How to be simultaneously right yet oh-so-wrong about homeopathy

I’ve often (perhaps too often) referred to homeopathy as The One Quackery To Rule Them All. If not homeopathy, what other quackery would rule? Homeopathy is, after all, the perfect quackery. Most of its most “potent” remedies are nothing more than water, because homeopaths believe that the more a solution is serially diluted (with succussion, or vigorous shaking, between each serial dilution), the more potent it becomes, and frequently dilute their solutions far beyond the point where it is likely that there is even one molecule of the original substance in the resulting homeopathic dilution. Indeed, with its other major dogma, the claim that “like cures like,” as in compounds that cause a symptom are the cure for that symptom, combines prescientific vitalism with sympathetic magic. Somehow, because of a quirk of fate in which the existing medications of the time were sufficiently harmful compared to doing nothing that all too often doing nothing was better, managed to remain popular throughout the 19th century and even into the early 20th century. Of course, “conventional” science-based medicine (or, as homeopaths disparagingly called it, “allopathic medicine”) quickly shed bloodletting, treatment with toxic metals such as mercury and cadmium, and other treatments that frequently did more harm than good, but for some reason the perfect quackery that is homeopathy persisted.

It persists still, more than 210 years after its “discovery” by Samuel Hahnemann. Part of the reason it still persists is because all too many scientists and doctors won’t simply call it what it is: pseudoscientific nonsense. Worse, there are government organizations who lend support, tacit or direct, to homeopathy. In this case, get a load of this introduction to homeopathy by the National Center for Complementary and Alternative Medicine (NCCAM). While striking some of the “right” notes (e.g., pointing out that not all homeopathic remedies are highly diluted) and being technically “right” in most respects, it still leaves the impression that there might be more to homeopathy than its being The One Quackery To Rule Them All. I’m not sure why this introduction popped up on my Google Alerts, given that it was last updated in May, but it did.

For instance, there is little to argue with here:

  • There is little evidence to support homeopathy as an effective treatment for any specific condition.
  • Although people sometimes assume that all homeopathic remedies are highly diluted and therefore unlikely to cause harm, some products labeled as homeopathic can contain substantial amounts of active ingredients and therefore could cause side effects and drug interactions.
  • Homeopathic remedies are regulated by the U.S. Food and Drug Administration (FDA). However, FDA does not evaluate the remedies for safety or effectiveness.

But then we see the most massive non sequitur I think I’ve ever seen:

  • Several key concepts of homeopathy are inconsistent with fundamental concepts of chemistry and physics. There are significant challenges in carrying out rigorous clinical research on homeopathic remedies.

OK, maybe that’s not a non sequitur. It does, after all, follow that there would indeed be significant challenges in carrying out rigorous clinical research on remedies whose claimed basis violate the laws of physics and chemistry, rather in the same way that there are “challenges” in carrying out “rigorous research” into Bigfoot, astrology, ghosts, but that doesn’t stop NCCAM from opining:

Homeopathy is a controversial topic in complementary medicine research. A number of the key concepts of homeopathy are not consistent with fundamental concepts of chemistry and physics. For example, it is not possible to explain in scientific terms how a remedy containing little or no active ingredient can have any effect. This, in turn, creates major challenges to rigorous clinical investigation of homeopathic remedies. For example, one cannot confirm that an extremely dilute remedy contains what is listed on the label, or develop objective measures that show effects of extremely dilute remedies in the human body.

So homeopathy is “controversial” within CAM research. That should tell you all you need to know about the quality of CAM research, because homeopathy is not the least bit controversial among scientists. Its tenets violate multiple laws of physics and chemistry, not to mention biology. Unless scientists are not just wrong, but massively wrong, in their understanding of how physics work, to the point that multiple fundamental laws of physics and chemistry need to be rewritten, homeopathy can’t work. Of course, it is always possible that scientists might be that wrong about the universe, but it’s highly unlikely. Moreover, it would take massive quantities of evidence of very high quality to bring such laws into question sufficiently that it might start to seem scientifically plausible that homeopathy works.

Upon reading that passage in the introduction above, I wanted to ask: Really? Homeopathy violates the laws of physics, and the best NCCAM can come up with is to say that “it is not possible to say in scientific terms how a remedy containing little or no active ingredient can have any effect”? I suppose that on a strictly literal level, that is true. It isn’t scientifically possible, but then homeopathy is not science. On the other hand, yes it is scientifically possible to say how homeopathic remedies “have an effect”: They don’t. Such remedies have no effect. As the Dothraki say, it is known. The larger and more rigorous the clinical trial, the smaller the observed effect size, which in the very best and most rigorous clinical trials is no detectable effect at all above that of placebo.

But that’s not all. The other “major challenge” that NCCAM points out is that “one cannot confirm that an extremely dilute remedy contains what is listed on the label, or develop objective measures that show effects of extremely dilute remedies in the human body.” No kidding. And if you can’t confirm that an “extremely dilute remedy” has what’s listed on the label, in scientific terms it implies that there is nothing at all in that remedy, at least nothing chemical. If there were a chemical that could act as a drug in a homeopathic remedy at a significant concentration, medicinal chemists could certainly confirm what is in the remedy. Scientists and physicians could do dose-response analyses. Biochemical mechanisms could be identified and dissected step by step. If there were objective effects of such remedies in the body, scientists and physicians could measure them. If they can’t be measured, then they either don’t exist or are so minuscule as to be insignificant from a clinical perspective.

One thing NCCAM gets sort of right is to mention the regulation of homeopathic treatments. I say “sort of” right because, again, while the facts are right on a strictly literal leve, the implications of those facts are ignored:

FDA allows homeopathic remedies that meet certain conditions to be marketed without agency preapproval. For example, homeopathic remedies must contain active ingredients that are listed in the Homeopathic Pharmacopeia of the United States (HPUS). The HPUS lists active ingredients that may be legally included in homeopathic products and standards for strength, quality, and purity of that ingredient. In addition, the FDA requires that the label on the product, outer container, or accompanying leaflet include at least one major indication (i.e., medical problem to be treated), a list of ingredients, the number of times the active ingredient was diluted, and directions for use. If a homeopathic remedy claims to treat a serious disease such as cancer, it must be sold by prescription. Only products for minor health problems, like a cold or headache, which go away on their own, can be sold without a prescription.

All of this is true, but it’s a problem baked right into the heart of the Food, Drug, and Cosmetic Act of 1938. Basically, the inclusion of homeopathic remedies as accepted drugs in this legislation was due to the efforts of a single Senator. This Senator, Royal Copeland, was one of the principal authors of the FDCA and was a physician trained in homeopathy. Basically, the FDCA identifies substances acceptable for sale as homeopathic medicines as those listed in the United States Pharmacopeia-National Formulary (USP-NF) and the Homeopathic Pharmacopeia of the United States (HPUS). The HPUS was first published by the American Institute of Homeopathy, a professional body for homeopaths, in 1897. It’s now published and maintained by the Homeopathic Pharmacopoeia Convention of the United States (HPCUS), an independent organization of homeopathic “experts.”

As Jann Bellamy points out, the HPCUS has written detailed instructions for approving new homeopathic remedies. She quotes a review:

The clinical benefits of the new drug must be established in one of the following ways: through clinical verification acceptable to HPCUS, after which there is a period of clinical verification; through published documentation that the substance was in use prior to 1962; through use established by at least two adequately controlled double-blind clinical studies using the drug as the single intervention; or through use established by data gathered from clinical experience encompassing the symptom picture before and after treatment, including subjective and any available objective symptoms.[citation omitted]

The criterion of clinical use prior to 1962 was used to grandfather many drugs during the 1970s and 1980s into acceptance. This criterion is now rarely, if ever, used, and HPCUS is rereviewing [sic] many monographs accepted under this approach. HPCUS reports that the criterion of clinical experience has never been used. Consequently, only the criteria of homeopathic drug “proving” and establishment by two adequate clinical studies are currently in actual use [citation omitted].1

A more detailed description of the process can be found here. As Jann also points out, this sounds all scientific and official and rigorous, but it completely ignores the fact that the vast majority of homeopathic remedies are diluted to nonexistence and are, at their core, water soaked into sugar pills and allowed to evaporate.

I’ve mentioned before that NCCAM has deemphasized homeopathy in that it hasn’t funded any significant trials of homeopathy in quite some time, at least a few years. This is good. The NIH shouldn’t be spending its money studying fairy dust. Unfortunately, even though it’s forced to acknowledge that there is “little” evidence to support homeopathy (it’s actually no credible scientific evidence) and that the precepts of homeopathy violate the laws of physics, even now, under its director Josephine Briggs, still can’t quite bring itself to come to the logical, scientific conclusion that flows from those admissions: That homeopathy doesn’t work and can’t work.