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Stephen Barrett, M.D.
Homeopathic "remedies" enjoy a unique status in the
health marketplace: They are the only category of quack
compounds legally marketable as drugs. This situation
is the result of two circumstances. First, the 1938
Federal Food, Drug, and Cosmetic Act, which was shepherded
through Congress by a homeopathic physician who was
a senator, recognizes as drugs all substances included
in the Homeopathic Pharmacopeia of the United States.
Second, the FDA has not held homeopathic compounds to
the same standards as other drugs. Today they are marketed
in health-food stores, in pharmacies, in practitioner
offices, by multilevel distributors, through the mail,
and on the Internet.
Basic Misbeliefs
Samuel Hahnemann (1755-1843), a German physician, began
formulating homeopathy's basic principles in the late
1700s. Hahnemann was justifiably distressed about bloodletting,
leeching, purging, and other medical procedures of his
day that did far more harm than good. Thinking that
these treatments were intended to "balance the body's
'humors' by opposite effects," he developed his "law
of similars" -- a notion that symptoms of disease can
be cured by extremely small amounts of substances that
produce similar symptoms in healthy individuals when administered
in large amounts. The word "homeopathy" is derived from
the Greek words homoios (similar) and pathos (suffering
or disease).
Hahnemann and his early followers conducted "provings"
in which they administered herbs, minerals, and other
substances to healthy individuals, including themselves,
and kept detailed records of what they observed. Later
these records were compiled into lengthy reference books
called materia medica, which are used to match a patient's
symptoms with a "corresponding" drug.
Hahnemann declared that diseases represent a disturbance
in the body's ability to heal itself and that only a
small stimulus is needed to begin the healing process.
He also claimed that chronic diseases were manifestations
of a suppressed itch ( psora) , a kind of miasma or
evil spirit. At first he used small doses of accepted
medications. But later he used enormous dilutions and
theorized that the smaller the dose, the more powerful
the effect -- a notion commonly referred to as the "law
of infinitesimals." That, of course, is just the opposite
of the dose-response relationship that pharmacologists
have demonstrated.
The basis for inclusion in the Homeopathic Pharmacopeia
is not modern scientific testing, but homeopathic "provings"
conducted during the 1800s and early 1900s. The current
(ninth) edition describes how more than a thousand substances
are prepared for homeopathic use. It does not identify
the symptoms or diseases for which homeopathic compounds
should be used; that is decided by the practitioner
(or manufacturer). The fact that substances listed in
the Homeopathic Pharmacopeia are legally recognized
as "drugs" does not mean that either the law or the
FDA recognizes them as effective.
Because homeopathic remedies were actually less dangerous
than those of nineteenth-century medical orthodoxy,
many medical practitioners began using them. At the
turn of the twentieth century, homeopathy had about
14,000 practitioners and 22 schools in the United States
. But as medical science and medical education advanced,
homeopathy declined sharply in America , where its schools
either closed or converted to modern methods. The last
pure homeopathic school in this country closed during
the 1920s.
Many homeopaths maintain that certain individuals have a
special affinity to a particular remedy (their "constitutional
remedy") and will respond to it for a variety of ailments.
Such remedies can be prescribed according to the person's
"constitutional type" -- named after the corresponding
remedy in a manner resembling astrologic typing. The
"Ignatia Type," for example, is said to be nervous and
often tearful, and to dislike tobacco smoke. The typical
"Pulsatilla" is a young woman, with blond or light-brown
hair, blue eyes, and a delicate complexion, who is gentle,
fearful, romantic, emotional, and friendly but shy.
The "Nux Vomica Type" is said to be aggressive, bellicose,
ambitious, and hyperactive. The "Sulfur Type" likes
to be independent. And so on. Does this sound to you
like a rational basis for diagnosis and treatment?
The "Remedies" Are Placebos
Homeopathic compounds are made from minerals, botanical
substances, and several other sources. If the original
substance is soluble, one part is diluted with either
nine or ninety-nine parts of distilled water and/or
alcohol and shaken vigorously (succussed); if insoluble,
it is finely ground and pulverized in similar proportions
with powdered lactose (milk sugar). One part of the
diluted medicine is then further diluted, and the process
is repeated until the desired concentration is reached.
Dilutions of 1 to 10 are designated by the Roman numeral
X (1X = 1/10, 3X = 1/1,000, 6X = 1/1,000,000). Similarly,
dilutions of 1 to 100 are designated by the Roman numeral
C (1C = 1/100, 3C = 1/1,000,000, and so on). Most remedies
today range from 6X to 30X, but compounds of 30C or more
are marketed.
A 30X dilution means that the original substance has
been diluted 1,000,000,000,000,000,000,000,000,000,000
times. Assuming that a cubic centimeter of water contains
15 drops, this number is greater than the number of
drops of water that would fill a container more than
50 times the size of the Earth. Imagine placing a drop
of red dye into such a container so that it disperses
evenly. Homeopathy's "law of infinitesimals" is the
equivalent of saying that any drop of water subsequently
removed from that container will possess an essence
of redness. Robert L. Park, Ph.D., a prominent physicist
who is executive director of The American Physical Society,
has noted that since the least amount of a substance
in a solution is one molecule, a 30C solution would
have to have at least one molecule of the original substance
dissolved in a minimum of 1,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,
000,000,000,000 molecules of water. This would require
a container more than 30,000,000,000 times the size
of the Earth.
Oscillococcinum , a 200C product "for the relief of
colds and flu-like symptoms," involves "dilutions" that
are even more far-fetched. Its "active ingredient" is
prepared by incubating small amounts of a freshly killed
duck's liver and heart for 40 days. The resultant solution
is then filtered, freeze-dried, rehydrated, repeatedly
diluted, and impregnated into sugar granules. If a single
molecule of the duck's heart or liver were to survive
the dilution, its concentration would be 1 in 100 200
. This huge number, which has 400 zeroes, is vastly
greater than the estimated number of molecules in the
universe (about one googol, which is a 1 followed by
100 zeroes). In its February 17, 1997 , issue, U.S.
News & World Report noted that only one duck per
year is needed to manufacture the product, which had
total sales of $20 million in 1996. The magazine dubbed
that unlucky bird "the $20-million duck."
Actually, the laws of chemistry state that there is
a limit to the dilution that can be made without losing
the original substance altogether. This limit, which
is related to Avogadro's number, corresponds to homeopathic
potencies of 12C or 24X (1 part in 10 24 ). Hahnemann
himself realized that there is virtually no chance that
even one molecule of original substance would remain
after extreme dilutions. But he believed that the vigorous
shaking or pulverizing with each step of dilution leaves
behind a "spirit-like" essence -- "no longer perceptible
to the senses" -- which cures by reviving the body's
"vital force." Modern proponents assert that even when
the last molecule is gone, a "memory" of the substance
is retained. This notion is unsubstantiated. Moreover,
if it were true, every substance encountered by a molecule
of water might imprint an "essence" that could exert
powerful (and unpredictable) medicinal effects when
ingested by a person.
Many proponents claim that homeopathic compounds resemble
vaccines because both provide a small stimulus that
triggers an immune response. This comparison is not
valid. The amounts of active ingredients in vaccines
are much greater and can be measured. Moreover, immunizations
produce antibodies whose concentration in the blood
can be measured, but high-dilution homeopathic compounds
produce no measurable response. In addition, vaccines
are used preventively, not for curing symptoms.
Stan Polanski, a physician assistant working in public
health near Asheville , North Carolina , has provided
additional insights:
. Imagine how many compounds must
be present, in quantities of a molecule or more, in
every dose of a homeopathic drug. Even under the most
scrupulously clean conditions, airborne dust in the
manufacturing facility must carry thousands of different
molecules of biological origin derived from local sources
(bacteria, viruses, fungi, respiratory droplets, sloughed
skin cells, insect feces) as well as distant ones (pollens,
soil particles, compounds of combustion), along with
mineral particles of terrestrial and even extraterrestrial
origin (meteor dust). Similarly, the "inert" diluents
used in the process must have their own library of microcontaminants.
. The dilution/potentiation process
in homeopathy involves a stepwise dilution carried to
fantastic extremes, with "succussion" between each dilution.
Succussion involves shaking or rapping the container
a certain way. During the step-by-step dilution process,
how is the emerging drug preparation supposed to know
which of the countless substances in the container is
the One that means business? How is it that thousands
(millions?) of chemical compounds know that they are
required to lay low, to just stand around while the
Potent One is anointed to the status of Healer? That
this scenario could lead to distinct compounds uniquely
suited to treat particular illnesses is beyond implausible.
. Thus, until homeopathy's apologists
can supply a plausible (nonmagical) mechanism for the
"potentiation"-through-dilution of precisely one of
the many substances in each of their compounds, it is
impossible to accept that they have correctly identified
the active ingredients in their compounds. Any study
claiming to demonstrate effectiveness of a homeopathic
medication should be rejected out-of-hand unless it
includes a list of all the substances present in concentrations
equal to or greater than the purported active ingredient
at every stage of the dilution process, along with a
rationale for rejecting each of them as a suspect.
. The process of "proving" through
which homeopaths decided which medicine matches which
symptom is no more sensible. Provings involved taking
various substances recording every twitch, sneeze, ache
or itch that occurred afterward -- often for several
days. Homeopathy's followers take for granted that every
sensation reported was caused by whatever substance
was administered, and that extremely dilute doses of
that substance would then be just the right thing to
treat anyone with those specific symptoms.
Dr. Park has noted that to expect to get even one molecule
of the "medicinal" substance allegedly present in 30X
pills, it would be necessary to take some two billion
of them, which would total about a thousand tons of
lactose plus whatever impurities the lactose contained.
Cell Salts
Some homeopathic manufacturers market twelve highly
diluted mineral compounds called "cell salts" or "tissue
salts." These are claimed to be effective against a
wide variety of diseases, including appendicitis (ruptured
or not), baldness, deafness, insomnia, and worms. Their
use is based on the notion that mineral deficiency is
the basic cause of disease. However, many are so diluted
that they could not correct a mineral deficiency even
if one were present. Development of this approach is
attributed to a nineteenth-century physician named W.H.
Schuessler.
"Electrodiagnosis"
Some physicians, dentists, and chiropractors use "electrodiagnostic"
devices to help select the homeopathic remedies they
prescribe. These practitioners claim they can determine
the cause of any disease by detecting the "energy imbalance"
causing the problem. Some also claim that the devices
can detect whether someone is allergic or sensitive
to foods, vitamins, and/or other substances. The procedure,
called electroacupuncture according to Voll (EAV), electrodiagnosis
, or electrodermal screening , was begun during the
late 1950s by Reinhold Voll, M.D., a West German physician
who developed the original device. Subsequent models
include the Vega, Dermatron, Accupath 1000, and Interro
.
Proponents claim these devices measure disturbances
in the flow of "electro-magnetic energy" along the body's
"acupuncture meridians." Actually, they are fancy galvanometers
that measure electrical tolerance of the patient's
skin when touched by a probe. Each device contains a
low-voltage source. One wire from the device goes to
a brass cylinder covered by moist gauze, which the patient
holds in one hand. A second wire is connected to a probe,
which the operator touches to "acupuncture points" on
the patient's foot or other hand. This completes a circuit,
and the device registers the flow of current. The information
is then relayed to a gauge that provides a numerical
readout. The size of the number depends on how hard
the probe is pressed against the patient's skin. Recent
versions, such as the Interro make sounds and provide
the readout on a computer screen. The treatment selected
depends on the scope of the practitioner's practice
and may include acupuncture, dietary change, and/or
vitamin supplements, as well as homeopathic compounds.
Regulatory agencies have seized several types of electroacupuncture
devices but have not made a systematic effort to drive
them from the marketplace.
Unimpressive "Research"
Since many homeopathic remedies contain no detectable
amount of active ingredient, it is impossible to test
whether they contain what their label says. Unlike most
potent drugs, they have not been proven effective against
disease by double-blind clinical testing. In fact, the
vast majority of homeopathic compounds have never even
been tested.
In 1990, an article in Review of Epidemiology analyzed
40 randomized trials that had compared homeopathic treatment
with standard treatment, a placebo, or no treatment.
The authors concluded that all but three of the trials
had major flaws in their design and that only one of
those three had reported a positive result. The authors
concluded that there is no evidence that homeopathic
treatment has any more value than a placebo.
In 1994, the journal Pediatrics published an article
claiming that homeopathic treatment had been demonstrated
to be effective against mild cases of diarrhea among
Nicaraguan children. The claim was based on findings
that, on certain days, the "treated" group had fewer
loose stools than the placebo group. However, Sampson
and London noted the study used an unreliable and unproved
diagnostic and therapeutic scheme, there was no safeguard
against product adulteration, treatment selection was
arbitrary, the data were oddly grouped and contained
errors and inconsistencies, the results had questionable
clinical significance, and there was no public health
significance because the only remedy needed for mild
childhood diarrhea is adequate fluid intake to prevent
or correct dehydration.
In 1995, Prescrire International, a French journal
that evaluates pharmaceutical compounds, published a
literature review that concluded:
As homeopathic treatments are generally used in conditions
with variable outcome or showing spontaneous recovery
(hence their placebo-responsiveness), these treatments
are widely considered to have an effect in some patients.
However, despite the large number of comparative trials
carried out to date there is no evidence that homeopathy
is any more effective than placebo therapy given in
identical conditions.
In December 1996, a lengthy report was published by
the Homoeopathic Medicine Research Group (HMRG), an
expert panel convened by the Commission of the European
Communities. The HMRG included homeopathic physician-researchers
and experts in clinical research, clinical pharmacology,
biostatistics, and clinical epidemiology. Its aim was
to evaluate published and unpublished reports of controlled
trials of homeopathic treatment. After examining 184
reports, the panelists concluded: only 17 were developed
and reported well enough to be worth considering; in
some of these trials, homeopathic approaches may have
exerted a greater effect than a placebo or no treatment;
and the number of participants in these 17 trials was
too small to draw any conclusions about the effectiveness
of homeopathic treatment for any specific condition
. Simply put: Most homeopathic research is worthless,
and no homeopathic product has been proven effective
for any therapeutic purpose. The National Council Against
Health Fraud has warned that "the sectarian nature of
homeopathy raises serious questions about the trustworthiness
of homeopathic researchers."
In 1997, a London health authority decided to stop
paying for homeopathic treatment after concluding that
there was not enough evidence to support its use. The
Lambeth, Southwark, and Lewisham Health Authority had
been referring more than 500 patients per year to the
Royal Homoeopathic Hospital in London . Public health
doctors at the authority reviewed the published scientific
literature as part of a general move toward purchasing
only evidence-based treatments. The group concluded
that many of the studies were methodologically flawed
and that recent research produced by the Royal Homoeopathic
Hospital contained no convincing evidence that homeopathy
offered clinical benefit.
Proponents trumpet the few "positive" studies as proof
that "homeopathy works." Even if their results can be
consistently reproduced (which seems unlikely), the
most that the study of a single remedy for a single
disease could prove is that the remedy is effective
against that disease. It would not validate homeopathy's
basic theories or prove that homeopathic treatment is
useful for other diseases.
Placebo effects can be powerful, of course, but the
potential benefit of relieving symptoms with placebos
should be weighed against the harm that can result from
relying upon -- and wasting money on -- ineffective
compounds. Spontaneous remission is also a factor in
homeopathy's popularity. I believe that most individuals
who credit a homeopathic product for their recovery
would have fared equally well without it.
Homeopaths are working hard to have their services
covered under national health insurance. They claim
to provide care that is safer, gentler, "natural," and
less expensive than conventional care -- and more concerned
with prevention. However, homeopathic treatments prevent
nothing, and many homeopathic leaders preach against
immunization. Equally bad, a report on the National
Center for Homeopathy's 1997 Conference described how
a homeopathic physician had suggested using homeopathic
compounds to help prevent and treat coronary artery disease.
According to the article, the speaker recommended various
30C and 200C compounds as alternatives to aspirin or
cholesterol-lowering drugs, both of which are proven
to reduce the incidence of heart attacks and strokes.
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