Article: A close look at homeopathy.
© 2004 Hans Egebo
The history of homeopathy has been told often, so I will try to make it brief. Around 1800, the German medical doctor Samuel Hahnemann, obviously appalled with the still mostly medieval medical practices of his contemporaries, set out to revolutionize medical science. During a long lifetime of hard and dedicated work, he wrote several books and constructed the mainstay of what was to become homeopathic medicine. His books and teachings still form the foundation and the main substance of homeopathy to-day. Starting from sound clinical practice, Hahnemann built a complete system of alleged natural laws (Hahnemann tended to declare his theories laws of nature) and an extensive pharmacopoeia of homeopathic medicines.
The basic principle of homeopathy is the notion that health and disease is based on the functioning of a vital force, which is described as a non-materialistic property of all living creatures. If the vital force is functioning well, the creature is healthy, if not, the creature becomes ill. Disease is defined as a unique set of symptoms characteristic for the particular condition of the particular patient. Homeopathy only recognizes disease causes as disturbing agents for the vital force, and distinct diseases only as categories of cases that display similar symptom profiles. Hahnemann specifically discouraged looking for hidden internal causes and diagnosing diseases per name.
The homeopathic diagnostic method centers around what is called a taking of the profile of the patient. Ideally, this involves a meticulous investigation of the patients background, family conditions, hereditary body conditions, work situation, social situation, plus all the symptoms perceived by the patients and, preferably, also by persons close to the patient. By symptom homeopathic practice refers to anything perceived as not usual.
To cure, one needs medicines, and as homeopathy basically only recognizes symptoms, which are interpreted them as disturbances in the functioning of the vital force, it follows logically that medicines must be substances that are somehow able to affect the vital force, causing some kind of symptoms to emerge. Elaborating on this train of logic, Hahnemann divided medicines into three groups:
1) Antipathic; medicines that cause effects that are opposite of those of the disease.
2) Homeopathic; medicines that cause effects similar to those of the disease.
3) Allopathic; medicines that cause effects that are neither similar, nor opposite to those of the disease.
Based on some practical observations and on logic, Hahnemann developed a theory he called the law of similars. According to this theory, a medicine that causes the same symptoms as those of the disease will override the disease, such that the morbid function of the vital force is now caused by the medicine, not the original disease, and as the effect of the medicine wears off, the patient will be left cured. Thus, Hahnemann declares the group of homeopathic medicines to be the one and only path to cure.
To find out what symptoms various substances caused, Hahnemann used a purely empirical approach: He administered the substance to healthy persons (often himself) and carefully recorded the effects. This is called proving. Thus, if a substance caused headache, it should be assumed to be able to cure headache. It is not as simple as that, however, because just as a disease is not viewed as a single symptom, but as a complete symptom profile essentially unique to each case, the effect of a substance on a healthy person is rarely a single distinct symptom, but rather a set of symptoms. Hahnemann recorded anything that the test subject felt during testing as caused by the medical substance, unless it was very evidently something the person had also been experiencing prior to the proving.
The result of the provings were compiled into a work called the Materia Medica, which has later been expanded by Hahnemanns followers. The idea of homeopathic treatment is that the patients symptom profile is taken, then the Materia Medica is carefully perused to find the medicine that provides the best (ideally perfect) match of that symptom profile. That is assumed to be the medicine that cures that particular case. During this matching, interestingly, a medicine is sought that matches as many of the patients symptoms as possible, whereas any symptoms recorded for the medicine, but NOT matching the patients profile are normally ignored; according to Hahnemann, some unspecified selective mechanism ensures that the right properties of the medicine are activated. This is very practical since most medicines have many symptoms on their list, sometimes hundreds.
Another cornerstone of homeopathy is the potentisation of medicines. Some of the basic substances tried by Hahnemann are quite toxic and caused some quite unpleasant, possibly even dangerous, poisoning effects (in fact, according to some sources, some of the test subjects actually died!). Obviously, apart from making testing dangerous, it would hardly seem expedient to add to the sufferings of sick people by giving them toxic substances, especially, since that was exactly what Hahnemann was blaming other practitioners for. So Hahnemann started diluting his substances, using a special procedure of vigorous shaking which he called succussion. For instance, he might put one drop of raw substance into a vial, add 100 drops of dilution medium (water or alcohol), succuss it, then repeat the procedure several times. After n steps, the dilution, or potency, is called nC. Potencies of 30C and much more are quite usual. Some solid substances are first ground for an extended time in a mortar, sometimes including dilution. Due to later advances of science, we now know that there is a limited number of molecules in a given amount of solution, and potencies beyond 12C are increasingly unlikely to contain even a single molecule of the original substance. Nevertheless, Hahnemann managed to record symptoms presumably caused not only by potentised versions of already tested substances, but also of substances that do not have any effect in the raw condition, e.g. sand. He concluded that the succussion process somehow purified and amplified the medical effect of substances, and indeed high potencies are generally considered more powerful than the low ones by homeopaths.
The heading should really be homeopathy versus conventional medicine. As noted in the opening chapter, the practices of conventional medicine were generally deplorable at Hahnemanns time. The understanding of the connection between micro-organisms and diseases was emerging, but the discovery of effective medicines against infectious diseases still lay a century into the future. With a dawning use of antiseptic practices, surgery might just have begun to save more than it killed, but everyday practice consisted of leeches, bloodletting, enemas, and various medieval medical substances that required a strong health to live through.
Hahnemann reacted strongly against this and his works are full of partly justified rage against conventional practitioners, whom he calls allopaths. Modern homeopathic proponents tend to follow this; they perceive modern medicine as evil and dangerous, as opposed to homeopathy, which is viewed as ideal and without adverse effects. It is hardly possible to enter into a discussion with any group of homeopaths without being met with angry attacks on allopathy.
The simplest part of homeopathy to address scientifically is potentized medicines. Basically, preparations over 12C consist of shaken medium, and even lower potencies contain so little original substance that it can hardly have any chemical effect. Homeopathic proponents hold that the medium somehow conveys the effect of the original substance; that it has a form of memory. There is no known mechanism within modern physics that can explain how this could happen, and no scientific disciplines within physics or chemistry have ever shown any effects that might hint at water (or alcohol) having any memory of substances not longer present.
For potentized medicines, the claim of homeopathy appears quite simple: Such a preparation has a distinct and perceptible effect when taken by a healthy person. It must therefore lend itself excellently to the double-blind placebo-controlled method of testing. By giving a group of persons either medicine or placebo, it ought to be possible to deduce from observation which group received medicine and which placebo. A number of tests against placebo have indeed been published, and some show an effect, some not. Some even show more effect from placebo. Generally, such tests have for some reason been conducted with more or less flawed methodology, and meta-analyses show that the more objective the methodology is, the more inconclusive are the results.
The law of similars is a little more complex. Some diseases, which have similar symptoms, are known to affect each other, in such a way that one disease supplants the other. This was what Hahnemann observed, and presumably led him to develop his theory. However, these instances can be explained by various effects, immunity against one microorganism working on a related one (cowpox/smallpox), the general reaction of the body being effective on several diseases (e.g. fever), and attention focus (a weak symptom not noticed in the presence of a strong one). Hahnemann lists a number of other examples that are supposed to support the law of similars, but they are generally unconvincing. For example, he notes that the glare of the sun suppresses the light of a lamp; not only do we know why this happens (and Hahnemann supposedly knew, too), but even if the lamp is not visible, it still burns, it is not extinguished by the sunlight. Modern science has not found any indication of a law of similars existing as a universal rule.
Homeopathy views disease differently from conventional medicine. Conventional medicine generally focuses on finding the cause of a disease; the cause is then targeted by the treatment, even though the exact symptom may vary from case to case. In contrast, homeopathy views each case as a unique set of symptoms, requiring its own particular choice of medication. Thus, two patients with the same disease (from a conventional POV) may be prescribed different medicines by the homeopathic practitioner, and indeed be viewed as having two different diseases. This makes it much more complicated to design tests, at least if they are to be accepted by both sides.
Homeopathy claims the existence of a vital force or vital principle. This vital force is said to be the difference between a living and a dead thing (although Hahnemann does not equte it to a soul), and it is assumed to be the superior regulator of health. At Hahnemanns time, the very limited knowledge of the functioning of the body left ample space for surmising such a force, but as we (against the explicit advice of Hahnemann) have conducted our research deeply into the inner workings of the living organism, we find that the vital force has very little possible space left in the physical world. Certainly Hahnemanns definition will no longer hold.
Homeopathy is one of the more widespread alternative medicines, with thousands of practitioners and a billion Euro yearly turn over of the relatively cheap medicines. So, what are the arguments in favor of homeopathy? Why do the practitioners and their patients believe in this, despite the lack of scientific basis?
First of all, homeopathy has a distinct air of science. Books of rules, complex procedures, a proprietary lingo. Secondly, the method of carefully listening to the patient, meticulously recording every symptom experienced, lots of details from the patients background, is bound to make practitioners feel important and a lot of patients feel good. Who wouldnt wish that their normal GP would take the time to listen a bit? Also, the taking of the case will no doubt often result in useful advice to the patient (try to be less stressed, get more exercise, you really should lose some weight, etc.).
As any medical regimen, from modern medicine to aboriginal witch-doctors, homeopathy can boast successful case-stories, often of apparently hopeless cases being wonderfully cured by the regimen. As proof of efficacy, these anecdotical accounts are basically useless, but one cannot help thinking: Given these stories, which surely cannot all be lies, something must be at work here. When assessing case stories, a number of things must be kept in mind:
1) Of course, any one of the stories might be fictional.
2) As homeopathy does not use the conventional method of reaching a diagnostic, the cancer case in the account might not be a cancer case at all.
3) Many diseases resolve with time, regardless of treatment. The fact that the patient became well after treatment does not necessarily mean that the patient became well because of treatment.
4) Patients often consult several practitioners, including their conventional doctor, at the same time.
Also, bear in mind that case stories are always, by any practitioner, selected among many. And no practitioner will carefully report the cases he bungled.
The human mind is built to interpret sensory input according to experience and expectation. When you hear a deep rumble from the outside, you think: Thunder. If it also rains, you will be willing to swear that there was thunder, but had you investigated, you might have discovered a fellow rolling an empty barrel across the courtyard.
Every kind of observational science is vulnerable to observation bias, but homeopathy literally thrives on it. In the Organon of Medicine, Hahnemann carefully describes how to conduct a proving of a medicine:
You need test persons who are free from disease, and who are delicate, irritable and sensitive
Also: During all the time the experiment lasts the diet must be strictly regulated; it should be as much as possible destitute of spices, of a purely nutritious and simple character, green vegetables, roots and all salads and herb soups (which, even when most carefully prepared, possess some disturbing medicinal qualities) should be avoided.
Moreover: He must devote himself to careful self-observation and not be disturbed while so engaged;
And: If the effects that result from such a dose are but slight, a few more globules may be taken daily, until they become more distinct and stronger and the alterations of the health more conspicuous.
So, you take sensitive and irritable persons, put them in a special test set-up, ask them to report anything they feel, and give them increased doses till they feel something. What is the probability that they will not report symptoms?
But it does not stop there. After the reportings have been collected, the researcher studies them and decides which ones are the interesting ones that go into the Materia Medica.
When treating a patient, the homeopathic practitioner takes the case, then prescribes some medicine. If it does not work, he/she retakes the case (sometimes just reassessing the original taking), prescribes a new medication, and so on. Many of the case stories recount as many as four or five different medicines used over a period extending over months, sometimes years. When the patient finally reports feeling well, the case is noted down as another successful cure!
Another example of bias is when homeopaths interpret observations as showing causative connections that do not logically seem to exist. For instance, if some effect appears that looks like the one expected from the medicine, it is attributed to the medicine even if it appears quite long after taking the medicines (days, even weeks). Likewise bad effects are attributed to allopathic practices, e.g. vaccination, even years later. So, in short, whatever good happens is attributed to homeopathy, whatever bad happens is blamed on allopathy.
Since homeopathy lacks scientific basis, but has a number of adherents who will usually say something like we know it works!, it is reasonable to see if it has the characteristics of a typical belief system. A belief system will typically comprise:
1) Some holy scripture. Hahnemanns works fill this role well, being constantly used as reference and being regarded as essentially true (although some concede that there are errors in it).
2) A prophet or guru. Hahnemann certainly fills this role.
3) Rituals. The preparing of medicines is very ritualistic.
4) Miracles. Since there is no physical way the medicines could work, their actually curing somebody would count as a miracle.
5) Legends. The many case stories, some of which are quite ancient, serve here.
6) Fixed dogmas. Certainly the case; you can discuss lots of things with homeopaths, and some will actually strive to find scientific explanations for homeopathic theory, but few, if any, are endowed with the gift of doubt.
7) Solidarity within the cult. When discussing with homeopaths, you will often notice how they uphold each other and avoid internal discussion despite obvious differences.
Time to clear up a definition: Within the homeopathic community, a homeopath is a practitioner of homeopathy, and one either with one of the educations offered within the community, or with considerable self-studied knowledge and experience. For an outsider, such as me, who does not recognize homeopathy as factual, it does not matter so much what education the person has, so I take the liberty to use the term homeopath about any proponent of the homeopathic system.
Because of the cult-like solidarity and closedness, the homeopathic community seems quite homogenous at a cursory glance, but in fact it is quite diverse. Some call themselves true Hahnemannians and adhere strictly to the scripture, Hahnemanns works. They will usually also be the ones that are most opposed to conventional medicine, sometimes declaring it evil quackery and ignoring or denouncing every result ever made by modern medical science.
At the mid-level are what we could call revisionists; they base their ideas on Hahnemann, but consider him a founder rather than a prophet. They investigate new methods, and will often be somewhat more open to at least parts of conventional medicine. Many in this group are willing to dispense with the thorough (and cumbersome) takings. Some are quite ready to suggest medicines to complete strangers after the patient has posted a few symptoms via an internet BB.
A special sect is the wannabe rationalists. They are bent on finding rational explanations for the homeopathic theories, theorizing about water clusters, piezo-electricity, and what have you. They still take the basic claims for granted, however, and will often stomp away angrily if you suggest that the investigation starts with testing if there is anything there at all.
Finally, there is a large group of general alternativists who simply carry a cursory knowledge of homeopathy and a few homeopathic medicines in their large inventory of alternative methods and beliefs. This group is not really recognized as homeopaths by the rest of the society, but are generally tolerated as long as they do not step too much out of line.
The entire community has some pet peeves that they will pounce on, given the slightest provocation. One is vaccinations. Homeopaths are mostly strictly anti-vac. This is a bit surprising since Hahnemann actually speaks favorably of vaccination. More understandable is the animosity against antibiotics; if there is one modern medicine that undermines the basics of homeopathy, it is antibiotics: Here we have a medicine that targets causes specifically and has been a vast success. In consequence, homeopaths focus on allergy and resistance problems, trying to claim that antibiotics do almost as much harm as good.
Outside the community are the pure quacks, also recognized as such by homeopaths. Those are the ones pinning a Homeopathy label on anything from snake oil to spoof electronic devices in order to boost sales.
It is not possible, as a skeptic, to ask questions in the homeopathic community without being drawn into sometimes very heated discussions, so I would like to share some of my experiences from many such discussions, so that others who might venture in that direction are a bit prepared.
Allopathy. This is an expression homeopaths often use for conventional medicine. It is a total misnomer, as modern medicine does not attempt to induce symptoms at all, but works from a totally different paradigm. However, homeopaths will often want to steer the discussion in the direction of the faults of allopathy, inevitably bringing up penicillin resistance and the Thalidomide affair. One can enter such discussions, but it is important to realize that they have nothing to do with homeopathy; whatever problems might exist with conventional medicine, this does in no way vindicate homeopathy.
Self-proving. You will immediately be confronted with the demand that you do a self-proving, that is, you take some homeopathic remedy and feel the effect for yourself. Homeopaths will maintain that as long as you have not done this, you have no right to discuss homeopathy. One of the points against homeopathy from a scientific point of view is exactly that the subjective perception of a single individual is worthless as evidence. So, as a scientist, whether I feel anything after taking a homeopathic drug, is basically irrelevant.
Nevertheless, I once decided to try to surpass this obstacle; I purchased a homeopathic drug, and following guidelines in Hahnemanns Organon of Medicine as for dosing and intervals, I tried it out. As it happened, I felt nothing out of the ordinary. When I reported this at a homeopathic BB, I was immediately met with retreats in all directions:
Of course, some simply accused me of lying.
The company I had obtained the drug from was not trustable. This is really a pity as that company is supplying a large fraction of the homeopathic drugs available on the market.
My dosage strategy was wrong. Pity, I only got it from Hahnemann.
One homeopath told me to continue taking the drug (which others had declared do be probably dud) for FOUR weeks, and even carefully listed the symptoms I should look for.
Several told me that the fact that I had known which type of drug I took made the experiment worthless. So suddenly blinding was OK? So knowing what to expect made me NOT feel it?
I was also told that I had to have my case taken first. Another thing Hahnemann had forgotten to mention. The reason was supposed to be that in order for a self-proving to work, the right remedy had to be selected for me.
So, my self-proving did not count. At least, some expressed appreciation of my good will, but basically, I was back at square one. Typically for a believers community, information that does not confirm the beliefs is rejected. Actually, later somebody even suggested another skeptic should take a remedy for an entire year.
Study homeopathy. Akin to the demand for trying out the drugs is the claim that you need to study and understand homeopathy in order to be able to discuss it. I studied the Organon of Medicine to a degree that I evidently knew it better than several of the other participants, but still was told that I did not know and understand. This is really typical of a believers viewpoint: To understand is to believe, so since you do not believe, you must lack understanding.
Placebo effect. Many homeopaths do not understand what the placebo effect is, and why placebo control is important. When suggesting that some of the perceived effects of homeopathic treatment is due to the placebo effect, you will be met with the argument that it also works on babies, unconscious patients, and animals. Since these, non-communicating, patients cannot know that they are expected to get better, how can the placebo effect work on them? Well, how do you communicate with such patients? Somebody (parent, family, or in case of pets, owner) determines from their behavior how they feel, and whether they get better, and this person knows they are expected to get better. You might call it placebo by proxy.
One-way view. Finally, you are going to see a lot of one-way view; arguments that proponents are somehow unable to see point right back at their own case. It really starts with Hahnemann: Early in the Organon of Medicine, he notes that people can get quite sick for psychological reasons, he even goes as far as claiming that people, reacting on a prediction of their impending death, can actually get sick and die. Yet he later builds his entire pharmacopoeia on what delicate, irritable and sensitive persons report when asked to feel carefully for symptoms.
Summing up, does homeopathy not work at all? Well, there are certain areas where something resembling homeopathy does indeed appear to work: Certain allergies have been successfully treated by administering the allergen in highly diluted form to the patient for a prolonged period. It seems that this trains the patients system to tolerate the allergen somehow. In these cases, the preparation is not diluted so much that the active ingredient is no longer present, it is just present in a very high dilution. For this and other reasons, that particular method is not pure homeopathy.
True homeopathy, both the version true to Hahnemanns principles, and the modern, somewhat revisionist form, is not only unsupported by scientific theory, but also denounced by experimental evidence. Numerous tests have been performed, and most show negative or inconclusive results. A few of the scientifically sound trials show a positive effect from homeopathic drugs over placebo, but none of those protocols are entirely above criticism (protocols seldom are).
Obviously, if an effect could be shown in practice, we would have to accept homeopathy, even if the scientific explanation is not known, so doesnt even one small positive test count? In my opinion, no. Homeopathy is based on a set of claims about reality (vital force, water memory) that will require rewriting large parts of modern science. This makes homeopathy an extraordinary claim, requiring extraordinary evidence. In other words, its existence is contradicted by a vast amount of evidence in a broad range of disciplines, from basic physics, over chemistry, to anatomy and pathology. Writing off the mass of research in all those areas must be accepted if solid evidence requires it, but it must be very solid.
There is a clear discrepancy between the way homeopathy is presented by Hahnemann and his successors, as the wonderful super system of universal cure, and the feeble results observable in the real world. How do we explain that Hahnemanns indubitable truths and laws of nature turn out to defy detection with simple test protocols and basic statistics? Homeopathy had been around for 200 years. Much of this time science was still searching for answers and general medical practice was encumbered by ignorance and medieval methods, and the commercial might of the pharmaceutical industry has only emerged during the last few decades, yet homeopathy has not managed to secure its position as anything but a minority movement. It has not come one step closer to establishing its superiority, or explaining its basic principles, since the times of Hahnemann.
So, how can we explain that a miracle regimen has not yet made a solid impact on the world and still defies objective testing two centuries after its invention? Well, if we see it as the belief-based system it is, it all becomes clear. Believers will stick to their beliefs in face of most evidence, in this and other belief systems. Tests will be avoided or explained away in this and other belief systems. Anecdotical tales will proliferate, in this system, as in others.
Does the belief in homeopathy hurt anybody (except for their wallets)? Unfortunately, it does. Every once in a while, somebody with a serious disease will forego effective medical treatment and rely on homeopathy till it is too late. This problem is not specific to homeopathy, it is a problem with all belief-based medical treatment. Normally, peoples beliefs may not hurt them, but when they start trusting it to change real conditions in the real world, the consequences are potentially grave.
Under this section, I had included some bits snipped from various internet debates with homeopathy proponents. They illustrated several of the points made above. However, after about one year some of the authors of the posts suddenly felt that their pride and copyright was infringed. All the snips were legal under the fair use clause, but one homeopath issued the equivalent of a cease and desist order about a case story of his, and in general, I felt that others had reason to feel embarassed about their old posts still being on display, so to make a long story short, I decided to remove this part of the article. After all, much has happened since, and we must all look forward.