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Why Yet Another Study of Homeopathy?

homeopathy ADHDThis post needs a bit of a background. A few weeks ago we noted that the Dean of Pharmacy at the University of Toronto was organizing a trial on using homeopathic preparations for the treatment of ADHD. A letter to the Dean asking how a Faculty of Pharmacy would get involved in studying something that is dismissed by the vast majority of the scientific community seemed appropriate. Eventually this letter was signed by more than ninety scientists and physicians and was sent off. There was no reply. In our view, not only is this a waste of funds, it adds an aura of respectability to a scientifically bankrupt notion. This is especially disturbing now in face of the measles outbreak since the private clinic where the study is to be carried out is a supporter of “nosodes,” the homeopathic “alternative” to vaccination. The original letter sent to Dr. Boon is reproduced below the following opinion piece that appeared in the Montreal Gazette.

Academic Freedom Comes With Academic Responsibility

Academic freedom is sacrosanct in universities. Researchers must be free to pursue their ideas, be they conventional or peculiar. But academic freedom also includes the freedom of others to question those ideas, and scholastic consideration dictates that those questions be addressed, especially when they are posed in a courteous letter signed by ninety scientists and physicians from around the world, including two Nobel Laureates.
The letter in question was sent to Dr. Heather Boon, Dean of the Leslie Dan Faculty of Pharmacy at the University of Toronto and focused on a study she was organizing to investigate the use of homeopathic preparations in the treatment of Attention Deficit Hyperactivity Disorder (ADHD) in children. Those of us who signed the letter, along with the vast majority of the scientific community, believe that numerous studies have concluded that the effects of homeopathy do not extend beyond a placebo response. The letter sought Dr. Boon’s views on why a Faculty of Pharmacy was organizing a trial that legitimizes homeopathy, a practice that has no scientific plausibility.
Homeopathy is not an umbrella term for alternative modalities. It is a very specific practice that originated before the dawn of the scientific era when little was known about disease or chemistry. Samuel Hahnemann, a well-meaning German physician, concluded that a substance that causes symptoms in a healthy person cures those symptoms in a sick person if it is sufficiently diluted. His process involved thumping the solution into a leather pillow between dilutions, and finally using a drop to impregnate a sugar tablet that would then serve as a “homeopathic medicine,” the term deriving from the Latin for “similar” and “disease.”
Hahnemann could not have realized at the time that the final solution did not contain a single molecule of the original substance. Today, homeopaths have to contend with chemical knowledge and have proposed that the curative effects are to be explained by the sequential dilutions leaving an imprint on the solution, although they appear to be at a loss to explain how such an image is transferred to a sugar pill or how a molecular ghost can have healing properties.
Stymied by the implausibility of nonexistent molecules having therapeutic potential, homeopaths point to papers in the scientific literature demonstrating a larger than placebo effect, as well as to the millions around the world who use homeopathy with satisfaction. Neither of these is surprising. Toss a hundred coins into the air and count heads and tails. Maybe 45 heads, 55 tails. Maybe 48 tails 52 heads. But do this a hundred times, and one event may come out 30 heads and 70 tails. If this is the only one reported, the impression would be that the coins were not fairly weighted. So it is with studies of homeopathy. Just by chance alone, some results will indicate efficacy. That’s why we look at all the studies and come to the conclusion that we are looking at a placebo response, which of course is valuable and should not be dismissed. Indeed, couple the placebo response with the fact that homeopathic treatments are administered by caring people who spend a lot more time with patients than physicians can, and that they mostly target self-limiting conditions or diseases that have their ups and downs, and you have a formula for satisfaction.
ADHD is a serious condition that merits serious research. Apparently the University of Toronto researchers carried out a pilot study involving homeopathy that seemed to indicate benefit. That study, however, was unblinded, devoid of randomization, had no control group and relied on a subjective outcome, making any data derived from it essentially meaningless. Even if we were to attach some importance to the claimed reduction of symptoms, the effect was about half of that seen with conventional medication, making the homeopathic treatment clearly inferior. Furthermore the proposed study would use individualized treatments for each subject as determined by a homeopathic consultation, so at best the results would be ambiguous in terms of making any recommendation.
The study is actually to be carried out at the Riverdale Homeopathic Clinic, a private institution that also offers ear candling, cranial sacral therapy and “nosodes,” which are homeopathic versions of vaccines. No public funding is involved; support comes from a foundation dedicated to alternative medicine. Nevertheless, one wonders why with various nutritional and biofeedback treatments with significant potential for helping with ADHD needing exploration, a scientifically insolvent notion is being pursued. One also wonders why a Dean of Pharmacy at a major Canadian Institution did not take the time to respond directly to repeated requests for her comments on a contrary opinion expressed by a large number of notable scientists and physicians.

ORIGINAL LETTER

Dear Dr. Boon

The following originates from the McGill University Office for Science and Society and has been signed by scientists and physicians from the international community. We are all devoted advocates of academic freedom and support the right of researchers to pursue any field of study they feel has merit. But we also feel that it is fair to ask colleagues questions about how a particular study they are engaged in may contribute to the bank of scientific knowledge. It should be emphatically stated that those who have added their name to this letter, including two Nobel Laureates, in no way wish to interfere with your research. Everyone is just interested in your response to the concerns expressed here.
Those concerns deal with the trial we understand you are organizing to investigate a homeopathic approach to the treatment of ADHD. First, let us point out that the McGill Office for Science and Society accepts no funds from any vested interest; our only allegiance is to the scientific method and to evidence-based science. It makes no difference to us whether any substance, including homeopathic products, is regulated or not, as long as the decision is arrived at through proper scientific evaluation rather than emotion, “they say” or pressure from vested interests.
Along with the majority of scientists, we find the notion of nonexistent molecules having a physiological effect through leaving some ghostly impression in water that is then transferable to a sugar pill simply untenable. Even if some sort of “memory” effect prevailed, there is no reasonable explanation for how it could affect biology. Furthermore, after all the sequential dilutions and succussions, the original impurities in the solvent would be more extensively present in the final solution than any component from the original homeopathic source. After evaluating the scientific literature, including a comparison of 110 homeopathic studies with 110 conventional studies for a number of disorders and outcomes, the most likely conclusion is that any benefit attributed to homeopathy can be ascribed to a placebo response.
Generally, scientists look askance at homeopathy, but don’t bother much with it because they consider it to be harmless folly. Unfortunately, this is not the case when homeopaths recommend “nosodes” as alternatives to vaccination, or attack the use of antibiotics for infections, or offer unproven treatments for ADHD.
The reason for this extensive email is to solicit your rationale, given your training as a pharmacist, for the study you are carrying out. Is the motivation a concern that parents are wasting money and possibly sacrificing effective treatment by resorting to homeopathy for ADHD, and that the study may clarify the situation? Or is there a belief that there may be some factor other than a placebo response involved? In that case, what mechanism may be operative?
You allude to the results of a pilot study that warranted this further research. That study, however, was unblinded, devoid of randomization, had no control group and relied on a subjective outcome, making any data derived from it highly questionable. You also note that the reduction of symptoms found in the pilot study was about half of that seen with conventional medication, making the homeopathic treatment clearly inferior.
Basically, as you have gathered, we are curious about why, given the need to investigate natural therapies that may actually have a potential for benefit, and faced with a scarcity in funding, a Department of Pharmacy is interested in investigating a subject that has been addressed extensively in the literature and has been found wanting both in evidence and plausibility. There is also a concern that just the mounting of such a study by a highly reputable researcher at a top notch university will be used by homeopaths to justify diverse aspects of their practice, including steering patients away from evidence-based treatments.
Looking forward to your comments,
Regards
Joe Schwarcz
Director, McGill Office for Science and Society

David Harpp
Macdonald Professor of Chemistry
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Homeopathy Bugs Me, But Not The Bugs

PICBD“It’s natural medicine.” “Herbal remedies.” “It’s like…acupuncture.” “No chemicals.” “Energy healing.” “Yogurt.” Such were the common responses when we asked random people, including physicians, about their thoughts on homeopathy. All wrong. Homeopathy is none of these. Several opined something along the lines of “alternative medicine” and a few knew that it had something to do with the supposed healing ability of extremely dilute solutions. And one gave a quick, succinct answer. “Homeopathy is an affront to science.” Bang on!

Homeopathy has nothing to do with herbal remedies, many of which have legitimate uses. Rather it is a practice hatched in the dark ages of science based on the idea that substances that cause symptoms in a healthy person can cure those same symptoms in an ill person. Onions, which make eyes itchy and tearful, can be used to relieve the symptoms of hay fever. There is no logic to this, but this is not where it stops. Homeopaths, defying everything we know about toxicology, believe that diluting a solution containing a homeopathic remedy increases its potency. In fact, to potentiate the remedy, dilutions are carried out to an extent that the final product in most cases doesn’t even contain a single molecule of the original “remedy.”

Modern day homeopaths have to admit this, and use the argument that the sequential dilutions and the tapping of the solution against a leather pillow after each dilution leaves an imprint of the original substance on the solution. This idea holds no water. Water has no memory, but even if it did, why should it remember only the substance the homeopath has added? Why is there no memory of the hundreds of thousands of other substances that water came into contact with in rivers, lakes and sewers? And why should a ghostly image of a molecule, even if such a thing did exist, have any curing ability? Here’s a suggestion. Why not just add a bunch of homeopathic remedies to drinking water? They will become diluted and according to the tenets of homeopathy become more potent. Just drinking tap water should then resolve many ailments.

Obviously it’s easy to make fun of homeopathy. The concept is absurd. But millions of people around the world do rely on homeopathic medications. “Can they all be wrong?” The simple answer is “yes.” Popular ideas are not necessarily right. After all, bloodletting went on for thousands of years, and at one time the notion that the earth was the center of the universe was quite popular. And today, many believe that the earth was created less than six thousand years ago. Science, though, is not a popularity contest. It relies on facts, not on opinion. And the fact is that homeopathic medications contain no active ingredients. And more importantly, while hundreds of studies on homeopathy have been published, there are no repeated trials that have provided proof of efficacy. But while the tenets of homeopathy are marinated in pseudoscience, homeopaths can serve a useful function. They ask a plethora of caring questions and lend a sympathetic ear, both processes that can translate to a reduction in stress and anxiety as the ailment naturally resolves. Add a dose of placebo, and you’ve accounted for the success of homeopathy. But problems can arise. And Health Canada’s Natural Health Products Directorate is partly to blame by having given an uncritical free ride to homeopathic preparations, even issuing specific homeopathic drug identification numbers.

It is hard to understand how this has happened since the Directorate’s stated goal is that “all Canadians have ready access to natural health products that are safe, effective and high quality, while respecting freedom of choice and philosophical and cultural diversity.” Safety is not an issue with homeopathic products because they contain nothing. I’m not sure what “high quality” means in this context, supposedly that the pills are produced in an environment free of contaminants. But what about efficacy? There is actually no requirement that homeopathic producers demonstrate this, which is lucky for them, because no proof of efficacy is to be had for homeopathic mercury, arsenic, “Berlin Wall,” or most alarmingly, homeopathic “vaccines” and mosquito repellants.

It seems that Health Canada has taken the view that freedom of choice is paramount as long as there is no safety issue. When it comes to a question of efficacy, regulators conveniently look the other way. In most cases there is no issue because in general consumers who use homeopathic preparations do so for mild conditions such as colds or minor aches and pains. But using homeopathic pills to deter insects from biting is potentially dangerous. Yet that is exactly what “Mozi-Q,” marketed as a natural homeopathic deterrent claims to do. Swallow a sugar pill and keep mosquitoes away! Not only that, it is also supposed to reduce the itching if you do get bitten.

What evidence is provided? There’s talk of how mosquitoes avoid delphinium flowers, which may or may not be true. But what does that have to do with swallowing pills sprayed with an extremely dilute extract of the plant? Are the nonexistent delphinium molecules exuding through the skin? And itching is supposedly relieved because a pill contains a trace of stinging nettle extract? According to the perverse theory of homeopathy, nettle causes stinging on contact with skin and therefore when diluted is a simple remedy for the same sensation. Simply asinine.

Mozi-Q also cites a reference to some homeopath who carried out a study in the 1960s, a study that cannot be found. What else? Supposedly Mozi-Q was tested over four seasons on people. How? Was there a control group? Why weren’t the results published? Pity the poor person who goes into a mosquito infected area thinking they are protected from bites by having swallowed a sugar pill. And remember that mosquito bites can be more than minor annoyances; they can transfer disease, such as that caused by the West Nile virus. And Health Canada thinks this is all right. It isn’t.

Given that the theory of homeopathy is based on the idea that the more dilute a preparation, the more potent it is, will you overdose if you forget to take your pill? Of course not. The only risk with homeopathy is an overdose of nonsense.

Joe Schwarcz

Homeopathy Debate Follow-up: Andre Saine & Joe Schwarcz

After our debate on November 26, 2012, “Homeopathy: Mere Placebo or Great Medicine”, homeopath Andre Saine and colleagues asked me to answer some further questions, which I am pleased to do. I should point out that I have already addressed many of these issues in a series of columns I wrote for the Montreal Gazette and in an answer to a letter from the President of the Syndicat professionnel des homeopathes du Quebec who attacked me in a rather unprofessional fashion.

Andre also queried how much I get for consulting fees with companies. The answer is zero. My salary comes from the university. He also asked why I would favour a lawsuit against a company that markets homeopathic products given that I had stated that placebos could indeed serve as effective medicine. The lawsuit is being funded totally by a group of lawyers who initiated it. The motive behind it is simple. Homeopathic medications are claimed to have active ingredients without any proof that they contain such. Therefore they are mislabeled. I had nothing to do with the suit but I do support it because I think all products that make medical claims should be held to the same standards of safety and efficacy. In comparison with the demands that regulatory agencies make for other drugs, homeopathic products are getting a free ride.

Part of the problem is that most people do not actually know what homeopathy is. They believe it is just some sort of general term for “natural medicine.” It is of course not that at all. Consumers are often shocked to learn that homeopathy is based on the principle of non-existent molecules having an effect. For example, Boiron’s flu remedy Oscillococcinum, is made by the repeated dilution of a single duck’s liver 200 times, equivalent to taking the liver and diluting it in a sphere of water far bigger than the observable universe. I have given a more detailed description of the folly of this remedy here.

Little wonder that Boiron has had to settle a class action lawsuit in California that alleged false advertising on behalf of Oscillococcinum. The company agreed to refund consumers a total of $5 million and has agreed to pay legal expenses and to add a disclaimer that their health claims have not been evaluated by the U.S. Food and Drug Administration. It also agreed to add an explanation of how the “active” ingredients have been diluted. Hopefully there will be a similar settlement of the Canadian lawsuit.

I believe that after digesting my previous remarks on the subject and perusing my answers below, Andre’s summary comment that “the future of medicine is homeopathy” will be seen in its true light.

Before tackling the questions, let me begin with a few preliminary observations.

It was back in 1865 that French physiologist Claude Bernard opined that “It is better to know nothing than to keep in mind fixed ideas based on theories whose confirmation we constantly seek.” He didn’t have homeopathy in mind but he certainly could have.

Embracing a fixed idea and sticking to it in the face of emerging contrary findings is a real stumbling block in the evolution of any scientific discipline. In true scientific methodology, errors are uncovered, and science rights itself. But in rare cases, an entire discipline can be based on a fundamental flaw, which I believe is the case for homeopathy. Its very underpinnings that relate to the effects of non-existent molecules inducing some sort of memory effect on water are scientifically implausible in the light of knowledge we have gained since the introduction of homeopathy by Samuel Hahnemann over two hundred years ago. Yet homeopaths today still embrace Hahnemann’s archaic ideas. No other scientific discipline has shown such a lack of evolution.

The argument that there has been no need for change because Hahnemann’s brilliant breakthrough cannot be superseded smacks of juvenile thinking and a lack of familiarity with the astounding amount of biological and chemical knowledge that has been acquired over the last two centuries. But it is unlikely that the cleft between homeopaths and their critics will ever be breeched because one side takes its nourishment from science while the other is mired in faith. Science versus faith arguments are not resolvable, but clearly both have merits and detriments.

Most visits to a physician are prompted by the patient experiencing a symptom or set of symptoms for which they hope to receive effective treatment. If they are fortunate, some sort of treatment will be devised and a cure will follow. The natural assumption is that the cure was due to the treatment. And it may well be. But there are a couple of other possibilities. Many illnesses are self limiting and resolve even in the absence of any intervention. If, however, there is some sort of intervention, it usually ends up getting credit. There is yet another possibility. That’s the placebo effect. Basically this is a “cure” that is not related to the pharmacological or physical effects of whatever intervention is undertaken, but is the result of the patient’s faith in the treatment and the physician’s belief that the treatment will be effective.

Patients are keen to believe that they are receiving appropriate therapy, and in response to patients’ claims of improvement, physicians may be readily deluded into thinking that they have offered effective treatment. While placebos do not affect the progress or outcome of disease, there is no doubt they can have a powerful effect on subjective phenomena such as pain or distress. And placebos do not necessarily have to be pills, potions or physical treatments, although there is evidence that the more invasive a treatment is, the stronger the placebo effect. Injections, for example, work better than pills. But a physician’s words and attitude can also serve as effective placebos. This was demonstrated in a fascinating fashion by a British family practitioner who designed a clever study as reported in the British Medical Journal in 1987.

Dr. K.B. Thomas studied 200 patients who presented with symptoms such as cough, sore throat, abdominal pain, back pain, leg pain, headache, fatigue, earache, neck pain and chest pain in whom no definite diagnosis could be made. Half the patients were dealt with in a so-called “positive manner,” in which they were given a firm diagnosis and were told with confidence that they would be better in a few days. The other half had a “negative” consultation in which no firm assurance was given, with the doctor saying, “I cannot be certain what is the matter with you.” Furthermore, each group was divided into two, with half the patients in each group being given a medication, the other half not. In the positive group the patients were told that they would benefit from the medication, in the negative group they were told that the drug may or may not help.

The results were stunning. Two weeks after the initial visit, 64% of those receiving a positive consultation got better compared with 39% of those who received a negative consultation. Even more interestingly, whether the patients were given a medication or not made no difference. So what are we to make of this? It seems the effect of a doctor as a placebo may be more powerful than the placebo effect of a medicine! It should come as no surprise then that homeopaths enjoy success even though their medications, which do not contain any pharmacologically active agents, are totally bogus. They are usually caring people who devote a great deal of time to their patients and confidently offer them positive outcomes. That’s the formula for an effective placebo.

Here then are the questions and my answers:

 

You said in the debate that a well-conducted randomized controlled trial (RCT) will be convincing. What was not convincing about the ADHD or the sepsis RCT presented by Andre Saine?

Essentially all of the questions posed here are very familiar to the critics of homeopathy and have been extensively answered in the scientific literature. Indeed, the cornerstone of science is the randomized controlled trial (RCT), or, more correctly stated, the PROPERLY CONDUCTED randomized controlled trial. Unfortunately, the literature is replete with RCTs that are extensively flawed. Either the blinding is faulty, the allocation of subjects isn’t truly random, there is a lack of proper accounting for drop outs, the sample size is inadequate or there are methodological problems with the statistics. Given that statistically significant results can occur by chance alone, a single outcome, even if the study is properly conducted, does not carry much weight. By convention, researchers abide by the P=0.05 factor in scientific studies, which means that once in twenty times the result can be due to chance alone. To give a specific example, if a hundred coins are tossed in the air, upon landing one might expect a result like 45 heads-55 tails, or perhaps 48-52, or 46-54. But if this is repeated twenty times, one might very well once get 40 heads and 60 tails. If this were the only trial reported, one would get the impression that the coins were biased.

For all these reasons, more than one RCT that deals with the same question in the same fashion and arrives at the same result is required before one raises the possibility of legitimate evidence. And only when a sufficient number of RCTs show consensus in a meta analysis do we consider that the point has been made. There is yet another issue. While peer-reviewed journals are regarded as the gold standard for scientific evidence, it should be recognized that not all such journals are equal. There are some 6500 peer-reviewed journals in circulation in the world, many with very weak criteria for accepting papers. A study about homeopathy published in a homeopathic journal cannot be regarded the same way as if it were published in The Lancet, JAMA or the New England Journal of Medicine. Yes, the paper may be peer-reviewed, but the “peers” asked to referee a paper destined for publication in a homeopathic journal are not likely to be totally objective. Indeed, it might be quite difficult to induce a main-line scientist to review the article. There are also journals that are commonly referred to by homeopaths that are not peer reviewed at all. For example, papers by Rustum Roy, commonly referenced by homeopaths actually appear in Materials Research Innovations, which is Roy’s own journal.

There is no argument that there have been individual published papers alleging a positive effect for homeopathy. But almost all of these are to be found in journals that cater to “alternative” modalities. It is curious to note that in such journals there are no reports of negative results. This is quite unlike mainstream scientific publications which commonly feature negative findings. It seems somewhat odd that when homeopaths carry out a study they never encounter a failure, while this is common in conventional science.

In summary, the studies that are claimed to provide proof of homeopathy just don’t stand up to the rigours of science. They either have not been repeated, are methodologically flawed, or report results that can be due to random chance. All of these issues have been discussed in much greater detail than is possible here and the so-called positive studies have been dissected by numerous experts. I would urge interested readers to take the time and digest the following before accepting the notion that homeopathy is supported by properly carried out randomized trials. The first is by surgical oncologist Dr. David Gorski who systematically dissects some recent attempts by homeopaths to scientify their discipline. This is followed by comments from physician Dr. Ben Goldacre, the U.K’s premier science commentator and physicist and engineer A. P. Gaylard.

http://scienceblogs.com/insolence/2012/12/17/just-how-stupid-do-homeopaths-think-we-are/

http://www.guardian.co.uk/science/2007/nov/16/sciencenews.g2

http://apgaylard.wordpress.com/2009/09/06/a-homeopathic-refutation-part-one/

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

http://apgaylard.wordpress.com/2009/09/25/a-homeopathic-refutation-part-three/

If homeopathy turns out to be a great medicine as homeopaths have claimed for more than 200 years what are the implications for our society as a whole and each individual?

If homeopathy turns out to be the great medicine that homeopaths have claimed, we will have to rewrite all of our chemistry, biology and physics texts and assume that basically everything we know about the workings of the world is wrong. If this turns out to be the case I will eat my hat or anything else that is offered.

Your claim from the beginning is that homeopathy is ‘unscientific’, that the pills have nothing in them and are therefore a placebo. Dr. Saine came up with study after study, all good SCIENCE, to refute your claims, but your brushed them away as if they meant nothing. If good science won’t convince you that homeopathy is scientific, what will?

I did not brush the placebo effect aside at all. It is perhaps the most important effect in medicine, conventional or alternative. As far as the studies go, Andre Saine’s interpretation of what is good science differs from mine and from that of the majority of the scientific community. I’ve already laid out the major points above and the question of the validity of studies relating to homeopathy has been in great detail in the references I provided. It must be remembered that “scientific” studies can be found to support almost any claim, but the nature of the studies has to be carefully scrutinized before jumping to conclusions.

http://www.skepticblog.org/2011/01/31/homeopathy-pseudoscience-at-the-huffpo/

If homeopathy is quackery as you say, can you define what is a quack and which aspects of it apply to Hahnemann?

A quack is either a fraudulent or scientifically ignorant promoter of ideas or practices that do not conform with knowledge that has been acquired through the proper practice of the scientific method. I would not call Hahnemann a quack. Medical knowledge at the time was virtually non-existent and within his empirical framework homeopathy made sense. His patients did better than those who were brutalized by conventional medicine at the time, and it is easy to see how he came to the wrong conclusion based on correct observations. Hahnemann could not have been aware of the fact that his solutions were so dilute that they didn’t even contain a single molecule of the original substance. Avogadro’s number, namely the number of molecules in a mole of a substance, was not determined accurately until Millikan’s famous oil drop experiment a hundred years after Hahnemann. The number was named after Avogadro, not by him. It is a myth propagated by homeopaths that Hahnemann was a great chemist who knew all about molecules.

An appropriate analogy here would be the theory of “phlogiston” which made sense to noted scientists like Robert Boyle and Joseph Priestly because it explained their observations about combustion. But the discovery of oxygen provided a much better explanation. Similarly, in the context of the times, before a proper understanding of molecules was developed, and before the full benefits of placebos were appreciated, Hahnemann’s ideas were not outlandish. He was without doubt a good man who did his best to help patients with methods that in all likelihood were superior to the “heroic” medicine practiced by other physicians at the time. But given what we know today about molecules, pathology, disease processes, drug mechanisms and mind-body reactions, the notion of “like cures like” and Hahnemann’s proposed inverse dose-response relationship has to be relegated to the junk heap of science. But junk can be dangerous. See following:

http://www.quackometer.net/blog/2012/12/will-any-homeopath-say-homeopathy-is-no-substitute-for-radiotherapy.html

When evaluating published RCTs, what criteria are you using to know if the researchers are actually testing genuine homeopathy? 

I’m not sure what this question really means. What is genuine homeopathy? The RCTs that are examined in meta analyses are ones that are designed by homeopaths so one would assume they are testing “genuine homeopathy.” Basically such studies come down to testing one placebo against another. I know that homeopaths often claim that their practice is so individualized that it is not amenable to randomized trials, but that is just a convenient “out.” I would be interested in hearing what would constitute a trial of “genuine homeopathy.”

You have high regards for the Shang meta-analysis. Can you comment on what Andre Saine said about the 6-8 studies being “non-homeopathic” studies.

It is not only I who has a high regard for this major meta analysis that was published in The Lancet, but everyone else who is well versed in scientific methodology. It was predictable that homeopaths and particularly manufacturers of homeopathic medications like Boiron Laboratories would attempt to skewer the study. They did try that with the following claim:

“In August 2005, the weekly journal The Lancet published a new study on the effectiveness of homeopathy. In its editorial the journal drew some surprisingly controversial and unfavourable conclusions on homeopathy. It concerns an analysis which like the 3 previous meta-analyses concludes that homeopathic medicine is effective. However, to arrive at the opposite conclusion, the authors implicitly removed series of trials afterwards, retaining just 14 (8 on homeopathy) of the 220 initial trials (110 of which were on homeopathic medicine).”

This criticism is invalid. Shang et al examined all the trials and relied only on eight which were of the highest quality. The rest just did not meet the scientific criteria. They certainly did not “implicitly remove” a series of trials afterwards. The surviving 8 homeopathic trials were simply the ones that made the cut. Shang’s conclusion was that there is “weak evidence for a specific effect of homoeopathic remedies, but strong evidence for specific effects of conventional interventions. This finding is compatible with the notion that the clinical effects of homoeopathy are placebo effects.”

It is noteworthy that Klaus Linde, the author of a previous meta-analysis that has been used by homeopaths to support their arguments sent the following letter to The Lancet: “We congratulate Aijing Shang and colleagues on their meta-analysis examining the clinical effects of homoeopathy. Their methods largely reproduce those of our meta-analysis on the same topic published in The Lancet 8 years ago. We agree that homoeopathy is highly implausible and that the evidence from placebo-controlled trials is not robust. Our 1997 meta-analysis has unfortunately been misused by homoeopaths as evidence that their therapy is proven.”

Andre Saine just reiterates the criticisms that have been aimed at the meta analysis apparently without being aware that these have been dealt with extensively by many, including Shang himself. It is fruitful to read through Shang’s reply which I’ve reproduced here:

Are the clinical effects of homoeopathy placebo effects? — Authors’ reply:

Homoeopathy dates back to the late 1700s when Samuel Hahnemann first formulated the principles of similars and potentisation. At that time, homoeopathy might well have been superior to conventional medicine, considering that bloodletting was the standard treatment for many disorders. Contrary to what Harald Walach and colleagues suggest, homoeopathy and allopathy thus both started from a poor evidence base. Our study showed that more than 200 years later, based on more than 200 placebo-controlled trials, it has become clear that the clinical effects of homoeopathy are compatible with the placebo hypothesis and probably due to the non-specific effects of complementary and alternative medicine discussed by Walach and colleagues. By contrast, with identical methods, we found that the benefits of conventional medicine are unlikely to be explained by unspecific effects.

We followed the approach of Klaus Linde and colleagues1 in assuming that, if the clinical effects of homoeopathy are placebo effects, the positive results seen in placebo-controlled trials of homoeopathy must be explained by bias in the conduct and reporting of trials. When these biases were taken into account in the analysis, little evidence remained for a specific effect of homoeopathy. Linde and Jonas now seem to discover major limitations with the approach they pioneered: they argue that, if homoeopathy works for some but not all conditions, our study could produce a false-negative result. Their argument is not supported by the evidence. The homoeopathy trials analysed in our study, including the large trials, and large trials of higher quality, covered diverse conditions ranging from childhood diarrhoea, warts, the common cold, to chronic headache. There was little evidence that treatment effects varied according to clinical topic (p=0·66). An important strength of our study is the inclusion of a carefully matched sample of conventional medicine trials. If the fact that a therapeutic system may work in some but not other conditions leads to false-negative results, why did this not happen in the case of conventional medicine?

We agree that the larger trials of higher methodological quality (references 46, 55, 71, 80, 84, 94, 96, 97 in web appendix 1 and 23, 25, 45, 53, 66, 72 in web appendix 2) should have been identified, and are grateful for the opportunity to rectify this oversight. Our study was not a standard meta-analysis of Cochrane reviews, which are typically based on fewer than 10 trials,2 but a large comparative study of 110trials of placebo-controlled trials of homoeopathy and 110 carefully matched trials of conventional medicine. In this situation it is difficult to report on every variable that may be of interest. This is also illustrated by Linde and colleagues’ 1997 article,1 which included 89 homoeopathy trials. Linde and colleagues failed to identify the trials that were adequately concealed, the trials that reported predefined outcome measures, or the five trials that they included in a “worst case” scenario (high methodological quality, indexed in MEDLINE, higher dilution).

Contrary to the claims of Peter Fisher and colleagues, we clearly stated the matching criteria and made all the references available in web appendices and provided additional information on outcomes in a webtable. A list of excluded studies, with reasons for exclusions, is now also available from http://www.ispm.ch.

We strongly reject Fisher and colleagues’ notion that our conclusions were based on “eight anonymous trials”. Following the same logic, Linde and colleagues’ study,1 which they and others have repeatedly quoted as proving the efficacy of homoeopathy, would be based on the five “anonymous trials” included in the worst case scenario. We estimated treatment effects in trials as large as the largest trials identified, based on an analysis of 110 trials. As for the analysis restricted to eight large trials of higher quality, we found no convincing evidence that homoeopathy was superior to placebo.

Neither of the two studies mentioned by Fisher and colleagues were regarded as large and of high quality. The influenza trial did not meet our prespecified quality criteria and the asthma trial was available as an abstract only and excluded. In response to Walach and colleagues, two of the larger homoeopathy trials of higher methodological quality assessed individualised classic homoeopathy, including the 1997 trial by Walach and colleagues (reference 96 in web appendix 1).

In response to Flávio Dantas and to Walach and colleagues, the pattern seen for trials of classic, individualised homoeopathy was closely similar to that seen for all trials of homoeopathy (figure). Our study affirms the poor reporting of clinical trials highlighted previously.3 The assessment of their methodological quality is therefore compromised, but it is clear that large, multicentre trials tend to be of higher quality than small trials.4 Dantas argues that homoeopathic laboratories “do not spend nearly as much money on marketing and product promotion as pharmaceutical companies”. Interestingly, we have been pursued by public relations firms paid by the manufacturers after our publications on rofecoxib (Vioxx)5 and homoeopathy. We agree with Dantas that we need to compare homoeopathy and allopathy: this was the aim of our study. We also need to be prepared to accept the results of well designed studies, even if they challenge our own fervently held beliefs.

References

1 Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of homoeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet 1997; 350: 834-843. Summary | Full Text | PDF(136KB) | CrossRef | PubMed

2 Sterne JAC, Gavaghan DJ, Egger M. Publication and related bias in meta-analysis: power of statistical tests and prevalence in the literature. J Clin Epidemiol 2000; 53: 1119-1129. CrossRef | PubMed

3 McNamee D, Horton R. Lies, damn lies, and reports of RCTs. Lancet 1996; 348: 562. Full Text | PDF(19KB) | CrossRef | PubMed

4 Kjaergard LL, Villumsen J, Gluud C. Reported methodological quality and discrepancies between large and small randomized trials in meta-analyses. Ann Intern Med 2001; 135: 982-989. PubMed

5 Juni P, Nartey L, Reichenbach S, Sterchi R, Dieppe PA, Egger M. Risk of cardiovascular events and rofecoxib: cumulative meta-analysis. Lancet 2004; 364: 2021-2029. Summary | Full Text | PDF(193KB) | CrossRef | PubMed

How can you explain that a homeopathic substance, which, according to you, is supposed to be placebo, can work effectively on animals and plants?

The straight forward answer here is that homeopathic substances do not work on animals or plants. This is a myth that has been created by repetition. There are no quality studies that show homeopathy working in animals, but humans do have an astounding ability to see what they want to see and believe what they want to believe. Animals can recognize when they are being cared for and can respond to interventions even if these are physiologically inactive. Again, Andre seems to be unaware of the massive amount of literature that exists on this issue. To simplify, a vet who is using homeopathic remedies, is using his authoritative position to convince the animal owner that the animal being treated with homeopathy is getting better. This can lead to a placebo effect by proxy where the animal’s owner is assured that the treatment will work and therefore becomes less anxious. An animal can sense this and responds to its owner’s more positive attitude. This can provide the illusion of efficacy but the animal remains medically untreated. Here are a couple of interesting analyses:

http://www.sciencebasedmedicine.org/index.php/is-there-a-placebo-effect-for-animals/

http://aillas.blogspot.ca/2008/08/does-apparent-effectiveness-of.html

What is your opinion on homeopathic and naturopathic schools being represented at McGill Graduate Schools and Professional Fairs?

These schools are legal educational institutions so there is no reason not to make students aware of their existence, especially given that admission requirements are much lower than for medical school. My experience has been that the few students who have gone in this direction have done so after failing to get into a medical school. There are, however, undoubtedly some students who find the naturopathic approach attractive and make this a first career choice. They should, however, have full knowledge of what they are getting into as well explained in the December 14 entry of science based medicine:

http://www.sciencebasedmedicine.org/

In many countries such as Switzerland, homeopathy is part of medicare, therefore considered effective enough for public health benefit. How can it be called placebo-based?

There is no requirement of efficacy to include homeopathy in a health care system. In a democratic society governments will cater to public desires whether these are scientifically legitimate or not. Since homeopathy is cheaper than conventional medicine, it can alleviate government spending on health care. Most people visit homeopaths for minor conditions that generally resolve by themselves or for chronic conditions that have stymied conventional doctors but which would not be helped by further visits. But there is always the concern about including a treatment that has not been properly validated in national health care systems which are publicly funded. This issue is coming to the fore in the United Kingdom where homeopathy has been on the National Health Service but a House of Commons Science and Technology Committee that has examined the situation has recommended that homeopathy be removed from the National Health Service.

http://www.sciencebasedmedicine.org/index.php/homeopathy-gets-a-reality-check-in-the-uk/

Can you comment on the Swiss study?

This was not a study but an opinion rendered by a group who judging by their affiliations and publications have a favourable view of alternative therapies. The report summary was written by Gudrun Bornhöft and Peter Matthiessen: Chair in Medical Theory and Complementary Medicine, University of Witten/Herdecke, Germany, Ursula Wolf, Institute for Complementary Medicine (KIKOM), Inselspital, University of Berne, Klaus von Ammon, Stephan Baumgartner and André Thurneysen, Institute for Complementary Medicine (KIKOM), Inselspital, University of Berne, Marco Righetti, Medical Practice, Zurich, Stefanie Maxion-Bergemann: PanMedion Foundation, Zurich. Dr. Righetti, who is listed as “Medical Practice” actually practices homeopathy and has written voluminously on the subject. There were many foxes in charge of this henhouse. Again, Andre appears to be totally unaware of just how much astute scientific criticism has been piled on the Swiss ‘”study.” Here is some interesting reading:

http://www.smw.ch/content/smw-2012-13594/

http://www.sciencebasedmedicine.org/index.php/the-swiss-report-on-homeopathy/

http://www.zenosblog.com/2012/05/that-neutral-swiss-homeopathy-report/

http://onlinelibrary.wiley.com/doi/10.1111/j.2042-7166.2012.01160.x/abstract

Isn’t it true that the only non-war statue in Washington DC is of Samuel Hahnemann?

There is an impressive statue of Hahnemann in Washington but it certainly is not the only non-war statue in DC. There are numerous statues, even in Congress, that have nothing to do with war. Indeed, outside the National Academy of Science building, there is an interesting statue of Albert Einstein who of course opposed war.

Is there any value in observational, animal and in vitro studies?

Absolutely. These all contribute to evidence-based science.

Have you ever been to a homeopath?

Only incognito. A remarkable experience. Not a positive one.

Someone in the audience wanted to know if you would submit a proving on your own?

No problem. I would be willing to take any homeopathic product.

 

As is evidenced by the foregoing, it is my view that homeopathy is a form of unscientific, fanciful thinking that is pursued by generally well-meaning individuals who have put critical thinking on the back burner and appear to be oblivious of the established fact that the placebo response occurs consistently in 30-40% of cases likely due to expectation of relief by the patient.

Homeopathy: The Controversy Ensues

Homeopathy is a controversial “alternative” practice.  Dr. Joe expressed his views in a series of columns in The Montreal Gazette – Homeopathy: Delusion through Dilution – which triggered a lengthy response from Ginette Beaulieu, President of the Syndicat professionnel des homeopathes du Quebec to which he, in turn, responded.

Recently I was treated to a rambling, disjointed letter from Mme Ginette Beaulieu, President of the “Syndicat professionnel des homeopathes du Quebec” in response to my series of columns on homeopathy in the Montreal Gazette.  I will ascribe the undignified and slanderous nature of the letter to the writer’s lack of familiarity with academic and professional demeanor and will overlook the crude attempt at personal defamation.

It is hard to know just how to respond to Mme Beaulieu’s rant, since she presents so many inviting targets.  She parrots the usual arguments raised by the defenders of homeopathy, apparently unaware that each one has been extensively addressed and deflated by experts around the world.  In his article in The Lancet (1), and in a more elaborate version in the Guardian (2), Dr. Ben Goldacre deftly skewers homeopathic claims and highlights the usual pattern of alternative practitioners’ juvenile reaction to criticism:

“With alternative therapists, when you point out a problem with the evidence, people don’t engage with you about it, or read and reference your work. They get into a huff. They refuse to answer calls or email queries. They wave their hands and mutter sciencey words such as “quantum” and “nano”. They accuse you of being a paid plant from some big pharma conspiracy. They threaten to sue you. They shout, “What about thalidomide, science boy?”, they cry, they call you names, they hold lectures at their trade fairs about how you are a dangerous doctor, they contact and harass your employer, they try to dig up dirt from your personal life, or they actually threaten you with violence.”

I can attest to the fact that such methods are not limited to the United Kingdom.  Dr. Goldacre is not the only one to take on homeopathy in an elegant, rational fashion.  Drs. Edzard Ernst and Simon Singh in their epic work “Trick or Treatment” unmask the practice further (3), and in “Suckers,” Rose Shapiro nimbly shreds the usual homeopathic assertions to pieces. (4)

Unlike Mme. Beaulieu, I will refrain from nit-picking over inconsequential historical details, such as whether my statement that “homeopathy is a specific practice conceived in the early nineteenth century by Samuel Hahnemann” is correct.  It is.  While Hahnemann did publish an article about his practice in 1796, he did not coin the term “homeopathy” until 1807 when he published his essay Indications of the Homeopathic Employment of Medicines in Ordinary Practice.  It was also Hahnemann, and not the ancient Greeks, who introduced the term “allopathy” as a pejorative term for conventional medicine.  Beaulieu’s comment that “homeopathy was never invented by Samuel Hahnemann,” as numerous history books and I maintain, “but goes back to ancient Greece,” is incorrect.  While some Greek physicians did raise the notion of “like cures like,” the idea of dilution and succession, which is the essence of homeopathy, was introduced by Hahnemann.  I won’t quibble about whether Hahnemann experimented with belladonna for sore throat or for scarlet fever.  Does it really matter how he arrived at his implausible conclusions?  In any case, Hahnemann’s Materia Medica clearly states that homeopathic belladonna is a treatment for sore throat.

Let’s get down to more important matters.  I’ve already expressed my views on the published trials of homeopathy.  The evidence, for all who care to read the scientific literature in its totality suggests that homeopathy is a placebo phenomenon.  The definitive meta-analysis published in the Lancet (5) concludes:

“Biases are present in placebo-controlled trials of both homoeopathy and conventional medicine. When account was taken for these biases in the analysis, there was weak evidence for a specific effect of homoeopathic remedies, but strong evidence for specific effects of conventional interventions. This finding is compatible with the notion that the clinical effects of homoeopathy are placebo effects.”

There have been numerous systematic reviews of homeopathy trials, and even systematic reviews of systematic reviews (6, 7).  One that is often presented by homeopaths as being favourable to their practice is the Swiss report “Homeopathy in Healthcare: Effectiveness, Appropriateness, Safety, Costs.”  Contrary to what is commonly claimed, this is not a report by the Swiss government, but rather a committee composed mostly of members who have a history of favouring alternative therapies.  Dr. Edzard Ernst, one of the world’s foremost experts on homeopathy, has dissected this review and has shown that due to omissions and misrepresentations of the conclusions of individual studies, the report is “methodologically flawed, inaccurate and biased.”(8)  Anyone interested in a thorough discussion of how the Swiss report has been twisted can check out the comments by Rudloff and Zeno (9).  The Cuban “study” that is sometimes brought up in support of homeopathy actually doesn’t provide such support, as is clearly explained by Dr. David Gorski (10).

A common argument made by homeopaths is that the placebo effect cannot work in the case of animals and infants.  This is plainly wrong as can be readily seen by carrying out a PubMed search.  It is well known that children respond to their parents’ expectations and pets to that of their owners. (11).

The often repeated assertion that homeopathy demonstrated its efficacy in the 19th century during cholera and typhoid epidemics by virtue of having fewer fatalities in homeopathic than conventional hospitals is often trotted out.  The explanation is simple.  Back then conventional physicians engaged in bloodletting, purging and other horrific treatments that did more harm than good.  At least homeopaths subscribed to the age old dictum, “first do no harm.”  Apparently they no longer seem to abide by that rule given that homeopaths have been known to prescribe ineffective malaria prophylaxis and commonly advise against vaccination.  The claim that homeopathy can be effective against AIDS is dangerous folly and recommendations to take homeopathic products as protection against radiation are absurd.  No wonder that a parliamentary commission in the UK has advised that the National Health Service should cease the funding of homeopathy. (12)

Dr. Luc Montagnier, a Nobel Laureate, has become a shining beacon for homeopaths who claim he has validated their practice.  He has done no such thing.  Prof. P.Z. Myers gives an excellent account of Montagnier’s bizarre experiment (13) and further insightful analysis is provided by Drs. Harriet Hall and David Gorski (14, 15). Even if this experiment, which purports to detect electromagnetic signals from a homeopathically diluted DNA solution, is ever reproduced, it says nothing about curing disease.  This critical fact is never addressed by homeopaths.  Even if water had some sort of memory, so what?  How does that have anything to do with treating disease?  Montagnier’s publication is reminiscent of Professor Jacques Benveniste’s paper in Nature describing an experiment that purported to show a homeopathic effect but could not be reproduced, as well as of Professor Madeleine Ennis’ experiments that suffered the same fate in the hands of experts on British television’s Horizon series (16).

“Can so many people be wrong?” is another lame argument often advanced to buttress the crumbling edifice of homeopathy.  The simple answer is “yes.”  Popular ideas are not necessarily right.  After all, bloodletting went on for thousands of years, and at one time the notion that the earth was the center of the universe was quite popular.  But science is not a popularity contest.

While the tenets of homeopathy are marinated in pseudoscience, homeopaths can conceivably serve a useful function.  They ask a plethora of caring questions and lend a sympathetic ear, both processes that can translate to a reduction in stress and anxiety.  But problems can arise if the homeopath does not recognize a medical condition that is amenable to treatment by conventional medicine.  There are plenty of such cases, with a classic one being the case of Penelope Dingle of Australia whose tragic death has been attributed to foregoing proper care in favour of homeopathic treatment (17).

It is edifying to consider the use of a specific homeopathic remedy such as Natrum Muriaticum.  That’s common salt.  Among other medical conditions, it is used in homeopathy to treat migraines, pain, weakness and unusual weight loss.  Not necessarily benign conditions.  The best results are said to be obtained with high potency preparations such as 30C or higher.  One grain of salt dissolved in all the water on earth would not get you near a 30C dilution.  In any case, using the homeopathic concept, salt is dissolved in pure water which is then sequentially diluted and succussed.  But hasn’t that water already been in contact with salt throughout its history, as well as with millions of other substances?  Yet, it will “remember” only the salt that the homeopath added?  And what will it do with that memory?  Imprint it on a sugar pill?  And then somehow, as the water evaporates, for the final pill contains no water, that imprint is left behind, unaffected by whatever impurities the sugar may have contained, or by the sugar molecules themselves.

A patient then swallows this pill with water that must harbour all kinds of molecular images with which it was stamped as it rampaged through rivers, flowed over waterfalls and was flushed down toilets, including that of salt.  When the pill enters the stomach, the sugar dissolves, and somehow the aura of the salt it had carried is liberated.  This aura must be different from all the other auras of salt that cruise through our body generated by the salt we eat, otherwise there would be no need for the homeopathic version.  And then what happens?  Does this aura multiply so that it can be carried around the bloodstream so that it can get to where the problem is?  And once it gets there, how does it perform a therapeutic function?  If there is to be some benefit, there must be some sort of biochemical change, since everything that happens in the body is the result of some sort of chemical activity.  So we must therefore conclude that this baffling, mysterious aura of salt, devoid of any mass, devoid of any evidence for its existence, has engaged in a chemical reaction.  Isn’t all that a little hard to swallow?

Homeopaths retort by saying that just because science can’t explain how homeopathy works doesn’t mean it can’t work.  They routinely criticize the “mechanistic” nature of science, yet take every opportunity to cloak themselves in its garb when it suits their purpose.  Anytime there’s wind of some research that deals with the structure of water, as in the case of water molecules forming diverse clusters, homeopaths are quick to imply that this somehow supports “water memory” and its healing effects.  This is a plundering of science to support a nonsensical idea.

Consider an analogy.  Suppose you have a theory that the crowing of a rooster brings on the light of dawn.  It flies in the face of everything known about science, but you are bent on proving you are correct.  Then you come across a phenomenon known as sonoluminescene that can be readily reproduced in the laboratory.  The sound of a high intensity ultrasonic horn immersed in a bubbly liquid causes some of the bubbles to burst and emit flashes of light.  You then rationalize that since it has been demonstrated that sound can produce light, it is possible that the crowing of a rooster brings on the light of dawn.  Obviously a preposterous conclusion.  As preposterous as suggesting that infinitely diluted solutions have some sort of healing ability because some esoteric experiments have demonstrated that water molecules can form clusters for tiny fractions of a second before they rearrange themselves to form a new pattern.

Admittedly, one can wade through the scientific literature and find studies that support patients benefitting from homeopathic treatments, although the majority of these tend to be published in homeopathic journals.  Curiously these journals never seem to report negative studies of homeopathy.  Are we to conclude that every study undertaken by homeopaths produces a positive result?  In any case, the question isn’t whether some patients benefit from homeopathy, the question is why.  The homeopathic rationale of course is that extremely diluted and succussed solutions trigger a physiological response.  I’ve already discussed the unlikelihood of such an effect, but here’s a further question.  Have manufacturers of homeopathic remedies carried out studies on the effectiveness of diluted but not succussed solutions?  Or the effectiveness of different dilutions?  If so, why have they not published the data?

I do not feel the need to deal further with Mme Beaulieu’s dubious defense of the ability of nonexistent molecules to cure disease, or with her menacing insinuations.  But I will repeat the challenge I presented in one of my columns.  I propose that the “Syndicat des homeopathes” be given ten unlabeled vials of homeopathic remedies along with a list of what these are.  Let the members of the Syndicat use any means they desire to identify the contents of the vials.  If they can do this, we will entertain the possibility that homeopathic medications may have some efficacy other than the placebo effect.  Any suggestion that homeopathic pills contain some sort of “vital force” that is not scientifically measurable is unacceptable.  That excuse amounts to sloppy thinking sprinkled with magic dust.  Magical thinking of course is not limited to homeopathy, most of alternative medicine is permeated with it.  Richard Dawkins in an episode of the outstanding series “Enemy of Reason” brilliantly dispels the magic with science. (18)  A “must see” not only for Mme Beaulieu but for everyone!

Finally, it is incumbent on those making a claim to provide the appropriate supporting evidence, and obviously homeopaths do claim that their preparations have some sort of therapeutic activity.  Since we can assume that there is no universal homeopathic remedy, the preparations must differ from each other.  And of course, according to their labels, they do.  Therefore we can conclude that a failure to identify the contents of the unlabeled vials in the proposed experiment means that the medications are in contravention of Canadian labeling laws.  Furthermore, since the label lists ingredients that cannot be shown to be present, homeopaths must be prescribing remedies that are falsely labeled.  How does one even know whether one is getting an “active” homeopathic remedy or a fake?  Then again, does it really matter?

I would suggest that supporters of homeopathy reflect upon the words of Isaac Newton, perhaps the greatest scientist who has ever lived: “We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances.”  This can be rephrased as other things being equal, a simpler explanation is better than a more complex one.  Isn’t it more reasonable to attribute the finding of a coin under the pillow to a loving parent than to the tooth fairy?  Isn’t it more reasonable to attribute the benefits of homeopathy to the placebo effect triggered by caring practitioners than to mythical molecular auras?

Perhaps Mme Beaulieu can take some time and cogitate on these matters so that next time questions are raised about the benefits of homeopathy she is less inclined to fire off discourteous letters that do no more than serve as a testimonial to a lack of scientific acumen and critical thinking.

References:

(1)    http://www.thelancet.com/journals/lancet/article/PIIS0140673607617061/fulltext

(2)    http://www.guardian.co.uk/science/2007/nov/16/sciencenews.g2

(3)    http://www.trickortreatment.com/

(4)    http://books.google.ca/books/about/Suckers.html?id=tr4eAQAAIAAJ

(5)    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)67177-2/abstract

(6)    http://www.ncbi.nlm.nih.gov/pubmed/12492603

(7)    http://www.smrv-journal.com/article/S1087-0792(09)00126-9/abstract

(8)    http://onlinelibrary.wiley.com/doi/10.1111/j.2042-7166.2012.01160.x/full

(9)    http://www.zenosblog.com/2012/05/that-neutral-swiss-homeopathy-report/

(10) http://scienceblogs.com/insolence/2010/11/30/homeopathy-in-cuba/

(11) http://www.sciencebasedmedicine.org/index.php/is-there-a-placebo-effect-for-animals/

(12) http://www.parliament.uk/business/committees/committees-archive/science-technology/s-t-homeopathy-inquiry

(13) http://scienceblogs.com/pharyngula/2011/01/24/it-almost-makes-me-disbelieve/

(14) http://www.sciencebasedmedicine.org/index.php/the-montagnier-homeopathy-study/

(15) http://scienceblogs.com/insolence/2010/11/23/luc-montagnier-the-nobel-disease-strikes/

(16) http://www.youtube.com/watch?v=X5wYNwstrQc

(17) http://www.danbuzzard.net/storage/Dingle_Finding.pdf

(18) http://www.youtube.com/watch?v=qONLXRNM3ss&feature=results_main&playnext=1&list=PL7CC31A5FCFE0E6D8

 

Further relevant information:

http://apgaylard.wordpress.com/2009/09/06/a-homeopathic-refutation-part-one/

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

http://apgaylard.wordpress.com/2009/09/25/a-homeopathic-refutation-part-three/

http://sciblogs.co.nz/molecular-matters/2012/05/29/whiny-homeopaths/

http://scienceblogs.com/insolence/2012/05/14/plausibility-bias-try-reality-bias-when/

http://www.cbc.ca/news/health/story/2011/01/14/marketplace-homeopathy.html

 

 

 

Homeopathy-Delusion through Dilution

HomeopathyHomeopathic products.  They are safe enough, no doubt about that.  Millions of people around the world swear by them.  No doubt about that either.  Furthermore, their label features the term “DIN-HM,” designating approval by Health Canada.  So why then do I and my colleagues at the McGill Office for Science and Society support a class action lawsuit launched against Boiron Laboratories and Shoppers Drug Mart for marketing Oscillococcinum, a homeopathic medication advertised as a remedy for colds and the flu?

I have absolutely no desire to limit anyone’s freedom of choice when it comes to choosing health care products, or any company’s right to sell items that the public wants to buy, as long as these are safe.  But I do have a desire to ensure that whatever choice consumers make is based on scientifically informed opinion.  In the case of homeopathy, misinformation can have consequences ranging from a needless waste of money to foregoing more effective treatments.  As an educator, I am also troubled by the promotion of a practice that is based on principles that cannot be supported by the established laws of chemistry, biology or physics.  Hopefully, the publicity the current lawsuit will generate should help people understand the true nature of homeopathy.

Let’s begin by explaining what homeopathy is not.  It is not an umbrella term for alternative or complementary practices.  The use of herbal medications or acupuncture or reflexology has nothing to do with homeopathy.  Homeopathy is a specific practice conceived in the early nineteenth century by Samuel Hahnemann, a conventionally trained German physician, who became disillusioned with bloodletting, leeches, suction cups, purges and arsenic powders, all standard treatments at the time.  It seemed to Hahnemann that these did more harm than good.  He was probably right.

One remedy that did work was an extract of the bark of the South American cinchona tree used to treat malaria.  But lacking standardized preparations, there was a problem with finding the right dose.  Hahnemann, interested in the maximum amount his patients could tolerate, became his own guinea pig and began to take increasing doses of cinchona bark.  He was surprised to find that at a high dose he developed symptoms much like the ones he witnessed in his malaria patients.  At that epic moment homeopathy was born!  Hahnemann derived the term from the Greek “homoios” meaning “like,” and “pathos” meaning suffering.  “Like cures like,” Hahnemann concluded.  A substance that causes symptoms in a healthy person will cure like symptoms in a sick person when given at a smaller dose.

Hahnemann went further and began to systematically test the effects of a large variety of natural substances on healthy people.  Such “provings” led him to conclude that belladonna, for example, could be used to treat sore throats, because it caused throat constriction in healthy subjects.  But belladonna is a classic poison.  Was homeopathy therefore dangerous?  Not at all.  Hahnemann had another idea.  He theorized that his medications would work by The Law of Infinitesimals.  The smaller the dose, the more effective the substance would be in stimulating the body’s “vital force” in warding off the disease.  A totally illogical conclusion.

“Active preparations” were made by repeated dilutions of the original extract.  Hahnemann was not bothered by the fact that at these dilutions none of the original substance remained; he claimed that the power of the curative solution did not come from the presence of an active ingredient, but from the fact that the original substance had in some mystical way empowered the solution with curative properties.  A simple dilution, however, was not enough.  The vial had to be struck against a special leather pillow a fixed number of times to be “dynamized,” before adding a drop of the solution to a sugar pill.

These were bizarre ideas to be sure, but Hahnemann must have been impressed by the success of his homeopathic treatments.  No surprise here.  The placebo effect can indeed be very impressive.  And patients certainly preferred a treatment that had no side effects to being bled or being purged.  A real curiosity was that Hahnemann did not advocate a homeopathic treatment for malaria using ultra diluted cinchona bark.  He must have recognized this would not work.

Hahnemann didn’t know about molecules, but today calculations readily show that homeopathic products such as Oscillococcinum 200C do not contain a single molecule of the duck organs that serve as the raw materials for the production of the final “remedy.”  The designation “C” represents an initial dilution of 1 to 100, and 200C means repeating this 200 times.  “C” is confusing to the consumer because a larger number actually means a smaller dose, and in any case, the term does not conform to the Canadian Weights and Measures Act.  This issue, while included in the law suit, is not its essence.

The main thrust of the legal action is that Oscillococcinum is mislabeled because the product clearly states that it contains the “medicinal ingredients,” Anas Barbarie Hepatis et Cordis extractum 200C (duck liver and heart), as well as the non medicinal ingredients, sucrose and lactose.  No chemical test can determine the presence of any “medicinal ingredient,” and furthermore, the label states that every one gram of product contains 0.85 grams of sucrose and 0.15 grams of lactose.  For anyone, except perhaps homeopaths, 0.85 and 0.15 add up to 1, leaving no room for any other ingredient.

How can a product claim to contain a medicinal ingredient when no such substance can in any way be detected?  Oscillococcinum amounts to a mislabeled sugar pill.  If it is to be marketed, it should be honestly labeled.  The lawsuit against Boiron and Shoppers Drug Mart aims to ensure that this happens, preventing the public from being misled.

Homeopaths of course have to admit that there is not a single molecule of the original substance in the final product, but they maintain that the dilution and shaking leaves some sort of imprint on the solution.

PART II

When I dilute my chicken soup, its taste suffers.  When I take one aspirin tablet instead of two, my headache doesn’t resolve.  When I use less detergent, my clothes do not come out as clean.  Yet, in the topsy-turvy world of homeopathy, less is more.  The more a biologically active substance is diluted, the more potent it becomes.  The most powerful homeopathic drugs, the ones that according to some homeopaths have to be used the most carefully, are the ones that do not even contain a single molecule of the original substance!  Oscillococcinum, the purported cold and flu remedy made from the liver of a duck falls into that category.  At the declared homeopathic dose of 200C, the total mass of pills that would have to be consumed to encounter a single molecule of the original substance would be billions of times greater than the mass of the Earth.  Yet the label on this product says it contains a “medicinal ingredient!”  And curiously it does not warn of the danger that such a “high potency” remedy presents.

Other homeopathic preparations may be prepared from an astounding array of substances that include snake venom, fecal matter, arsenic, gold, plutonium, blister beetles and the south pole of a magnet.  Even more bizarre are “light from Venus” and “Berlin wall,” a homeopathic dilution of which is supposed to help people with a lot of conflict in their lives.

Given that homeopaths have scientists breathing down their neck for an explanation of how nonexistent molecules can provide a therapeutic benefit, they have had to come up with some sort of a theory.  The usual claim is that the process of dilution and “succussion” (banging the solution into a leather pillow between dilutions) “dynamizes” the remedy by leaving an “imprint” of the original substance.  Chemists are prone to start pulling their hair when they hear something like that.  Not to worry, though, homeopathy has a treatment for hair loss, natrium muriaticum.  That’s sea salt.  But going for a swim in the ocean won’t do, the salt is way too concentrated.

Can there be anything to the “water memory” idea?  Water molecules do associate with each other momentarily through what any student of chemistry recognizes as “hydrogen bonds.”  But these connections last only nanoseconds before the molecules rearrange themselves.  In any case, past a dilution of 30C, the solution contains no water molecules that have ever come into contact with the original substance!  Furthermore, that original substance, as in the case of duck liver, is composed of thousands of different compounds.  Which one is the water supposed to remember?  And why does it not remember any of the other compounds it has encountered as it flowed through rivers and sewage systems?  This, though, is hardly the point.  Even if there were such a thing as water memory, why should that have anything to do with treating a disease?  Homeopaths never address that question.  They are too busy coming up with various pseudoscientific explanations about imprinting the memory of substances on water.

Another point that homeopaths seem to ignore is that their pills do not even contain any water!  A drop of the diluted and succussed solution is added to a pill made of sucrose and lactose, but the water soon evaporates.  So does it leave behind a ghost of the memory it supposedly contained?  And how exactly is that ghostly memory released when the pill is swallowed and the sugar dissolves?  Of course if you are willing to abandon or misuse the laws of chemistry, physics and biology, you don’t have to concern yourself with such issues and can be satisfied by explanations that invoke “vital force” or “quantum entanglement.”

Sometimes the effectiveness of homeopathy is likened to the effectiveness of vaccination.  This is a hollow argument.  First of all, vaccines contain measurable amounts of active ingredients.  And we know how they work.  They give rise to measurable amounts of antibodies.  Furthermore, the active ingredients in vaccines are similar to the disease causing agents.  Homeopathic remedies contain no measurable ingredients, give rise to no measurable changes in the body, and the undiluted original “medicinal ingredient,” such as duck liver, bears no resemblance in any way to the disease causing organism, which in the case of a cold or the flu is a virus.

At a loss to explain how homeopathy works, homeopaths essentially invoke Hamlet’s musings.  “There are more things in heaven and earth than are dreamt of in your philosophy.”  Seems appropriate, since both Hamlet and homeopaths appear to believe in ghostly images.  Basically, the homeopathic argument comes down to, “we may not know how it works, but it works.”

Homeopaths are convinced of the efficacy of their treatment because of the positive feedback they get from patients.  But is this because their pills are effective, or is it because they tend to be caring people who listen to patients and spend a lot more time analyzing concerns than conventional physicians?  Homeopaths will point out that there are proper randomized trials that show a benefit for homeopathy.  Indeed, it would be shocking if there weren’t any.  When you carry out enough trials, some will by chance alone show a positive result.  If you repeatedly toss a hundred coins into the air, it won’t be long before you come up with a result that differs significantly from fifty-fifty.  That’s why instead of looking at individual studies, we rely on a “meta analysis,” a study of studies.

Here the results are clear.  The effects of homeopathy are indistinguishable from the placebo effect.  Not surprising, since homeopathic remedies are indistinguishable from each other.  Or from sugar pills.  The James Randi Educational Foundation offers a million dollars to anyone who can by any means identify an unlabeled homeopathic remedy.  Certainly any pharmaceutical company can readily identify any of their products.  If this cannot be done for homeopathic remedies, how can a homeopath know he or she is giving the right substance?  In fact how can we differentiate between a real and a fake homeopathic remedy?

PART III

Critics of homeopathy have been known to swallow entire bottles of homeopathic pills to make the point they contain nothing but sugar.  But homeopaths are not disturbed by this demonstration because according to the tenets of homeopathy, increasing the dosage actually reduces the effect.  So, the critics would face danger not by taking more pills, but by just licking one.  Or, perhaps, they could overdose by staying away from the pills altogether.

We can safely say that homeopathic remedies pose no risk of side effects or of toxicity.  Just try calling a poison control center to say that you accidentally took too many homeopathic pills.  You’ll get a response along the lines of “forget it,” or “bogus product.”  But does this mean that homeopathy presents no risks?  Not at all.  There are several concerns.

Some homeopathic remedies may not actually be homeopathic.  More seriously, some homeopaths offer pills for protection against malaria or radiation exposure.  Others claim that they can treat cancer, with the most outrageous ones urging their victims to give up conventional treatment.  Finally, there is the matter of Health Canada issuing a DIN-HM (Drug Identification Number-Homeopathic) to homeopathic products implying to the consumer that these remedies have been shown to be safe and effective.  Safe, yes.  Effective, no.

Let’s amplify.  Marketers sometimes use the term “homeopathic” to describe products that are not at all homeopathic.  A classic case is Zicam, sold as an intranasal homeopathic cold remedy until 2009 when the Food and Drug Administration advised that the product be avoided because of a risk of damage to the sense of smell.  How can a homeopathic remedy do that?  Simple.  It was mislabeled.  Zicam actually contained a significant amount of zinc gluconate.  This, though, is not nearly as serious as recommending ridiculous malaria protection pills that contain no active ingredient to people travelling to areas where the disease is endemic.

And how about “Homeopaths Without Borders?”  I kid you not.  Here is one of their gems: “with the onset of the rainy season in Haiti there will be a great need for remedies to treat dengue, malaria, cholera and other tropical diseases.”  Claiming that homeopathy can treat these diseases is criminal.  Jeremy Sherr of “Homeopathy for Health in Africa,” goes even further: “I know, as all homeopaths do, that you can just about cure AIDS in many cases.”  Nonsense of course, and even disparaging to most homeopaths who draw the line at claiming cures for serious diseases.

Perhaps the most reprehensible practitioners of homeopathy are those who prey upon desperate cancer victims.  The following comes from the “Wisconsin Institute of Nutrition,” whatever that may be: “The important thing to know about cancer and choosing whether to use homeopathy or not is that surgery will not remove the disease.  Most people will still opt for conventional treatment, so how can homeopathy be useful to them?  They can take the appropriate remedy after surgery to prevent recurrence.  For strict homeopathic thinking such a procedure is not optimum.”  Needless to say, there is zero evidence that sugar pills can prevent a recurrence of cancer.

Homeopaths are not ones to miss a marketing opportunity.  Soon after the Fukushima nuclear power plant disaster in Japan, several offered remedies for either the treatment or prevention of radiation poisoning.  Believe it or not, one of the suggested remedies was “X-ray.”  What is it?  A sugar pill treated with a homeopathic dose of x-rays.  I wonder how one dilutes x-rays.  What bunk.

Homeopathy has always been challenged by scientists, but now consumers are beginning to realize the delusion of dilution.  In California, homeopathic manufacturer Boiron settled a $12 million class-action lawsuit that alleged the company had violated false advertising laws by claiming that homeopathic remedies have active ingredients.  Boiron will now be adding a disclaimer to say that their claims have not been evaluated by the U.S. Food and Drug Administration as well as an explanation of how their active ingredients have been diluted.  In Australia, a woman is suing a homeopath who she claims offered misleading information to convince her sister to give up conventional cancer treatment.

In Britain, The House of Commons Science and Technology Committee released a report stating that homeopathic remedies work no better than placebos and should no longer be paid for by the UK Health Service.  The Committee also criticized homeopathic companies for failing to inform the public that their products are “sugar pills containing no active ingredients.”  And at a British Medical Association Conference, an overwhelming vote supported a ban on any funding of homeopathic remedies, calling them “witchcraft.”

In Canada, our Natural Health Products Directorate has a mandate “to ensure that Canadians have ready access to natural health products that are safe, effective and of high quality.”  Yet, it licenses homeopathic products without requiring proof of efficacy.  Why should the manufacturers of these products be less accountable than those of other pharmaceuticals?  Knowing this, how can pharmacists in good conscience sell sugar pills that claim to have ghostly images of molecules?

Homeopathic remedies work through the placebo effect.  That of course is not negligible.  Placebos can have success rates of over 30%!  But if you think there’s something more to homeopathy, consider the following.  How come different homeopaths prescribe different remedies to the same person for the same condition?  How come drugs, other than homeopathic remedies, do not increase in potency when they are diluted?  How come that trace impurities in the sugar used to make the tablets, or in the water or alcohol used for dilution, which are present at higher concentration than the supposed active ingredient, have no effect?  How can remedies that are chemically indistinguishable from each other have different effects?  And how come a producer of homeopathic remedies given an unidentified pill cannot determine the original substance used to make the dilution?  Finally, how come there are no homeopathic pills for diabetes, hypertension or birth control?

Now I think I’ve said enough.  According to homeopathic principles, if I say more and more about the irrationality of homeopathic remedies, the effectiveness of my arguments will become less and less.

Homeopathy and the Flu

Here is a recipe. Into a liter bottle, pour a mixture of pancreatic juice, glucose and water. Then decapitate a muscovy duck and add 35 grams of its liver and 15 grams of its heart to the mixture. Seal the bottle and allow it to stand for 40 days until it becomes a goo. Then shake the bottle a hundred times, banging it into a leather pillow each time. Then take a milliliter of this solution and add it to a hundred milliliters of water in another bottle and shake it again the same way a hundred times. Repeat this dilution and shaking (succession) two hundred times. Then take a drop of the final solution and drop it on a little sugar pill. You have just made a homeopathic remedy against the flu! All this would be funny if it weren’t so ridiculous and dangerous. The “remedy” isn’t dangerous in any way, since after 200 dilutions there isn’t even a single molecule of the original concoction in the final product. So there is no question of poisoning the body. But there is certainly poisoning of the mind. (more…)

You Asked: How can homeopathic teething “remedies” that essentially contain nothing have an adverse effect on infants?

question markThe FDA in the U.S has raised alarm about homeopathic teething pills that may have caused seizures in babies and possibly even caused some deaths. But how can homeopathic “remedies” do this, given that they contain nothing? The bizarre tenet of homeopathy is that a substance that causes symptoms in a health person can relieve those symptoms in a sick person as long as it is diluted to an extent that contains almost zero or a just a trace amount of the original substance. Homeopathic teething remedies are made by diluting a solution of belladonna in an extreme fashion.

Why belladonna is the preferred substance is bizarre since according to homeopathic doctrine, to relieve pain, it should cause pain when used at a high concentration. While atropine, the active ingredient in belladonna can cause many adverse symptoms, it doesn’t cause pain. In any case, when diluted homeopathically, it should have no effect.

Now it seems some homeopathic companies are not very adept at making dilutions and the effects on the babies were likely caused by an overdose of belladonna. Dilution is really a very simple process, so it is hard to see how they could get it so wrong. It seems homeopaths are not only incompetent when it comes to understanding chemistry and medicine, some are also incompetent at carrying out dilutions. Obviously homeopathy is not always just benign nonsense.

Joe Schwarcz PhD

Forget Homeopathic Arsenic for Stress Reduction

stressDuring a recent talk on the relation between the body and the mind, I mentioned the newest anxiety-relieving craze, colouring books. Aimed at adults, these feature intricate patterns that provide quite a challenge for staying inside the lines. The contention is that focusing on the special patterns distracts the mind from anxiety and stress. Evidence is sketchy, but millions of colouring books are flying off the shelves, topping best-seller lists. That in itself says something about our society.

After my talk I was approached by a lady who claimed she had something better than colouring books to relieve anxiety and slipped a vial full of pills into my hand. She didn’t seem like a clandestine drug pusher so I thought I would look down and find some pills of lorezapam or maybe St. John’s Wort. Such was not the case. The label on the vial read “Arsenicum album 30C.”

No, she was not trying to poison me. These were homeopathic arsenic pills based on the curious notion that a substance that in large doses causes certain symptoms can, in homeopathic potency, repel the same symptoms. Since arsenic poisoning is associated with anxiety and restlessness, a person suffering such symptoms should find relief in a homeopathic dose of arsenic. In the bizarre world of homeopathy, potency increases with greater dilution, and a dose of 30C is said to be extremely potent. Such a pill is made by sequentially diluting a solution of arsenic a hundred fold thirty times and then impregnating a sugar pill with a drop of the final solution. At a dilution of 30C, not only is there no trace of arsenic left, there isn’t even a water molecule that has ever encountered any of the original arsenic.

Homeopathy is a scientifically bankrupt practice that was invented over two hundred years ago by German physician Samuel Hahnemann who was disenchanted with bloodletting and purging, common medical procedures at the time. He was a good man who searched for kinder and gentler treatments and homeopathy fit that rubric. Since knowledge of molecules was almost non-existent at the time, Hahnemann could not have realized that his diluted solutions contained nothing. Actually, the truth is that they did contain something. A hefty dose of placebo!

Now here is the kicker to this story. Hahnemann was quite accomplished in chemistry and actually developed the first chemical test for arsenic. In 1787 he found that arsenic in an unknown sample was converted to an insoluble yellow precipitate of arsenic trisulfide on treatment with hydrogen sulfide gas. When in 1832 John Bodle in England was accused of poisoning his grandfather by putting arsenic in his coffee, John Marsh, a chemist at the Royal Arsenal, was asked to test a sample of the coffee. While he was able to detect arsenic in the coffee using Hahnemann’s test, the experiment could not be reproduced to the satisfaction of the jury and Bodle was acquitted. Knowing that he could not be tried for the same crime again, he later admitted to killing his grandfather.

The confession infuriated Marsh and motivated him to develop a better test for arsenic. By 1836 he had discovered that treating a sample of body fluid or tissue with zinc and an acid converted any arsenic to arsine gas, AsH3, which could then be passed through a flame to yield metallic arsenic and water. The arsenic would then form a silvery-black deposit on a cold ceramic bowl held in the jet of the flame and the amount of arsenic in the original sample could be determined by comparing the intensity of the deposit with that produced with known amounts of arsenic.

The Marsh test received a great deal of publicity in 1840 when Marie LaFarge in France was accused of murdering her husband by putting arsenic into his food. Marie was known to have bought arsenic from a local chemist which she claimed was to kill rats that had infested the house. A maid swore that she has seen her mistress pour a white powder into her husband’s drink and Marie had also sent a cake to her husband who was travelling on business just prior to his becoming ill. The dead husband’s family suspected that Marie had poisoned him and somehow got hold of remnants of food to which she had supposedly added arsenic. The Marsh test revealed the presence of arsenic in the food and in a sample of egg nog, but when the victim’s body was exhumed the investigating chemist was unable to detect arsenic.

To help prove Marie’s innocence by corroborating the results of the investigation of the exhumed body, the defense enlisted Mathieu Orfila, a chemist acknowledged to be an authority on the Marsh test. Much to the defense’s chagrin, Orfila showed that the test had been carried out incorrectly and used the Marsh test to conclusively prove the presence of arsenic in LaFarge’s exhumed body. Marie was found guilty and sentenced to life in prison. The controversial case captured the imagination of the public and was closely followed through newspaper accounts making Marie LeFarge into a celebrity. It would also go down in the annals of history as the first case in which a conviction was secured based on direct forensic toxicological evidence. Because of Mathieu Orfila’s role in the case, he is often deemed to be the “founder of the science of toxicology.” The Marsh test became the subject of everyday conversations and even became a popular demonstration at fairgrounds and in public lectures. This had an interesting spin off. Poisonings by arsenic decreased significantly since the existence of a proven, reliable test served as a deterrent.

As far as claims about relieving anxiety with homeopathic arsenic go, well, they cause me anxiety. I think I’ll flush those homeopathic tablets down the drain (no worry about arsenic pollution here) and buy a colouring book.

Dr. Joe Schwarcz

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