“This Mechanism Is Not Well Understood” – Lacunae in Science

Medline, that key repository of all things biomedical, holds more than 20 million citations.  Of those, over 1 in 200 state variations on one of my favourite sentences in science: today’s title theme (not well, not clearly, not yet, not currently…) – biomedical mechanisms defying science.  Searching Google at  ‘advanced reading level’ (aka ‘so not Yahoo Answers’) , the relevant terms turn up in 29% of indexed pages pertaining to health or science or medicine:  a rough measure to help along a general ‘I wonder’ about the Unknown in science and medicine.

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The ‘mechanism’ in many CAM therapies – notably in homeopathy – ‘is not well understood’.  Skeptics have been trying to transmute this – by media drip feed –  into ‘there is no mechanism’.  Or, as then-US-Defence-Secretary Rumsfeld explained to justify a war: stick with what we can see – ignore the ‘unknown unknowns’.

But even if all placebo-only allegations in relation to complementary therapies held true, would not this too mean homeopathy and other CAM must be ‘better understood’? Placebo is a frontrunner among the mechanisms in healthcare which are barely understood.  So where are the skeptic researchers investigating possible placebo aspects in CAM? Assumption, assertion and strange mud-slinging is all we get.

The louder skeptics in the UK have elevated themselves to a new science police, notably in the current ASA campaign that prompted this blog: persecuting individual practitioners, not large companies.  The ‘multi-million pound industries’ in CAM often cited by skeptic groups consist almost entirely of over the counter sales of vaguely alternative health supplements. Guess who owns Seven Seas, the biggest supplier in this market?  German pharma giant Merck.  Now there’s a really big target…  Yet the one-person CAM practices in little clinics up and down the country are what the right-thinking skeptic aims at.  Advice from the Woo-finder General to his hench-writers: pick anything on your chosen target websites – the ASA is duty-bound to investigate, and your complaint might just stick even if spurious.

One key argument between ‘science’ and ‘homeopathy’ (an arbitrary polarisation much fostered by skeptics) hinges around plausibility.  On whose authority?   Why would someone who readily accepts the wilder reaches of quantum concepts and the possibility of multi-verses, who expects that material proof of the Higgs boson is just around the corner, and doesn’t discount the graviton, insist so strongly that this one modality is simply impossible?  None but the most egg-headed of boffins have even a small proportion of the science pieces they need to puzzle together for themselves what makes sense in the big picture and what doesn’t.  Everyone else… takes it on trust.

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Here’s Brian Cox quoting a contemporary of Hahnemann’s , Humphry Davy – a ‘personal hero’ no less.  So let’s hear it for Samuel Hahnemann, pioneering thinker and embattled scientist, Professor Cox.  But no, he’s gone to the Dark Side: Brian Cox is proud patron of and speaker for those indiscriminate CAM-busters, the ‘Skeptics in the Pub’ movement – that’s the people who hire strategists to enthuse and instruct their acolytes in the art of malicious mass campaigning, the groups who teach debating techniques the better to hammer opponents with spurious ‘logical fallacy’ attacks, in short, the would-be freethinkers whose sole aim is to score points against what they present as rip-off pseudoscience (rolling everything from UFO conspirators to integrated medicine on the NHS into one tidy package).

"Fweee Bwian!"

But still we trust in Brian.  And Ben.  And Simon.  Even that dodgy Edzard with his movie baddie accent.  In spite of clear evidence of bias.  Trust – what a wonderful thing.  Safety, certainty.  If I trust that you tell me the truth, then I need look no further: a lot less hard work.  So if you adopt ‘the facts’ pre-digested from the Messrs Cox and Dawkins (sorry – Professors, to give them their correct, authority-bestowing titles), taking it in good faith that they have worked out the difficult bits you don’t quite get, then life is so much easier.  But isn’t that … just faith?  It certainly isn’t scepticism.

Meanwhile, lacunae of unknowing in the current information base of science and of medicine remain, the voids filled at need with apparently tidy cover stories. Like ‘it’s just placebo’.  Just?  Some things scientists know (and admit) they don’t know.  It’s the ‘unknown unknowns’ they struggle with but – unlike the benighted Rumsfeld – anyone, not just scientists, can embrace and face that completely open uncertainty… that’s how the ‘c’ gets back into scepticism.

To Infinity and Beyond

What is a homeopathic remedy?  A sugar pill? ‘Just water’?  Homeopathy was named by one Dr. Samuel Hahnemann.  First-rate scientist, rubbish PR person.  Homeo-pathy?  Awkward man – awkward word: difficult to spell, easy to lampoon.  Even easier to misrepresent.

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My favourite skeptic skit… completely misleading, but – anything for a laugh, eh?

Laughs aside, homeopathy – a remarkably cheap, effective, low-tech health care option, affordable even to the poorest nations – deserves proper research funding.  Key elements of treatment:

• Symptom similarity  –  determined through tests on the healthy (pathogenic trial, proving)
• Individualisation – symptom similarity is as individual as people
• Serial dilution/agitation –  developed to minimise drugs toxicity/side effects

‘Homeopathy’ is not a protected term; mis-use of the word commonly confuses public perception.  Here is someone else who seems confused about homeopathy:

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Very likely this man knows quite well that his seaside dropper stunt is misleading nonsense.  Ah – isn’t that… yes, skeptics call homeopathy ‘misleading nonsense’ while spreading misleading nonsense about this widely used and accepted healing modality.

Dilution to the infinitesimal  is not what makes a medicine ‘homeopathic’.  Ultra-high diluting was Hahnemann’s answer to drug-induced pathogenic (‘side’) effects.  He employed serial dilution, a method still commonly used in pharmaceutical labs.  He just took it an inexplicable, observation-based step further.

Confirmed similarity to symptoms of disease makes a substance homeo-pathic – similar to the individual’s suffering.  Fact is, most ordinary medication too works because a given substance can cause in the healthy just those symptoms it is designed to treat –  medicinal substances have naturally both anti- and homeo-pathic effects.  This is most easily seen in the so-called ‘paradoxical effect’ – e.g. analgesics inducing pain.  The use of Zolpidem*, an insomnia treatment, to rouse coma/PVS patients is one example of the homeopathic similarity principle in ‘off label’ drug use.

The simillimum aspect of ordinary medicines is easiest to spot in herbal remedies, for example chamomile (e.g. induces nausea if over-used = soothes stomach in normal use) or arnica (over-use a.o. causes microhaemorrhages = effective treatment for bruising).  Such similarity is a key factor in much primary drug action – which means a large chunk of medicine is in fact crudely homeopathic.

Conversely, if someone dishes out potentized remedies bought from a homeopathic pharmacy, this does not equate to homeopathicity: no similarity, no treatment, no effect.  That’s one reason why the ‘homeopathic suicides’ stunts are so risible: “Look, look I’m not dead – ha ha ha!”  “Yes, we know, dear… isn’t that nice?  We’d hate to see you damaged by your own stupidity.”

this man does not understand homeopathy - skeptic campaigner 'suicide' stunt

The beauty of potentized ultra-high dilutions is just that:  they can induce amazing health changes if properly prescribed  –  yet pass through harmlessly if ‘dissimilar’, that is, not needed or not properly individualised to a patient.

Hahnemann prescribed standard doses of  his newly discovered ‘similars’, successfully, for several years.  In his quest for minimising side effects, why would an ambitious young doctor still building a reputation scupper his chances? Why refine this peculiar dynamization process unless it worked well?  Were both he and his patients the first gullible victims of homeoathy – just like the 500 million worldwide who use it today?  All of us? Just fools?  Really?

Some medics were disparaging homeopathy on the grounds of implausibility decades before the science community accepted Avogadro’s Constant.  What today’s skeptics believe about homeopathy is worn-out old tricorn jazzed up with the high-tech feathers of molecular biochemistry.

Edzard Ernst demonstrates the double blind method

In Europe, much homeopathy (and a related application, ‘homotoxicology’) is practiced using low 1:10 serial dilutions.  Definite material doses are still present in such preparations. In dismissing these as much as high potencies, professional CAM ‘debunker’ Edzard Ernst and friends gloss over the pharmacologically quantifiable content.   I’d agree that the degree of homeopathic dilution really is just a question of … degree.  So, naturally, 1:10 dynamisations, like infinitesimal ultra-high preparations, do work. Being materially small doses, they act less subtly, treatment indications are more limited: a half-way-house between the holistic, individualised applications of the ultra-high level and the single-track biochemical usage of modern medicine.

Ultra-high dilutions are not easy to understand.  There is no known mechanism that shows definitely why they work; there is much new-agey mis-information.  Some people are attracted to homeopathy because it all seems so miraculous.  Others get angry at the inexplicable.

Science has a long history of revolutionary discoveries that overthrow old world orders, from Copernicus to Einstein and beyond. The unknown is unknowable – until it is discovered.   I can see the action – and results – of the infinitesimal in my practice every day.  Whether or not a biochemical, quantum or other explanation for homeopathic medicine will be discovered eventually… it really doesn’t matter to the people who get better.

*Incidentally, Zolpidem is an example of the evidence-mindedness of medical care: although studies have to date failed to confirm the early promise of this application for the drug, many if not most PVS patients are given Zolpidem on an experimental basis.  And why not?  It’s just that if one went strictly by the demands of EBM, doctors would not agree such off-label use until confirmed in large-scale trials.

What’s So Special About the Geeks?

Who are the ‘skeptics’?  There’s celebrity woo-hunters, like Simon Singh (journalist, physicist), Ben Goldacre (journalist, almost fully qualified psychiatrist) and Brian Cox (TV presenter, physicist).  As successful media players, they have a public profile, readers, fans. But their reputation is critically fed by a substantial subgroup of skeptic supporters – groupies? – who follow them around in cyberspace and in the real world.  Who are these unsung skeptics?

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(should this be all Greek to you, then shut up, Bignose – he means Geek!)

The O.E.D. explains a geek as one “extremely devoted to and knowledgeable about computers or related technology. […] self-designation, not necessarily depreciative” and “obsessively devoted to a particular pursuit”.  ‘Science geek’ has not yet earned an entry even in the Urban Dictionary, but give it time:  this is a sub-group now (as in much skeptic newspeak, meanings shift – ‘science’ here no longer means science as we knew it but a vague, quasi-Newtonian-post-Darwinist dogma).  The word once meant a foolish/offensive/worthless person, which by extension became ‘dupe’ – someone who is easily misled, a fool.

It is worth noting then that the unelected king of the skeptic movement is one James Randi, a conjurer who has often pointed out that making dupes of people is his profession and his pleasure. It’s just his followers, the self-designated geeks, assume he doesn’t mean them… .

A tag cloud created from skeptic twitter biogs:  the interest focus, distilled into 30 words, of a wide network of twitter-linked skeptics who share in active efforts to discredit and ridicule the work of complementary practitioners everywhere, by fair means and foul.

Foul?  Depends on your point of view: Ben Goldacre prefers to call it “the simple, enduring pleasure of baiting morons”.   Like the growing trend to orchestrated mail deluges.  One ombudsman-judged mass campaign that was made public was declared officially ‘vexatious’.  And how about pretending to be a homeopathy student, stealing postings from a confidential practitioners’ forum, or passing university teaching material to blogger skeptics for ridicule and mis-representation in public?  A simple pleasure?

Because there is now a small army of such bandwaggoners, UK skepticism has become more than just a harmless hobby for Mr. Dawkins and friends. There’s almost 6000 people on the so-called badscience forums, more elsewhere. Many engage in the ‘pleasure’ of ‘moron baiting’ activism.  Almost all self-define as ‘geeks’.

That tag cloud reflects the aspirational more than the actual – so here, synthesised from the wealth of skeptic online self-expression, is a fine portrait of the would-be hero of rationalism: Average Skeptic Geek.

A bloke, of course (there are girl skeptics. But few).  He’s ‘into’ rock music and treasures his vintage Led Zep t-shirt.  His science comes from New Scientist. He works at a glass-clad company HQ outside Reading, in IT.  He’s 26: still young enough to have all the answers – or trust that someone else does and it’ll only be a question of time until he too has acquired the knowledge t-shirt.

Meantime he’s happy to copy what Simon (Singh) Says.  “200 studies show that homeopathy has no effect beyond placebo”. Has he read the studies, can he assess the methodologies? No (Even Simon hasn’t read them critically, actually – too risky; he might find out he got it wrong) – he isn’t a medic but a software guy.  He likes things in black and white, and his science is rooted in the simple ‘truths’ of the school syllabus, expanded by knowledge-lite ingested from celebrity-fronted TV shows.

Thanks to youth and luck he’s never been seriously ill so has little experience of just how ‘evidence based’ our health service is (not), and his insight into drugs effects is strictly recreational.  He applauds the skeptic bloggers who dissect interminably anything they consider ‘woo’, spends hours online in skeptic pursuits.  His activities, his consumption, his books by Dawkins, Singh et al, feed a deep need: to feel himself anchored in a reassuringly mechanical universe in which all the cogs click along explicably, and all gaps will fill ‘logically’ in the course of guaranteed progress. Of course he is ‘an atheist’.

His fandom embraces the ‘skeptic’ comedians who make this world view seem so right, so obvious, and easy laughs make him feel at one with the virtual community of bods who seem to have the truth on ‘life’ and the ‘universe’.  He doesn’t consider the ‘everything’ too much, that limitless expanse of uncertainty.

Uncertainty is the geek’s great fear.  That’s why he lashes out at people who offer a different viewpoint.  He has no hope of explaining everything from within the safety of the mechanistic paradigm .  So the fearful inexplicable morphs into ‘woo’ – cue the ‘enduring pleasure of moron baiting’.  Skeptic forums, skeptic pub meets: occupational therapy for the geeks?  Aw, bless ’em.

“The Plural of Anecdote is Data”

Once upon a time… but no, hold on.  Every homeopath, every patient, can give many ‘anecdotal’ reports of treatment success.  So what is an anecdote?  “a narrative of […] a single event […] in itself interesting or striking”.   In terms of someone’s experience, what’s wrong with that?  And when is an anecdote not an anecdote?  When it’s qualitative research.  Or as political scientist Raymond Wolfinger said, “the plural of anecdote is data”.

Statistics rule modern medicine, seemingly – yet much of the information that shows what patients and healthcare professionals do and experience derives from qualitative research.  That’s when a group of individuals is given the space to talk about their personal experience, embedded in a formal piece of research.  Large quantitative studies lack the instruments to capture such information, and healthcare providers are happy to use qualitative data to assess quality of care, including outcomes.  But in science ‘anecdotal’ is a dirty word: it implies value-less, baseless assumptions, wishful thinking, deliberate charlatanery – so is favoured by skeptics when discussing ‘implausible’ modalities.

Until about fifty years ago, humanity’s medical evidence base derived largely from experience and observation.   Yet modern medicine is a development of what went before, not a grail that sprang, new- forged, from a sudden realisation that all that had gone before was false.  There have always been theories: humours theory, spagyrics and hundreds more.  Our medical model, amazingly, stands on the ancient shoulders of Galen and Avicenna as much as Koch and Pasteur – and it is just as much based on theories.  Because new, we trust today’s theories to be true.

But seemingly scientifically well-founded ‘best practice’ often enough turns into its opposite.  Much like Delia’s latest ‘superfood’ promotions, it changes all the time:  Take aspirin daily, it will save your life.  Don’t take aspirin – it doesn’t prevent heart attacks, it makes your stomach bleed.  And aspirin, like vast numbers of modern medicines, originates in ‘superstitious’ folk medicine: pharmacists learnt to synthesise the active ingredient of willow bark in the 19^th century, one of the earliest pharmaceutical best-sellers.  Did it matter that Culpepper 300 years before thought willow was ‘ruled by the moon’?  He knew how to use it – for pain and fever, as today – from handed-down folk experience: anecdote.

© David Davies 2009

Homeopathy works.  A bold statement – from my own experience and the experience of millions who have been helped, often saved, by homeopathy. One chestnut skeptics like to hurl invokes an analogy between the millions who ‘believe’ in homeopathy and the masses adhering to faith and religion.

The difference: faith in the existence of a higher being is necessarily just that: the ability to have faith itself is a predicate of faith.  Philosophers  of all schools argue the essential unknowability of divinity.  In homeopathic treatment, the patient need not ‘believe’ in the method, may not know they are receiving treatment (babies, coma patients), may be extremely sceptical: the most fanatical homeopathy-denier will still benefit.  Few expose themselves to such a risk of challenging cherished beliefs, not to mention loss of a close-knit community. Like leaving the church for a Catholic, only on the internet?

So what’s the proof of my anecdotal pudding?  Even some homeopathic researchers propose that ‘the consultation’ may be the key to success.  But no: in many settings, the consultation is no longer or ‘nicer’ than the average GP appointment.  Overall, homoepathic treatment outcomes are comparable, no matter interview style and length (across the board, around 85% of homeopathic patients improve significantly in vastly varied treatment conditions).

While, just as in ordinary medicine, other explanations may apply in a proportion of cases – natural resolution to an acute episode, sudden remission of serious illness – the sheer mass of direct reporting of homeopathic successes speaks for itself: not every cure can be explained away, not every patient is a gullible fool, by the million, worldwide.  People understand this, otherwise homeopathy would have long-since been consigned to the quack-heap of history.

Key factor: if the wrong remedy is prescribed, the patient doesn’t improve; once the right prescription has been found, the patient’s health changes.  Wrong remedy = no cure, right remedy = cure – no matter the belief of patient or practitioner.  It’s when homeopaths get it wrong that the crucial importance of the remedy shows itself – if the remedy were ‘only’ a placebo, the actual prescription would make no difference.  We may not know why medicines at such high dilutions work, but we can see their effect on health, directly and patently.  Patients and practitioners everywhere tell us so – whether you want to call that data or anecdote.

Exploring the New Skepticism – the View from Woo

“Infamy! Infamy! They’ve all got it in for me!” – so They did.

And the loose alliances which populate virtual and real spaces from the Badscience chatrooms to ‘Skeptics in the Pub’ hook-ups have it in for complementary therapies in the UK.

When on 1st March the Advertising Standards Authority (ASA) remit was widened to include the web, the skeptics were in the starting blocks, ready to go with an orchestrated shop-a-homeopath campaign, and it’s going strong.  ‘Them’ against ‘Us’: a farce, and it’s not funny!  No room to breathe, to debate or question is left in the crammed confines of ideological scientism.  The new skeptics seem to have forgotten about sceptical enquiry or that key term of science vernacular,  ‘poorly understood’.

Instead there rises a newspeak certitude where skepticism means ideology, where science is reduced to mechanistic computability, yet elevated to quasi-religion.  Such scientism throws the homeopath and the tarot reader into the same pit of sinister woo peddling. 21^st century skeptics don’t doubt who owns the truth: they do.  That’s why they are ‘They’.

Google ‘homeopathy’ plus ‘skeptic’ and that unbiased scientific term ‘woo’ (from ‘woo-hoo…’  spooky movie sound effect!).  You may find yourself wholeheartedly agreeing with what you find – or perhaps you haven’t given it much thought and have been entertained/taken in by the funnymen who make sport of ‘woo’:  often hilarious, always shallow, never scientific.

On the other hand you may find yourself shocked at the mega-doses of vitriol and palpable malice that are poured on homeopathy and CAM.  Would you agree with boycotting a yoghurt brand because the cows get homeopathic remedies sometimes? There are some skeptics inciting that boycott right now.  You may wonder also, in passing, how so many of ‘Them’ can find so much time to attack ‘Us’.

And who are ‘They’?  My unscientifically sound investigations show that most skeptics

• have no personal experience of using complementary therapies
• are not doctors
• base ‘scientific’ credibility on a subscription to New Scientist

High profile skeptics, those who get to speak at gatherings, are a heterogenous bunch.  A survey of speakers from a selection of recent big-name skeptic events reveals, for amusement purposes divided into fairly accurate percentages,

• 45.7% entertainers/performers – of whom 25% magicians and 18.7% comedians
• 25.7% social scientists (including psychology, policy, philosophy etc)
• 22.8% ‘real’ scientists with degrees (biology, pharmacology, physics etc)
• 11.4% politicians and lawyers
• 5.7% IT experts
• 2.8% medical doctors

You could make your own pie chart (Lacking online tech skills, I can’t oblige). As can be seen, there is no ‘average’ skeptic celebrity.  Unless it be Stephen Fry.  Except that he is not average.  Misguided, but quite brilliant.  And of course, neither a scientist nor a doctor, so – in the topsy-turvy rationale of the new skeptic movement – ideally placed to judge homeopathy and other CAM.   Stephen: have you tried proper homeopathic treatment?  It could really help you!

Why this exploration of skeptic identity?  Because They do ‘have it in for me’.  I mean Us. Why would they pour so much time and resources into hounding complementary therapists?   Even Ben Goldacre has noticed that most of us are “well-meaning, caring people”.  The newly founded ‘Nightingale Collaboration’ exists to get as many homeopaths’ websites reduced to meaningless blurb as possible by inciting orchestrated complaints to the ASA.  The site provides instructions on how to turn even harmless and well-meaning information into an alleged ‘misleading claim’.

Hundreds, perhaps thousands, of homeopaths – most of whom practice solo under shoestring conditions – are being systematically targeted with legalese ASA complaints (some generated by a specially-created piece of software, so the blogosphere tells me)  The world of twitter has been a-chirp with exploits like “I’m releasing a weapon of quack destruction”.   I’m not sure whether grappling with understanding this strange mindset can make a difference.  Still, it beats ignorance.

The Reluctant Blogger

“Never!”  I said. “Never will I be a blogger”.  For the reasons why I’m now here, blogging, after all, please see my About page.

This by way of a preamble – the first post will follow in a couple of days.  If you’re curious, why not sign up for an alert?  See you soon.