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Scotty, The Naked Time, stardate 1704.3, Episode 7

A homeopathic refutation – part two

Posted by apgaylard on September 13, 2009

This post is the second in a series examining the claims made in a recent essay that seeks, in part, to refute common criticisms of homeopathy (Milgrom, 2009).  I have already examined the empty assertions about evidence for clinically useful specific effects.  Now, I would like to move on to examine an attempted refutation of claims that, “Homeopathy is deadly”. 

black_rubber_pirate_duckHow deadly is homeopathy?

Milgrom starts with a bit of distraction: “The claim that homeopathy is deadly has never been substantiated, primarily because it cannot be proved anyone has died as a direct result of taking a homeopathic remedy.” 

This is entirely irrelevant; no critical discourse that I have come across has made the claim that the remedies themselves are toxic*.  As I pointed out in my last post: the problem is not in the pills, but in their uselessness; and the attitudes of some homeopaths.  He then moves to the actual concerns of sensible critics: 

“The claim arises over concerns that those taking homeopathic remedies might forgo ‘life-saving’ drugs. This is a false perception: many who come to homeopathy do so only after conventional treatments have failed.”

And this is not right either: those who are able to turn to homeopathy after conventional treatment has failed are not going to be suffering from life-threatening illnesses.  They are generally people who are suffering from chronic complaints for which modern medicine has no good treatments (such as certain kinds of back pain, stress, medically unexplained fatigue, and modest viral illness – Goldacre, 2007).  The danger, such as it is, lies in choosing homeopathy instead of proper medicine for serious illness. That many will be using homeopathy to treat illnesses that are not life-threatening doesn’t mean that all users (or practitioners) of homeopathy are as conservative.

Milgrom’s rejection of any suggestion that homeopathy can harm is disappointing.  There are documented cases of people choosing homeopathy, or having it chosen for them, and dying as a direct result.  The number of fatalities appears to be low, but denying that there is any problem at all is rash. 

For instance, Gloria Thomas died at nine months of age, from sepsis, after her homeopath father ‘treated’ her eczema with homeopathy instead of seeking proper medical aid.  A UK GP, Dr Marisa Viegas was eventually struck-off after a she advised a patient with idiopathic dilated cardiomyopathy to take homeopathic treatments instead of the drugs she needed.  The patient died as a result. 

An example of the dangers of the disregard that some homeopaths show for conventional medicine and evidence is seen in the untimely death of Russell Jenkins, a CAM practitioner.  He took the advice of homeopath Susan Finn, who suggested that he treat an electrical burn with Manuka honey.  As a result of this improper treatment, he died from gangrene.  This is a different form of harm, but no less dangerous. 

Add to this the documented incidents of UK homeopaths advocating homeopathy for malaria prophylaxis and the activities of homeopaths in developing countries who believe they can treat AIDS and malaria: there are real risks. 

Again, I would not want to over-state the problem; but it is inappropriate for Milgrom to ignore it. 

Other homeopathic harms

Not all the harms of homeopathy are directly deadly ones.  A risk analysis that only focuses on extreme outcomes is too simplistic: there are real harms that don’t kill.  For instance, Goldacre (2007) identified a range of other risks associated with homeopathy.  These include medicalisation, “the reinforcement of counterproductive illness behaviours, and promotion of the idea that a pill is an appropriate response to a social problem, or a modest viral illness.” 

Also, by knowingly prescribing placebos medical practitioners can undermine the notions of informed consent and patient autonomy.  

As Milgrom’s essay shows, homeopaths are apt to denigrate conventional medicine.  This attitude can also lead some homeopaths to undermine public-health campaigns, like those promoting vaccination

Finally, as Milgrom shows, homeopaths have a tendency to misrepresent scientific evidence, undermining the public understanding of both science and medicine. 

It is important to recognise that even placebo medicine has a range of risks associated with it. 

What are homeopaths for?

Milgrom then moves on to flirt with the placebo effect.  After making what we have seen is the unjustifiable assertion that there, “is evidence to support homeopathy is more than a placebo response.”  He notes that, “homeopaths like other health practitioners, responsibly encourage expectation of positive outcomes”.  This is fair enough.  The evidence shows that any benefit that homeopaths deliver through the therapeutic encounter is due to expectation effects (Shang et al, 2005).  If homeopaths were open about this then, perhaps, there could be a role for them in a clinical setting. 

However, there is a sizable fly in the ointment.  As Milgrom says, health practitioners, “responsibly encourage expectation of positive outcomes.”  Proper medical practitioners can deliver specific effects through their interventions, along with non-specific expectation effects.  They also have the advantage of diagnostic training and don’t disparage other medical disciplines.  Given this, who needs homeopaths? 

Neither does encouraging positive expectations reduce the risks involved with homeopaths pretending to treat malaria, AIDS or other dangerous diseases.  This line of attack has little relevance to the matter at hand. 

Wouldn’t that be NICE?

Similarly irrelevant are the author’s claims about Prozac: a particular pharmaceutical being either ineffective or unsafe doesn’t mean that homeopathy is either effective or safe.  Anyway, Milgrom’s analysis is problematic in its own right: 

“One of the world’s top-selling drugs, the anti-depressant Prozac, was recently shown to be no better than placebo [22]. Yet, with an effect size of only d ~ 0.3 (the National Institute for Health and Clinical Excellence – NICE – recommends d = 0.5 for clinical efficacy), there are no urgent calls for Prozac’s withdrawal through ‘lack of efficacy’.”

His reference [22] is to Kirsch et al. (2008) and it does not say what he claims it says.  First, this paper looks at what evidence was available before Prozac was licensed, not the totality of the data.  As Ben Goldacre has observed**:

“It is common for quacks and journalists to think that the moment of licensing is some kind of definitive “it works” stamp of approval. It’s not, it’s just the beginning of the story of a drugs’ evidence, usually.”

So this paper does not show what the best evidence is for the efficacy, or otherwise, of Prozac (fluoxetine) for the treatment of depression.

Milgrom has also confused the result for a specific drug, fluoxetine, with a pooled analysis of all the drug groups against their placebo groups (Table 2, Model 3a).  The paper says that the drug group: 

“[…] does not meet the three-point drug–placebo criterion for clinical significance used by NICE. Represented as the standardized mean difference, d, mean change for drug groups was 1.24 and that for placebo 0.92, both of extremely large magnitude according to conventional standards. Thus, the difference between improvement in the drug groups and improvement in the placebo groups was 0.32, which falls below the 0.50 standardized mean difference criterion that NICE suggested.”

So, this is where Milgrom’s “d ~ 0.3″ comes from.  It does not relate specifically to fluoxetine, but rather to a pooled analysis for all the drugs covered in this review.  In fact, the mean difference between the drug and placebo groups, “easily attained statistical significance.” 

The paper does show that the drugs studied achieved both statistically and clinically significant improvements, compared to placebo, for the most severely depressed.  As Figure 3 shows (below), they also exceeded the NICE criterion for these patients (the green bit).

Kirsch_Figure_3

Neither does the essay contain any mention of the weaknesses of this study, or the criticisms that have been levelled at it***.

Milgrom’s argument is further weakened by the fact that NICE have, since 2004, taken the position that:

“Antidepressants are not recommended for the initial treatment of mild depression, because the risk–benefit ratio is poor.”

So, for cases where the evidence does not support the use of drugs like Prozac, NICE recommends they are not used.

Here Milgrom overstates the scope of Kirsch et al. (2008) by implying that it is a definitive assessment of the efficacy of Prozac.  He also turns the argument into a simple binary choice: either the drug works or it doesn’t.  Reality is more complicated: the effectiveness of this (and other) drugs varies with the severity of the depression.  Whilst they may not be justifiable treatments in some cases, they are in others.

By arguing that drugs which don’t meet the NICE criteria should be withdrawn, he is also setting the bar too high for homeopathy.  It’s notable that he provides no “d” values for any single homeopathic treatment.  Prozac may not be very useful for treating all but the most severe cases of depression, but there is no evidence that homeopathy can help at all.  After reviewing the literature Pilkington et al (2005) concluded:

“Evidence for the effectiveness of homeopathy in depression is limited because of a lack of high-quality clinical trials.”

I am sure that it’s possible to argue that anti-depressants are over-prescribed and their benefits are at times over-stated.  However, their limitations appear to be appreciated by the medical community and strategies are in place to align their use with the available evidence.  There may be legitimate controversy here, but it is clear that drugs like fluoxetine have some benefit, compared to placebo: not the zero benefit Milgrom alleges.  Furthermore, Milgrom appears to have misunderstood the paper he has cited: ascribing the results for a pooled analysis of number of drugs to a single drug.  He also has missed the guidance from NICE to limit the use of anti-depressants based on their risk-benefit ratio.

This essay is meant to be making the case for homeopathy.  In this context the discussion of Prozac is irrelevant.  This section of the essay is also meant to be overturning the notion that homeopathy is dangerous; again, a flawed analysis of Kirsch et al. (2008) does not contribute to this objective.

Real medicine has risks … but are they this big?

Then again, neither does his next argument, which claims that:

“Those who denounce homeopathy as ‘deadly’ should consider conventional medicine’s safety record; something recently scrutinised by the UK’s House of Commons Public Accounts Committee [23]. Including fatalities, this committee found that in 2006 alone, at least 2.68 million people were harmed by conventional medical interventions; representing 4.5% of the UK population …”

Milgrom’s reference [23] is this report:

Leigh E: A safer place for patients: Learning to improve patient safety. 51st report of session 2005–06 report, together with formal minutes, oral, and written evidence. House of Commons papers 831, 2005–06, TSO (The Stationery Office). July 6, 2006.

It can be found here.  The first thing that stands out is that it was published in early July 2006: so it’s obvious that it cannot provide data for “2006 alone”.  This raises some suspicion about the rest of the claims.

As does the fact that I cannot find Milgrom’s figures in this report.  What Leigh (2006) examines is how patients can be treated more safely.  It looks at the incident reporting systems in the NHS, along with how it can better learn lessons when things go wrong.  It does not provide any estimates of the number of people “harmed by conventional medical interventions”.  It’s concerned with episodes of unintentional harm: medical accidents.  On this specific topic it quotes a previous report which, “estimated that one in ten patients admitted to NHS hospitals are unintentionally harmed”.   This is consistant with a recent report on patient safety from the House of Commons Health Committee (Barron, 2009).

So, if we take this rate of harm and apply it to 2006, how close do we get to Milgrom’s figures?  For the year 2005/06 the NHS Hospital Episode Statistics count 12,678,628 admission episodes.  If one in ten of these admissions resulted in harm, this implies around 1.3 million incidents of harm.  The report cites nothing which would allow us to assess the number of people harmed, or include medical accidents that may occur to patients who were not admitted to hospital (under the care of a GP or treated as an out-patient, for example). This report only provides information on harm done to hospital in-patients; and a crude estimate at that.

Terry et al(2005) also points out that injuries due to falls ranks as one of the most common causes of these incidents.  To place these events at the feet of conventional medicine, rather than the process of caring for the sick, would seem to be harsh.

Finally, it is, of course, not valid to relate this figure to the UK population as the data refers to incidents not individuals.

Either I’m missing something (always a possibility) or Milgrom’s figures must come from elsewhere.  It might be that they are correct and that this is just a mis-citation.  In any case, he should make clear where these numbers actually came from.

Ultimately this is another irrelevance.  The rate of harm resulting from conventional medicine must be set against the benefits it delivers.  We have seen that homeopathy’s magic pills and potions may offer no risk in themselves – because they don’t contain anything – but neither do they provide any benefit. 

It must also be recognised that conventional hospitals often care for desperately sick people with complex conditions: under these circumstances mistakes are more likely.  However, Milgrom’s simplistic analysis makes no attempt to do this, rendering it useless.  Further, it has no relevance to concerns about the safety of the practise of homeopathy.  It’s just a bit of tu quoque.

Ultimately, all healthcare providers should be striving to do less harm.  The rate of medical accidents within the UK’s NHS – whilst comparable to that in other developed countries – is still too high.

However, safer medical practise should also include stopping homeopaths treating serious medical conditions and the abandonment of medical interventions that incur risk without benefit. 

Critics refuted?

So has Milgrom managed to refute the charge that, “Homeopathy is deadly and those who practice it are at best purveyors of a placebo effect”?  I don’t think so.   This part of the essay is very weak.

It  steadfastly ignores the documented incidents of harm caused by homeopaths treating serious diseases.  His concept of homeopathic damage is simplistic, limited to deaths which are not acknowledged.

It may be that homeopaths, “responsibly encourage expectation of positive outcomes”.  But that is all they have.  Real medicine can offer this and more: effective treatments.

Going on the offence, Milgrom offers nothing more than two examples of ill-founded tu quoque.  First, nasty critics call homeopathy a placebo, so he says Prozac is nothing more than a placebo.  Of course, that’s not really true; Milgrom has mis-read the evidence, not acknowledged its limitations and ignored the effectiveness of anti-depressants under particular circumstances.  He also invokes NICE criteria when discussing Prozac, even though it’s clear that no homeopathic intervention could meet this standard, unlike the drug he disparages.

Similarly, critics say homeopathy is dangerous, so Milgrom says conventional medicine is too.  However, the source of Milgrom’s figures is obscure – they do not come from the report he cites.  Neither are they relevant: the failings of conventional medicine don’t make homeopathy any better.  And even with its failings conventional medicine is massively more successful than homeopathy can ever be.

All-in-all this is an empty attempt to justify an empty practise.  The scholarship is slap-dash and the arguments are flawed.  It is hard to imagine that this essay was subject to any meaningful review.

Next, I’ll look at Milgrom’s attempted refutation of “The claim that homeopathy is unscientific”.

Also in this series

A homeopathic refutation – part one – evidence.

Disclaimer

I am not a doctor.  This does not constitute medical advice.  If you need that consult a properly qualified and registered medical practitioner.

These are just my opinions, but I try to make sure that what I write is both accurate and fair.  If you think that I have got anything wrong please let me know.  If you are right I will happily change what I have written.

Notes

*Not all homeopaths use non-existent ‘medicine’.  Some of these could be toxic.

**Ben Goldacre made some interesting observations on this paper in a piece published in the Guardian, “A quick fix would stop drug firms bending the truth” (blog version)

***The Pyjamas in Bananas blog has looked at this paper in detail and provides a good reference for this controversy.  This topic is clearly more complex than the caricature provided in this essay suggests.

References

Barron K, (chairman). Patient Safety – Health Committee – Sixth Report of Session 2008-09 – Volume I: Report, Together with Formal Minutes. London: The Stationery Office Limited; 2009. Available from: http://www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/151/151i.pdf.

Goldacre B. Benefits and risks of homoeopathy. The Lancet. 2007 November;370(9600):1672–1673. Available from: http://dx.doi.org/10.1016/S0140-6736(07)61706-1.

Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration. PLoS Med. 2008 February;5(2):e45+. Available from: http://dx.doi.org/10.1371/journal.pmed.0050045.

Leigh E, (chairman). A safer place for patients: Learning to improve patient safety. 51st report of session 2005/06.  Report, together with formal minutes, oral, and written evidence. London: The Stationery Office Limited; 2006. Available from: http://www.publications.parliament.uk/pa/cm200506/cmselect/cmpubacc/831/831.pdf

Milgrom LR. Under Pressure: Homeopathy UK and Its Detractors. Forsch Komplementmed. 2009 September;16(4):256–261. Available from: http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowAbstract&ArtikelNr=228916&Ausgabe=248719&ProduktNr=224242

Pilkington K, Kirkwood G, Rampes H, Fisher P, Richardson J.  Homeopathy for depression: a systematic review of the research evidence. Homeopathy : the journal of the Faculty of Homeopathy. 2005, July; 94(3):153–163. Available from: http://view.ncbi.nlm.nih.gov/pubmed/16060201.

Shang A, Huwiler-Müntener K, Nartey L, Jüni P, Dörig S, Sterne JA, et al. Are the clinical effects of homoeopathy placebo effects?  Comparative study of placebo-controlled trials of homoeopathy and allopathy. Lancet. 2005;366(9487):726–732. Available from: http://dx.doi.org/10.1016/S0140-6736(05)67177-2.

Terry A, Mottram C, Round J, Firman E, Step J, Bourne J. A safer place for patients: learning to improve patient safety. London: National Audit Office; 2005. Available from: http://eprints.whiterose.ac.uk/3427/.

Acknowledgements

dvnutrix for pointing this nonsense out to me.

Edits

None yet!

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29 Responses to “A homeopathic refutation – part two”

  1. warhelmet said

    Excellent post!

  2. Mea Culpa said

    [...] so happens that no sooner was this posted than there appeared Part 2 of the devastating refutation of Lionel Milgrom’s attempt to defend homeopathy, written by AP Gaylard. Thanks to Mojo (comment #2) for pointing this [...]

  3. Good work! No comments or additions needed.
    Really, Milgrom’s article is more marketing than science. Even by alternative standards, a journal with titled “Forschende Komplementärmedizin” (Research in Complementary Medicine) should have second thoughts about publishing this.

  4. gimpy said

    Excellent analysis. I do hope Dr Milgrom chooses to respond to this criticism.

    On the subject of Kirsch et al., PJ and others did some analysis of that paper that provoked a response from the authors. You can find details on his blog.

  5. asteriz said

    “Homeopathic Individualized Q-potencies versus Fluoxetine for Moderate to Severe Depression: Double-blind, Randomized Non-inferiority Trial”
    http://ecam.oxfordjournals.org/cgi/content/full/nep114#B44

    This recent RCT found that both treatments were viable in moderate to severe depression. Adverse effects were more frequent in the fluoxetine group, but appear to be balanced by the exclusions due to worsening of depression in the homeopathy group. Fixed positions for and against homeopathy may be as inappropriate as they are regarding Prozac.

    • elboffo said

      “Hahnemann’s dynamization gained support of physics: thermoluminescence emitted by ‘ultra-high dilutions’ (dynamizations) of lithium chloride and sodium chloride was specific of the salts initially dissolved, despite their dilution beyond the Avogadro number (11). ”

      With rubbish and outright lies like this in the paper can you expect anyone to take it seriously?

      Fixed positions on homeopathy are acceptable given the overwhelming evidence that it is nonsense.

      • asteriz said

        Thanks for pointing that out. Ref 11 is Louis Rey, “Thermoluminescence of ultra-high dilutions of lithium chloride and sodium chloride” Physica A: Statistical Mechanics and its Applications, 2003, 323:67-74. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TVG-481MMWB-2&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=0dd37a60a935ce27e1ac6ccc41b2ef1c

        I’m not sure that the appropriate response is to call Rey a liar. Or maybe you’re calling the depression trialists liars? Personally, I would rather know if Rey’s work has been replicated.

      • apgaylard said

        @asteriz
        You might be interested to know that Rey published very similar data in the issue of Homeopathy in 2007 that addressed so-called water memory. The work has been criticised on several grounds (see here and here). A regular on this blog also caught him out claiming his work had been replicated (R. Van Wijk) when it had not. It would appear that this is actually a failed replication which should raise doubts about the validity of Rey’s ideas.

        I think that one of the peoblems with the paper you cite is that it relies on this single piece of work to substantiate a broad claim, without being objective about its potential weaknesses.

        Other problems with this paper are:
        1. It’s published in a low-quality CAM journal.
        2. It has near to zero prior probability.
        3. It’s a single, relatively small, DBRCT – judgements need to be made on a body of literature due to the problem of false positives (due to fluke and various biases)
        4. (Linked to 3) It’s unreplicated.

        Whilst I would not call anyone a liar, I do think that its very easy to be mistaken. My position on homeopathy is that there is no robust evidence that it works and no reason why it should. Yes, there are trials where it seems to – with enough researchers producing trials and imperfect controls for biases there are bound to be. What matters, as Shang et al (2005) demonstrates, is what the totality of the evidence says as you progressively filter out biases. On the matter of putative mechanisms of action, like water memory, there are many suggestions and lots of low-quality endevour. There is no plausible suggestion as to how water might remember at all, let alone with the specificity homeopathy requires. Next, there is no mechanism for communicating this to the person. And again, no way for the water to talk to the sugar pill that’s often used and for it to remember what it has been told!

        Homeopathy is effectively a set of extraordinary claims for which there is not even ordinary evidence.

        Show me extraordinary evidence and I’ll review my position; but I’ll not get excited over a single trial.

    • asteriz said

      @apgaylard
      Sure, a small DBRCT, but who would start a large trial without results from a small one? This was a reasonably sized trial following on from a noninferiority pilot that had the same result. Your criticism is a priori, not about internal and external validity. Further research is justified.

      I’m not a physicist, so forgive me if I have misunderstood anything during a readthrough of the 2 primary thermoluminescence papers today. Rey refers readers of the summary in Homeopathy to his 2003 paper for the methods. He used controls, and gave separate graphs for D2O versus D2O plus LiCl or NaCl. He referenced the reason for selecting LiCl, based on his prior research (results also shown), and gave the starting concentrations for the dilution tests. His critics seem to have ignored all those points, which suggests they didn’t read the 2003 paper.

      Rey stored the irradiated blocks for 1 week before measuring thermoluminescence. Van Wijk wanted to investigate time factors, and stored different irradiated samples for 1, 2, or 3 weeks before thermoluminescence. He did not find significant differences after 1 week, but did after 3 weeks. He also found highly significant differences between D2O and homeopathically diluted D2O that again increased with storage time. The critics don’t mention any of that, which suggests they didn’t read this paper either.

      Instead, they just cite “the difference from all of these recordings of these substances was not statistically significant” as evidence of a failed replication. As a medical editor, I would have had to ask the Dutch authors what they meant by that, given that they did report statistical differences. I suspect they meant, “Not all the differences were statistically significant”. That fits their findings, and if that’s what they meant, it’s a bit different from a failed replication. As they said, the phenomena are unexplained and merit further research. Whether it sheds any light on homeopathy is another matter.

      • apgaylard said

        Thanks for an interesting reply. Maybe I’ll get around to doing something a bit more comprehesive on the Adler paper later. I note that you haven’t addressed the issue of prior probability; given this I am less than convinced that any further research is worthwhile.

        I’ll make some comments on Rey’s work in the next installment. In the meantime, I’ll tell you why I’d say that Van Wijk is a failed replication of Rey. This is what the paper says:

        “We report here differences in thermoluminescence between C15 D2O and C15 LiCl, which correspond with the observations reported by Rey (2003). However, the difference from all of these recordings of these substances was not statistically significant. The present data suggest that such differ-ence tended to be significant only when the experiment was carried out three weeks after preparation of the substances and with a short time be-tween irradiation and thermoluminescence recording.”

        So on a strictly like-for-like comparision Van Wijk didn’t find what Rey did. Van Wijk did seem to find something, but it’s different to Rey. I don’t think that the critics have failed to read this paper; rather they have picked up on the failure to find what Rey found under the same conditions.

        There are some more things that I can say, but I’ll leave that for my next post.

  6. metherton said

    Milgrom seems to have entirely invented the figures in his reference to the Public Accounts Committee report. For a start, as Apgaylard points out, it cannot refer to 2006 figures since it was published in July that year. What’s more, it was agreed by the Committee in June and the oral evidence session took place in January. Even though the Department of Health and the National Audit Office (NAO) each submitted written evidence after the oral session, the figures not cover 2006 either. The DoH figures on updating patient deaths (Ev 18 in the report) quote the NPSA’s first Patient Survey Observatory report, published in July 2005, so the figures presumably come from 2004 at the latest. Similarly, the NAO’s supplementary evidence (Ev 21), on incidents per 1,000 staff, gives figures from 2003-04 and 2004-05.

    The Committee’s oral evidence session was, as usual for the PAC, based on an NAO report. This is referenced in fn 1 of the PAC report (in the Summary) and can be found at http://nao.org.uk/publications/0506/a_safer_place_for_patients.aspx The figures of 2.68 million or 4.5% of the population do not appear anywhere in the NAO report either. What the NAO report does say is that based on information from 96% of NHS acute, ambulance and mental health trusts, in 2004-05 there were about 974,00 reported incidents and near misses. The report makes clear that this is probably an under-estimate and that, for a start, there were likely to have been some 300,000 more incidents arising from hospital acquired infections. It goes on to say that the most common incidents reported were patient injury (due to falls), followed by medication errors, equipment related incidents, record documentation error and communication failure. Surely Milgrom is not suggesting that homeopathic treatment stops people falling over?

  7. metherton said

    Sorry, I’ve just noticed that Apgaylard has already referenced the NAO report (as Terry et al. But the point remain that the figures Milgrom cites as appearing in the PAC report quite simply are not there.

    • apgaylard said

      Thanks for your comments. Glad that you can’t find them either. It makes me more confident that I’ve not missed something. Though, thinking about it, Milgrom’s numbers are so dire that I would have thought that they would be prominantly displayed in the report.

  8. draust said

    Shock horror: homeopaths make startling discovery –

    For the best chance of staying healthy, it is preferable not to be ill.

    In other breaking news:

    Pope reaffirms Catholic faith;
    Bears refuse to use indoor flush lavatories -”prefer woods”

    *sigh*

    On the whole, it is the elderly and ill who are in hospital. When Mrs Dr Aust worked in hospital general medicine, the average age of her patients was in their 70s, and the working definition of “elderly” in medicine is now 78+.

    While the level of medication errors, and treatment errors, in medicine is not good news, and is something people are actively working on bringing down, many of the “adverse drug reactions” are inevitable results of giving people biologically active compounds for perfectly good reasons. For instance, if you are an elderly lady with osteoporosis and are at risk of falling, breaking your hip, and subsequently dying in a hospital bed, then giving you a powerful anti-osteoporosis drug that is likely to help keep your bones strong enough for you to stay at home is probably a good thing. However, it will carry (inevitably) a risk – hopefully low – of some unwanted side-effects.

    This, of course, is what doctors (and other people with a brain) call “risk-benefit analysis”. If the balance is strongly towards benefits, then the endless homeo-wailing about the risks of treatments is really beside the point. It is all based upon the completely erroneous idea that if the person hadn’t been treated, then all would have been absolutely fine.

    It doesn’t take a rocket scientist – or a doctor – to work out that this is bollocks.

  9. [...] http://apgaylard.wordpress.com/2009/09/13/a-homeopathic-refutation-%E2%80%93-part-two/ [...]

  10. Asteriz,

    I’m the “regular” who “caught out” Rey’s rather optimistic claim that his work has been replicated. To be honest, I’m slightly irritated by the insinuation that I might not have (thoroughly) read the papers by Rey or (their alleged replication) by van Wijk. If I hadn’t read them, i wouldn’t have written on them.
    Be that as it may, I just had another look at van Wijk’s paper to refresh my memory and I really can’t find any other meaning to it than the one already mentioned: some trends went in the same direction as Rey’s observations, but the overall differences between C15 D2O and C15 LiCl in D2O were not statistically significant. Other differences are significant, as you’ve correctly observed, but changes between C15 D2O and untreated D2O aren’t really related to the memory of water concept.
    In fact, as far as I can tell, van Wijk’s is a decent paper that (unlike Rey’s original papers!) seems quite honest about the limitations of the experiments it describes. The authors freely admit that the scatter of the data is large. The whole of the data doesn’t really make sense in view of Rey’s original hypothesis. Rather, a summary of “complex phenomenon with lots of scatter and no clear trends” seems like an accurate description.
    So the most optimistic summary is that “more research is needed”. Van Wijk certainly hasn’t refuted or debunked Rey’s ideas – but Rey’s claim that he has confirmed them (i.e. reproduced the experimental findings) just isn’t correct.

  11. asteriz said

    @apgaylard
    I thought I mentioned priors twice: yours fixed (‘a priori’?), mine moveable (pilot study then trial?).
    What originally sparked my interest in the Adler trial was not homeopathy but the SSRI prior in kids:
    http://www.cks.nhs.uk/depression_in_children/drugs_in_this_topic

    @Philippe
    Sorry, no offence meant – I scanned enough of the criticism recommended by apg to suspect they had not read either primary paper, but not enough to realise you had. I agree with your analysis in general, but also with van Wijk that they found something inexplicable.

    Just because the Brazilian trialists used Rey as a figleaf doesn’t automatically mean they lied about their results.

    • apgaylard said

      “I thought I mentioned priors twice”

      Yes, sorry, I missed that in my haste. I Also take your point about small trials before large ones. There is also the issue with homeopathy as to whether even small ones are justified, not just in the absence of basic research, but in the face of it. If homeopaths focussed on some simple basic low-noise research models and got clear, consistant, positive results then small clinical trials would be a logical next step. As it is, testing medicine with no medicine in it seems futile. As Shang et al (and others) have shown: the larger better trials show no real clinical effects.

      It does look like van Wijk found something, but it’s very premature to see this anomaly as anyhting other than a prompt for further work. It would be nice to see this properly followed up.

      I entirely agree with your observation:

      Just because the Brazilian trialists used Rey as a figleaf doesn’t automatically mean they lied about their results.

  12. draust said

    Rey’s papers do not have much in the way of controls, though there is no suggestion he was other than painstaking.

    The basis for the thermoluminescence technique Rey used (i.e. the scientific basis of the emissions recorded – “what do these kind of readings tell us?”) is actually pretty obscure. The technique relies on freezing the sample, irradiating it in one of a number of ways, and then watching the thermoluminescence emissions while the sample re-warms. The general message is that the emissions depend upon “structural irregularities” in the crystal lattice of the frozen sample, but the details, to repeat, are poorly understood.

    As I once noted on David C’s blog, since loads of shaking probably produces lots of gas micro-bubbles in a solution, a frozen liquid that had contained micro-bubbles might easily have more/less “crystal structural irregularities” than a liquid that had not been shaken as much before freezing. But that would, of course, say nothing about mysterious “memories of previously dissolved molecules”. So Rey’s work really says nothing at all about homeopathy – “used… as a figleaf” is exactly right.

    • apgaylard said

      Thanks for the insight. I like the micro-bubble hypothesis. It fits with the best evidence for significant differences van Wijk reported being for his diluted and shaken solvent system compared to the base solvent, i.e. D2O vs C15 D2O. It would be good to see someone follow this up.

  13. Asteriz, APGaylard, Dr. Aust,

    I agree with your last comments. As Asteriz says, the experiments by Rey and van Wijk suggest that there is something interesting going on. With the evidence as scarce as it currently is, I’d tentatively subscribe to the idea suggested by Dr. Aust: that the vigorous shaking of the water somehow influences how much gas is dissolved in the water and/or how many micro-bubbles are in it. This in turn is likely to affect the thermoluminescence patterns. In fact, this was already hinted at in van Wijks paper. And it does fit with the reported differences between “original” D2O and the “shaken and stirred” (C15) preparations.

    So, to summarize on the thermoluminescence experiments: interesting, but not revolutionary.

  14. In his Homeopathy article (2007), by the way, Rey also mentions and discusses the nanobubble hypothesis. This can be found here:
    http://www.badscience.net/2000/01/journal-club-can-low-temperature-thermoluminescence-cast-light-on-the-nature-of-ultra-high-dilutions/

    Some evidence is even provided that the atmosphere under which the subsequent dilutions take place affect the thermoluminescence patterns. This kind of undermines the connection with the memory of water… in any case, again, there is no information from Rey about reproducibility, which really takes away much of the value of the whole paper. We’ll have to wait and see if others find similar results.

    • apgaylard said

      Thanks for the reminder.

    • draust said

      Yes, I should say that my comments on microbubbles owe a good bit to a brief email exchange I had with José Teixeira a couple of years ago when the online “journal club” on the Homeopathy special issue was ging on. I wrote to him about Rey’s work and he said that the “microbubble” idea was an obvious competing interpretation – see, in particular, Rey’s experiment that seemed to show that the atmosphere present during the shaking made a major difference (Figure 4 in Rey 2007, see Phillipe’s last link).

  15. draust said

    *sigh*

    WordPress is stripping the links out of all my comments, for some reason I don’t understand, unless it thinks BT Broadband is a spammer.

    Jose Texeira wrote “Can water have a memory? A Sceptical View” in the same special issue of Homeopathy. Adrian gives the reference in part 3 of his response to Lionel Milgrom.

  16. [...] http://bit.ly/d7e0Oq (2003) //distinguishing one homeopathy medicine from another Interesting, but largely irrelevant wrt homeopathy. Discussed here http://apgaylard.wordpress.com/2009/09/13/a-homeopathic-refutation-%E2%80%93-part-two/ [...]

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