Academy of Pediatrics. Judicious Use of Antimicrobial Agents. In Redbook 2000: Report of the Committee on Infectious Diseases, 25th edition. pp. 647-648. I am aware that subsequent to that time, new guidelines provide for a period of observation without antibiotics in some cases of acute otitis media. These were not in place at the time of the homeopathy trial, nor would they have applied to most of the experimental subjects in that trial. The children in the homeopathy trial, moreover, were also not given analgesics and antipyretics.
Next: A summary, and Hints that the Fix was In.
*The Harvard Medical School series:
- Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.3: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (concluded)
†The Homeopathy Series:
- Homeopathy and Evidence-Based Medicine: Back to the Future – Part I
- Homeopathy and Evidence-Based Medicine: Back to the Future – Part II
- Homeopathy and Evidence-Based Medicine: Back to the Future–Part III
- Homeopathy and Evidence-Based Medicine: Back to the Future Part IV
- Homeopathy and Evidence-Based Medicine: Back to the Future Part V
- Harvard Medical School: Veritas for Sale (Part III)
- The Dull-Man Law
- Smallpox and Pseudomedicine