Neutral Switzerland is partial to homeopathy

Neutral Switzerland is partial to homeopathy WDDTY VOL 23, NO 1, MAY 2012

In April and May of 2012, WDDTY took part in the promotion of a report fraudulently misrepresented by homeopaths as an impartial Swiss Government report endorsing homeopathy as safe and effective. In fact, it was no such thing.

The flaws in the report, including undeclared conflicts of interest, rewriting the hierarchy of evidence and an utterly credulous approach to sources supportive of the authors’ agenda, were readily apparent. Within a month it had been characterised as “a case study in research misconduct” in the Swiss Medical Weekly, and subsequent clarification by Dr. Felix Gurtner of the Swiss Federal Office of Public Health authoritatively refuted the claim that this was an official report of any kind.

In truth, this was obvious form the start. Skeptical investigators took only days to analyse the reports claims and find glaring errors.

The promotion of this report by homeopaths is understandable, given that the evidence situation has developed not necessarily to homeopathy’s advantage, but it is unforgivable in a publication that seeks to present itself as an analytical voice objectively assessing health claims.

The story in April and the subsequent May cover story were blatant propaganda and strong evidence of chronic unreliability in the editorial process. An analysis illuminates the lack of critical attention and wilful blindness to obvious red flags which characterise much of WDDTY’s content.

Further resources on the “neutral Swiss report” that is not neutral and not a Swiss report.

Neutral Switzerland is partial to homeopathy WDDTY VOL 23, NO 1, MAY 2012

Lynne McTaggart

The home of two pharmaceutical giants comes out strongly in favour of homeopathy, legalizing national-health reimbursement

This was the result of a referendum in which the authors of the Bornhöft paper were apparently lead players in the Yes campaign; the referendum existed only because the headline claim is false: the PEK process resulted in the withdrawal of reimbursement. See later commentary for the reasons why this alone should have alerted McTaggart and the editorial panel to the fact that they were being sold a pup.

The most comprehensive assessment ever conducted by any governmental body into homeopathy has concluded that not only does it work, but that it is far more cost-effective than conventional medicine. In fact, it works so well that patients should be reimbursed for it on the National Health.

The report is not identified by anybody other than its promoters as being by a Swiss governmental body (even its authors do not actually make this claim). It is identified as being written by a team including anthroposophists and other homeopathy believers, and it is published not by the Swiss Government but by a commercial publisher.

The reference to the NHS may be an allusion to the UK’s House of Commons Science and Technology Committee Evidence Check 2: Homeopathy. Bornhöft et. al. is referenced within that document, a fact which even a minimally careful evaluation should have revealed, and would have also shown the context of its failure to

In a rare departure from its history of neutrality on many issues, the Swiss government conducted a detailed inquiry into homeopathy and other alternative therapies largely in response to their wide-spread use by both doctors and patients.

Another red flag that should have alerted the editorial board to fraudulent claims. First, the Swiss government is militarily neutral but not politically neutral. Second, if it was historically politically neutral, then why is this story not bigger?

Remarkably, nearly two-thirds of all medical practitioners in Switzerland rate alternative medicine, about 40 per cent use it and 85 per cent of the country wants their country’s national health to include these therapies.

Irrelevant appeal to popularity.

The study follows the 1998 decision by the Swiss government to expand its national insurance to include a number of alternative treatments, such as homeopathy, traditional Chinese medicine, and herbal and anthroposophical medicine. Nevertheless, government reimbursement was provisional, pending the outcome of an extensive government-commissioned study of the various treatments.

Provisional for five years, and it ended with the PEK process. Why did the editors not join the dots here?

Assessing the evidence

The task fell to the Swiss Network for Technology Health Assessment created by the government in 1999 to determine the best value for money invested on health.

The book-length report, called Homeopathy in Healthcare: Effectiveness, Appropriateness, Safety, Costs, edited by Gudrun Bornhöft and Peter F. Matthiessen, from both the University of Witten/ Herdecke in Germany and PanMedion Foundation in Zurich, comprehensively reviewed all the major evidence for homeopathy from major preclinical research (human cell lines, in plants and animals, and biochemical findings) and the big ‘gold-standard’ trials in humans—the randomized, double-blind, placebo-controlled ones—to systematic reviews, meta-analyses and epidemiological studies.

Only in the sense that it noted the gold standard evidence did not support its conclusions, so argued instead for a complete reversal of the usual hierarchy of evidence in medical science.

The report’s methodology had been used by the UK’s National Institute for Health Research as a means of assessing true effectiveness, safety and cost-effectiveness of the treatments available from the National Health Service. It has also been widely adopted by many other international agencies.

Misleading. The NIHR guidelines are wilfully abused.

The Swiss scientists had two major criteria for judging study quality: internal validity (quality of the study design and execution); and external validity (how accurately the studies reflect the use of homeopathy in real life).

These are the criteria they asserted in order to trample over the overwhelming consensus that homeopathy is a placebo intervention, yes.

Why did the editors not notice that these are non-standard criteria and clearly designed to allow placebo effects to be claimed as clinical effects?

Evaluating external validity is particularly crucial as research into homeopathy is often done by doctors and scientists with little understanding of how it should be used or which treatments work best for which patients. Many high-profile studies purporting to debunk treatments like homeopathy are essentially set up to fail because the researchers essentially don’t know what they’re doing.

Often, the researchers use the wrong remedy or use it inappropriately. Some homeopathy studies have attempted to use a ‘one-size-fits-all’ remedy for a condition, when it is widely understood that many conditions require individualized remedies.

This is standard homeopathy apologia. “You can’t evaluate our woo with your reductionist science” basically. The ways in which homeopaths rationalise failure (e.g. “wrong” remedy) are beyond the scope of this analysis but are well-known.

Why did the editors not challenge the obvious framing? Why did editorial review not pick up this use of the tu quoque fallacy?

After assessing all the available data, the Swiss team concluded that the high-quality investigations of preclinical basic research proved that homeopathic high-potency remedies induce “regulative and specific changes in cells or living organisms”.

There is plenty of analysis of this in the literature, and it notes that these studies are generally poor and rarely reproduced or reproducible. One of the authors of the document in question, Matthieson, was also an author of a document showing that most primary research into homeopathy is not reproduced, and only a minority of that which is reproduced, is replicated (source).

If this claim were true, it is clear that the widespread condemnation of homeopathy’s total lack of a plausible theoretical framework would not be valid so should not exist. Why did editorial review not pick up this glaring red flag?

 

Of the systematic reviews of human research, said the report, 20 out of 22 detected “at least a trend in favour of homeopathy”, and five showed “clear evidence for homeopathic therapy”.

The report found particularly strong evidence for the use of homeopathy for upper respiratory tract infections (URTIs) or allergic reactions: of studies showing a positive overall result in favour of homeopathy, six out of every seven showed at least equivalence to conventional interventions and, of 16 placebo-controlled studies, half showed significant results with homeopathy.

This is another red flag. if it works, it works. Why would it only work for some conditions, and not for other similar conditions? This is another red flag that should have been picked up by the author and editor.

Perhaps most significantly, the report concluded that the effectiveness of homeopathy “can be supported by clinical evidence” and “regarded as safe”. Applied properly, it said, “classical homeopathy has few side-effects and the use of high potencies is free of toxic effects” (Forsch Komple-mentmed, 2006; 13 Suppl 2: 19–29).

This contradicts the House of Commons Evidence Check, which also references this document. Why was this obvious incompatibility not noticed?

Bornhöft and Matthiessen concluded there was “sufficient evidence” for the “clinical efficacy of homeopathy and for its safety and economy compared with conventional treatment”.

Yes, they did. And then they wrote a report to support that conclusion…

Assessing cost-effectiveness

The Swiss government also examined whether homeopathy was saving or costing money by studying data from Swiss health insurers, including all costs for consultations, medications, physiotherapy and laboratory analyses.

It did. it concluded that they weren’t. Which is why reimbursement stopped. Did the author and editor not check the facts at all?

As it turned out, doctors who specialized in homeopathy cost at least 15-per-cent less than conventional doctors, even though those seeking homeopathy tended to have more chronic or serious ill health—factors that would usually translate into bigger health bills.

When treatments for specific illnesses were compared, homeopathy again proved cost-saving: children with URTIs had fewer recurrences of illness and required fewer antibiotics than those receiving conventional drugs.

This cherry-picking is routine, of course.

Homeopathy led to less dependence on drugs. In more than 500 patients with rheumatic disease, nearly a third were able to stop taking conventional medication, and another third reduced their use of drugs.

Homeopathic fertility treatment for women offered one of the largest cost-savings of all compared with standard medical treatments.

This is another glaring red flag. Fertility treatment is a highly studied area. If homeopathy were genuinely a cost-effective treatment, why has Lord Winston called it pseudoscience? He is probably the best-known authority on human fertility in the UK and his wife’s mother was a homeopath. (Aside: that story claims that the crash in which she died was the only air crash over Britain apart from Lockerbie. This is of course twaddle. It was however the deadliest prior to Pan Am 103).

Homeopathy also saved on hospital bills: female patients using homeopathic doctors were six times less likely to land in hospital than those using conventional doctors.

There were also many indirect cost-savings, such as fewer days off sick, with patients opting for homeopathy.

Furthermore, homeopathy users reported fewer side-effects and better doctor–patient relationships. On comparing patient satisfaction with homeopathic vs conventional therapies in more than 3000 subjects, significantly more homeopathic patients (53 per cent) were “completely satisfied” compared with 43 per cent of those taking conventional medicines (BMC Complement Altern Med, 2008; 8: 52).

The only reference in the document, and it’s to a customer satisfaction survey of no clinical relevance?

Alternatives as mainstream

The Swiss are leading the way in the integration of alternative therapies into mainstream healthcare. Following a national referendum in 2009, where a two-thirds majority voted to integrate complementary and alternative medicine into the Swiss healthcare system, the Swiss Minister of Health approved reimbursable payment for five of the most popular alternatives: homeopathy; herbal medicine; traditional Chinese medicine; anthroposophical medicine; and neural therapy (based on the idea that trauma produces disturbances in the electrochemical functioning of tissues).

MASSIVE red flag here. Why was a referendum necessary after the 1999 process? McTaggart shows she understand the document to have been part of the PEK process. The PEK process wa sin 199 as a review of efficacy in connection with a temporary reimbursement.  The document is said to be the official pronouncement on that process.

If these things are true, why would a referendum be necessary?

Governments do not conduct referendums to ask for permission to offer evidence-based treatments in the context where they are stated (by homeopaths at least) already to be in common use.

Perhaps the most remarkable aspect of all this is not simply that, as a result of the new report, homeopathy is now enshrined in the Swiss constitution and paid for by public money, but that this has happened in a land where two of the top largest pharmaceutical firms have their base.

It is not “enshrined in the Swiss constitution”. The reimbursement following the referendum is also temporary. This is not difficult to verify.

It has also occurred at precisely the point where EU initiatives (of which Switzerland is a part) funded by the pharmaceutical industry are busily banning or drastically curtailing the availability of nutritional supplements and many alternative treatments despite their long history of success.

Logical fallacies: begging the question, poisoning the well. Actually “big pharma” makes shedloads of cash from supplements, the problem is not that they are sold despite being effective but that they are sold despite lack of evidence that they are effective.

To paraphrase the words of Mark Twain, the Swiss are sending a firm message to the pharmaceutical giants, in their continued attempts to discredit alternative medicine, that reports of its death are greatly exaggerated.

Lynne McTaggart

Nope. The Swiss sent a message to homeopaths and other SCAM providers that the game is up: they can no longer pretend to be evidence based, the evidence does not support them. Reimbursement is purely political.

This is completely obvious form the history of reimbursement in Switzerland.

Which McTaggart apparently did not think to check.

Factfile: Not quite the end yet

The Swiss government’s report was particularly scathing about the 2005 meta-analysis by Shang et al., which was published in the Lancet and widely publicized by sceptics of alternative medicine as signalling the “end of homeopathy”.

In the Shang study, the scientific team evaluated 110 clinical trials of homeopathy and then compared them with the same number of trials of conventional medicine. Although the aim was ostensibly to compare the 22 high-quality homeopathic trials with nine high-quality conventional studies, the team devised a set of criteria to eliminate the majority of the best homeopathic trials, thereby supporting their conclusion that homeopathy doesn’t work.

As the Swiss authors noted, Shang and colleagues neglected to follow the basic accepted QUOROM (quality of reporting of meta-analyses) guidelines on best practices for scientific reporting (Forsch Komplementmed, 2006; 13 Suppl 2: 19–29).

The Swiss report also quoted the views of Canadian Dr David Sackett, considered one of the leading experts in ‘evidence-based medicine’, who argued that the ‘gold-standard’ study—the randomized, placebo-controlled trial—may not be the only means of judging the safety and effectiveness of a treatment; it certainly could not be used to evaluate surgery, for example.

This is also a red flag if McTaggart was even remotely critical, as Shang et. al. was part of the PEK process (and indeed is a “Swiss report” every bit as much as Bornhöft et. al.). The “criticism” of Shang is already discussed in the literature: their selection criteria were governed by the need to compare trials of homeopathy and medicine on a like-for-like basis. Other meta-analyses of homeopathy such as Linde et. al. (1999) also fail to support effect beyond placebo and indicate a strong correlation between study quality and result, with positive results more likely from bad studies, and good studies more likely to deliver negative results.

Sackett’s comments are not an escape hatch for quackery, they are merely a recognition that where an intervention is clearly a life or death matter, it may be unethical to randomise. And indeed this is one of the leading criticisms of ongoing trials of homeopathy, and the trial of chelation for heart disease: it is unethical to continue to test a treatment where there is no remotely credible reason to think it might work (under the Declaration of HelsinkiW).

Why don’t doctors tell you that the Swiss Government endorses homeopathy as safe and effective?

Because it isn’t true.

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