Jun 27 2012
In 2011 the Swiss government completed an official examination of homeopathy, as part of its consideration of whether or not insurance companies should be made to cover homeopathic treatment. Their report, which concluded homeopathy is effective and should be covered, was published in English in February 2012. Not surprisingly, homeopathy promoters, like Dana Ullman writing for the Huffington Post, were quick to proclaim the virtues of the Swiss report and tout it as evidence for the effectiveness of homeopathy. Recently, however, a more critical review of the Swiss report has been published, revealing the report to be biased and scientifically suspect.
Ullman begins his crowing about the Swiss report with this dubious statement:
The Swiss government has a long and widely-respected history of neutrality, and therefore, reports from this government on controversial subjects need to be taken more seriously than other reports from countries that are more strongly influenced by present economic and political constituencies.
Political neutrality is not equivalent to being scientifically unbiased. Ullman, and other homeopaths, however, are keen to prefer the Swiss report over other government reports. This is because in 2010 the UK government performed their own systematic review of homeopathy – Evidence Check 2: Homeopathy. In their report they concluded that homeopathy is essentially witchcraft – that it does not work, its underlying principles are scientifically invalid and tantamount to magic, that it should not be covered by the national health service, and that it is not even worth any further research. Ullman strangely does not mention this report directly in his article.
How can two governments analyze the same question with the same set of data and come to opposite conclusions? The review of the Swiss report, by David Martin Shaw, gives us a clue. He writes:
This paper analyses the report and concludes that it is scientifically, logically and ethically flawed. Specifically, it contains no new evidence and misinterprets studies previously exposed as weak; creates a new standard of evidence designed to make homeopathy appear effective; and attempts to discredit randomised controlled trials as the gold standard of evidence. Most importantly, almost all the authors have conflicts of interest, despite their claim that none exist. If anything, the report proves that homeopaths are willing to distort evidence in order to support their beliefs, and its authors appear to have breached Swiss Academies of Arts and Sciences principles governing scientific integrity.
The data they looked at was the same – scientific studies showing that homeopathy does not work. Published systematic reviews of clinical trials of homeopathy do not show evidence that homeopathy has any physiological effect. Edzard Ernst reviewing these reviews concludes:
The findings of currently available Cochrane reviews of studies of homeopathy do not show that homeopathic medicines have effects beyond placebo.
What is very telling is that even reviews of homeopathic trials that try to put a positive spin on the data can’t help giving away the game, such as the conclusion of this review from France (perhaps the center of support for homeopathy):
There is some evidence that homeopathic treatments are more effective than placebo; however, the strength of this evidence is low because of the low methodological quality of the trials. Studies of high methodological quality were more likely to be negative than the lower quality studies. Further high quality studies are needed to confirm these results.
They are looking at the same evidence as Ernst but desperately try to focus on the positive – there is some evidence of effect. But high quality studies were more likely to be negative. That pattern is what tells the tale. If you look at the literature of any scientific question what you see is an inverse relationship between study quality and the spread of results. Low quality studies are all over the place, while high quality studies tend to zero in on the true effect size of what is being studied (in the case of homeopathy, zero). Basing any conclusions on the low quality studies is pure nonsense and an indication of bias.
Further, the low quality studies are not randomly scattered but often show systematic bias toward being positive, both researcher and publication bias. This bias can sometimes be revealed in so-called funnel plots, which graphically display the relationship between study quality and outcome.
What all this means is that if you want to actually answer the question, does homeopathy work, you need to rely upon the most rigorously designed placebo-controlled trials. Anything less is likely to reflect bias and be highly misleading. Systematic reviews generally reflect this, and the UK report on homeopathy reflected this reality – when properly studied, homeopathy does not work.
The Swiss study looked at the same data, but apparently wanted to come to a favorable conclusion. So they argued for a change in the normal rules of evidence, a common strategy among CAM proponents. They decided to rely more on “real-world effectiveness,” which is just CAM newspeak for “poorly controlled studies.” In the real world we cannot control for variables and blind subjects – those are artificial conditions of rigorous trials. Homeopaths are not the only ones to try this gambit. Acupuncturists, for example, have been trying to push “pragmatic” studies as if they were efficacy studies, which they are not (again, because they study “real-world” conditions and are not properly controlled).
In other words, this is all an elaborate deception as a means of preferring low quality studies that are amenable to a positive bias to rigorous studies that are more likely to reflect the true (non-existent) effect of homeopathy. Pragmatic studies are meant only to compare treatments that have already been demonstrated to have efficacy in rigorous trials. They are not a substitute for double-blind placebo controlled trials, and they certainly should not be used to trump the results of more rigorous trials.
In his critical analysis Shaw zeroes in on the bias evident in the Swiss report, quoting:
If homeopathy is highly likely to be effective but this cannot be consistently proven in clinical trials, the question arises of what conditions are needed for homeopathy to show its effectiveness and realise its potential, and what conditions threaten to obscure this?
In this statement they are assuming homeopathy works, but are frustrated by the fact that high quality clinical trials show that it does not work, therefore they want to find a kind of evidence that will fit their pre-determined conclusion and help them to promote homeopathy. This is what Ullman concludes is unbiased. Rather, this is a core feature of CAM and even pseudoscience in general – starting with a desired conclusion and then looking for evidence to support it.
Shaw also points out that the majority of the authors of the Swiss report were in fact homeopaths. There was only one medically qualified expert on the panel who was not a homeopath or CAM practitioner. The fix, clearly, was in. And yet they declared no conflicts of interest. Shaw is very clear in his condemnation of this lack of scientific integrity:
The ethos of the research integrity guideline is that “Scientific misconduct must not be tolerated.” In this case, it has not only been tolerated but given the stamp of approval by the Swiss government and used to inform health policy: from January 2012, homeopathy will be included in health insurance cover, contributing in part to a rise in insurance premiums of as much as 4.4%.
The Swiss report represents a biased review largely by homeopaths who changed the rules of evidence in order to declare that homeopathy works. Other homeopaths then present this review as unbiased and definitive. This is behavior that would make even the most unscrupulous pharmaceutical rep blush.
This is also, unfortunately, not an isolated incident. This represents a general strategy apparent in the world of CAM – to present themselves as the experts so that they can pack panels with proponents and then advocate for changing the normal rules of scientific evidence in order to produce highly biased assessments of CAM. Further, they portray skeptics (meaning those who advocate for consistent and rigorous scientific methods) to be biased so that when they point out that the emperor has no clothes they can be dismissed.
The Swiss report on homeopathy represents an embarrassing failure for the Swiss government. They should suspend any decisions based upon this report and put together an new scientific panel to perform a fresh and legitimate review of homeopathy. Or, they don’t have to reinvent the wheel – they can just review the UKs thorough and rigorous report and adopt its findings. Homeopathy is witchcraft and deserves no government support of any kind.
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