An article published in the Guardian is making the rounds quite rapidly among my social media circles. The article, coverage of a report by the Australian National Health and Medical Research Council, makes some pretty bold statements about the efficacy of homeopathy – namely that it doesn’t work:
But the NHMRC review, conducted by a working committee of medical experts, said it had no impact on a range of conditions and illnesses including asthma, arthritis, sleep disturbances, cold and flu, chronic fatigue syndrome, eczema, cholera, burns, malaria and heroin addiction. For the 68 conditions – including those listed – the review either concluded definitively that homeopathy was not more effective than a placebo, or at the very least there was no reliable evidence to suggest it was.
The skeptics in my Facebook and Twitter feeds are, perhaps unsurprisingly, feeling pretty vindicated by this report. They (we) have been saying for quite some time that homeopathy is nothing more than a hoax perpetrated against a credible public by people who are either so craven as to intentionally exploit people’s ignorance, or so irresponsible as to refuse to examine the abundant scientific evidence that homeopathy is simply a placebo with an elaborate ritual preceeding it. I myself have participated in a couple of demonstrations of the fact that homeopathy simply does not work, both times taking an “overdose” of homeopathic “sleeping pills” that are, in fact, nothing more than sugar pills.
However, if you are not close friends with someone in the skeptics community, or if you simply don’t care to follow this particular debate, you might find yourself a bit lost. I thought I would provide my somewhat-informed take on this report and what lessons we should take away from it.
What is homeopathy?
Homeopathy is a system of medicine founded on the belief that “like cures like”. That is, if you can stimulate the body’s natural responses to a condition like fever, nausea, insomnia, etc., then you can cure that condition. Homeopathy holds that using minute amounts of substances that have an effect, they can stimulate the body into counteracting that effect and ‘correcting’ whatever imbalance is causing the disease. So, for example, if you can’t sleep, you could take a very small amount of caffeine – this would cause the body to produce its natural reaction to being stimulated by the caffeine, causing sleepiness.
On the surface, and in the absence of any formal medical or physiology training, the principle described above doesn’t seem wildly implausible. Chemical imbalances do absolutely exist, and the body does have a remarkable ability to heal itself. There’s nothing that screams “hoax” there… yet.
The way that homeopathic practice works contemporarily is through a series of repeated dilutions of the substance in water. So you take your small amount of caffeine, and you place it in some distilled water, and then you shake it to thoroughly dilute it (these ‘shakings’ are termed “succussions”, because it wouldn’t be medicine if there weren’t a bunch of fancy-sounding words for simple things). Then you repeat this process, taking a small amount of the diluted substance and further diluting it in more distilled water, with still more succussions. This process is repeated often as many as thirty times, resulting in a mixture that almost certainly contains not even a single atom of the original substance (due to a pair of pretty fundamental concepts in chemistry called the mole and a thing called Avogadro’s Number). The result is, in every meaningful way, nothing more than water. Why do this dilution process? Because homeopathy holds that the more dilute the substance, the stronger the effect.
There’s more levels of arcane strangeness to homeopathy, including things like water having “memory” and the process of “provings”, but I’m fine stopping the explanation here. I do, however, want to point out that many people have a strong misconception about what homeopathy actually is. Many people have insisted to me that it’s about using herbs and natural cures and exercise. It is absolutely not those things. Homeopathy is a specific term that refers to a specific practice – it is not a “catch-all” for ‘natural medicine’. Naturopathy, a system of medicine that most often includes homeopathy, does involve the use of plant extracts and a holistic approach to disease diagnosis and treatment, but ‘naturopathy’ and ‘homeopathy’ are not synonyms.
Now, this is usually where the eyeballs of skeptics are rolling out of their heads, but I want to stress here that just because homeopathy sounds weird doesn’t make it impossible. Phrased in a particular way, anything can sound too weird to be plausible – “you’ve got cancer, so we’re going to blast you with radiation until the cancer goes away”. The question is not whether or not something sounds silly, it’s whether or not it works. Skeptics have, for a long time, been insisting that homeopathy not only does not work, but that it cannot work because it flies in the face of everything we understand about physics, chemistry, and biology. Dilute solutions are not stronger than concentrated ones, a solution that contains nothing of the solute doesn’t retain its effect, and like doesn’t cure like.
However, there always remains the possibility that we don’t know as much about the world as we think we do. Certainly the boundaries of science are constantly being pushed – many of the things we know today would largely be considered “impossible” by minds as brilliant as Aristotle or Newton. It’s absolutely possible that the fact that homeopathy simply cannot work is not sufficient grounds to conclude that it doesn’t work.
Which is where the study referenced in The Guardian comes in. Scientists reviewed all of the available published scientific studies on homeopathic treatment for a variety of medical conditions. This process, known as meta-analysis, is considered to be the highest standard of evidence in science. While individual studies may have a bias toward or away from a given finding, it is unlikely that multiple studies will have the same biases. By aggregating the available evidence, we get a clearer answer to the question “what do we know about this phenomenon?” Through the use of statistical techniques and appraisals of the quality of the evidence available (e.g., large studies are better than small ones, blinded trials are better than unblinded ones, studies with a control group are better than single-arm ones, etc.), we can get past the limitations that any single study will have.
What the Australian scientists found (and please note, they were not simply looking at Australian studies) is that the evidence leads to one of two conclusions for each of the 68 medical conditions they examined:
- There isn’t enough evidence to be able to say conclusively that homeopathy is effective (i.e., we don’t know if it works or not)
- The evidence suggests that homeopathy does not have an effect that is different from a placebo (i.e., we know it doesn’t work)
The first conclusion is very commonly caused by small numbers – if there haven’t been a lot of studies, and the studies that do exist are on a small number of people, it’s not possible to make the claim that two treatments have different effects. Any differences we see might simply be due to chance – if you flip a coin three times and get three ‘heads’, that doesn’t mean that you have discovered a perfect heads-flipping technique; it almost certainly means you were just lucky (or unlucky, if you wanted ‘tails’).
The second conclusion carries with it a bit more force – if you give someone a homeopathic treatment, it works exactly as well as if you give someone a fake treatment and simply tell them it’s homeopathic (or alternatively, don’t tell anyone whether or not they’re getting a homeopathic treatment). The act of giving someone something causes changes in their behaviour and physiology through a very weird and very fascinating thing called the “placebo effect”. While we might not be able to state with absolute certainty that homeopathy is just a placebo, we can state with some confidence that homeopathy doesn’t do anything better than a placebo and then make the tiny logical leap.
I want to turn next to some things that I hear people say when presented with findings like the ones in the aforementioned report.
“We know homeopathy works because it’s a long-established traditional method of healing”
Even if this were true (and it’s not – homeopathy is only ~250 years old), the fact that something is old doesn’t mean it works. One of the oldest models brought forward by “Western” medicine is the “four humours” hypothesis, which teaches that the body contains a mixture of four different types of fluids, and that disease is caused by imbalances between them. This, incidentally, is where we got the idea to do things like blood-letting. There is a very good reason that we don’t use this much older tranditional healing method any more – because it’s dangerous nonsense that has no basis in fact. Many people have been maimed or killed over the centuries by doctors using tradition instead of evidence. It is undoubtedly true that we are still doing this in contemporary medicine. That doesn’t mean, however, that we should simply adopt a healing method simply because it’s old – otherwise we’d still be sacrificing fatted animals to appease the gods.
“Homeopathy is better than conventional medicine because homeopathy doesn’t have any side effects”
It is only partially true that homeopathy doesn’t have any side effects. In the sense that homeopathy doesn’t have any effects, it’s quite true that it doesn’t have side-effects. After all, it’s just water and/or sugar. There’s nothing in it that could cause side-effects.
However, in the sense that people taking homeopathy are often not taking evidence-based medicine for their illnesses, they are putting themselves at risk of the “side effect” that comes with having an untreated disease. For something like a cold or headache this is merely inconvenient – you don’t feel any better but you also don’t feel any worse. However, if you take another look at some of the conditions that were evaluated in this study – asthma, malaria, cholera – the consequences of not having treatment could be fatal. While homeopathy (water) won’t make your asthma worse, it’s the wrong thing to reach for when you’re having an attack.
“Many conventional treatments are also not evidence-based”
This is both true and a classic example of “two wrongs don’t make a right”. I am no great fan of big swaths of conventional medicine. There are certainly treatments that a doctor will prescribe to you that have as little evidence of effectiveness as homeopathy does. Overprescription of antibiotics for influenza – a treatment that only works on bacteria and not on viruses like flu – is causing a looming and massive health scare worldwide. I would never in my life claim that conventional medical treatment and practice are infallible.
The answer to the failings of conventional medicine can’t be to use another failed system. We must absolutely fix the problems in medical care (this, to some degree, is what I do for a living) by using the scientific evidence, not abandoning it. There will always be hucksters trying to push the latest “miracle cure” for something. They can’t all be right, but they can absolutely all be wrong. That’s why we do science – to separate fact from fantasy.
“Homeopathy might not work for everyone, but it worked for me”
I think Lisa Simpson probably has the best answer for that question:
Homer: Not a bear in sight. The Bear Patrol must be working like a charm.
Lisa: That’s specious reasoning, Dad.
Homer: Thank you, dear.
Lisa: By your logic I could claim that this rock keeps tigers away.
Homer: Oh, how does it work?
Lisa: It doesn’t work.
Lisa: It’s just a stupid rock.
Lisa: But I don’t see any tigers around, do you?
[Homer thinks of this, then pulls out some money]
Homer: Lisa, I want to buy your rock.
We can’t simply assume that because someone got better after they used homeopathy, that the homeopathy caused the improvement. Any number of factors, including the aforementioned placebo effect, could easily explain why someone might see a change in their health. Think of any number of things you don’t believe in: ghosts, UFOs, demon possession, faith healing, Scientology, reincarnation, pick from a long list. For everything you don’t believe is true, you’ll be able to find at least one person on the planet who will swear that they’ve seen it directly.
This is the reason we do scientific studies – there are a whole bunch of biases that the human brain immediately seizes upon when trying to make the connection between cause and effect. Because the brain is so easy to trick, we have to very carefully test in order to rule out other causes. When people try to do that for homeopathy, homeopathy fails the test.
“I tried homeopathy because nothing else worked”
There really is no quick answer to this one. Oftentimes people have tried a whole host of expensive and ultimately ineffective conventional treatments for their chronic pain or fatigue or insomnia and have found no relief. In their desperate search for an improvement, they turn to “alternative” approaches like homeopathy. In some cases, they experience temporary or even permanent recovery afterward. It would take a really ghoulish person to look at someone who is no longer in pain and say “you should have kept suffering because studies say homeopathy doesn’t work”. I am certainly not such a ghoul.
However, as we established above, there’s no evidence at all that homeopathy (rather than the placebo effect) is what caused the improvement. What is certain, however, is that homeopathic practitioners will charge far more than I will for tap water accompanied by an elaborate ritual. If homeopaths were giving out their (probably-) placebos for free out of the goodness of their hearts, then maybe I wouldn’t care. But sick people who have no relief from conventional treatments are exactly the kind of people who will pay any price to anyone who promises them a miracle. And I don’t think that we should be in the business of encouraging or allowing what is essentially medical fraud simply because some people mistake it for healing. We certainly shouldn’t be stocking it on shelves in pharmacies and calling it medicine, or giving it as vaccinations against virulent disease.
We do an imperfect job of giving people medical care. We make it expensive, hard to access, and we overburden doctors to the point that they are giving insufficient care to people who desperately need help. All too often, we ignore low-cost alternatives and long-term systemic solutions in favour of what is exciting and novel. We do have a tendency to look for intervention in a reductive way, rather than recognizing that human health is a multifaceted and complex interconnected system. Fixes and improvements are desperately needed in order to ensure that people seeking relief can find it in a way that is safe and convenient. Those improvements must be guided by the best-quality scientific evidence.
The scientific enterprise is not without its faults either. The “publish or perish” model of academia has resulted in a dangerous erosion of the quality of the peer-review process, while creating an incentive to make scientific findings more sensational-sounding than the facts warrant. Scientists are human, with all of our attendant flaws and sins and biases. Improvements must also be made in the ways that we synthesize and report evidence, to ensure that we are making decisions based on reality and not what looks best on someone’s résumé.
All that being said, the flaws of the medical and scientific systems do not rescue homeopathy from being no better than water wrapped up in a lot of smoke and mirrors. And while people who have not been able to find relief from their pain have my profound sympathy, that does not change the fact that no amount of diluted nonsense is going to produce reliable results. The less time and effort we have to spend dealing with the harms of homeopathy, the more we free up to address the serious flaws in the medical system.
And while skeptics like myself may be enjoying some well-deserved smugness at the latest confirmation that homeopathy is a hoax, we must not allow ourselves to bask in our own shadenfreude. The second half of the statement “Homeopathy doesn’t work” has to be “so let’s find out what does”.