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Homeopathy was helping my patients. Then I tested it and figured out why

  16:30aktualizováno  27. ledna 16:49
The practice of homeopathy has survived for 200 years. But is it still relevant today? Effectiveness must be determined based on solid evidence, maintains Professor Edzard Ernst. Having a background in medicine, science and homeopathy encouraged him to conduct clinical trials of complementary and alternative medicine.

Professor Edzard Ernst (collage using a photo from 2015) | foto: Wikimedia/Nederlandse Leeuw, montáž: Pavel Kasík, Technet.cz CC-BY-SACreative Commons

Homeopathy is hard to swallow. There is often not a single molecule of the advertised substance in the pill. Yet this treatment is still popular in many countries, including the Czech Republic, United Kingdom and Germany, where this treatment originated in the early 1800s.

German-born doctor and scientist Edzard Ernst was fascinated by his positive experience in a homeopathic hospital. So he later used his position to conduct scientific experiments to test the effectiveness of homeopathy: “I definitely would have liked to prove that homeopathy works,“ he told us during our interview in Prague. “But looking at the systematic review of evidence, we see clearly that homeopathy works no better than a placebo.“

This is the English version. Český překlad rozhovoru si můžete přečíst zde.

His career predisposed Ernst to become the world’s first head of Complementary Medicine at a university department in 1993. His team at Exeter University tested the effectiveness of dozens of different alternative medicine therapies. Even after leaving the university, the Professor Emeritus still publishes books and blog posts on alternative medicine. But we had to start at the beginning.

Can you remember when you first heard of homeopathy?
Both my father and grandfather were doctors. My father, like many doctors in Germany at that time, knew of homeopathy and sometimes prescribed it. When I was five, my parents got divorced and I lived with my mother who was very keen on homeopathy. Our family doctor was a homeopath. So I grew up with homeopathy and for me, there was no difference between homeopathy and medicine. I didn’t think critically about it at all.

Eventually, I decided to study medicine and at university I felt a certain animosity towards homeopathy. The pharmacologists usually go absolutely apoplectic when they hear the word. I learned that there is no pharmacological reason that homeopathy could work, or even could work.

And then I finished my studies and was looking for a job. At that time, there were too many doctors in Germany. By coincidence, I landed a job at the only homeopathic hospital at that time, in Munich. It still exists. There I was confronted with homeopathy and learned how to practice homeopathy.

Dr. Edzard Ernst

* 30. ledna 1948

Studied at medical school and received training in homeopathy, acupuncture and other alternative therapies. He served as a Professor of Complementary Medicine at the University of Exeter (1993 - 2011). He now holds the title of Emeritus Professor.

Professor Ernst maintains an active blog and authored several books: Trick or Treatment? Alternative Medicine on Trial or SCAM: So-Called Alternative Medicine.

Were you good at it? Were your patients happy with your care?

Of course the patients were happy. They came to a homeopathic hospital so they expected homeopathic care. But I was very surprised.

I didn’t expect homeopathy to have such good results. However, the results were brilliant. Patients did get better. I thought to myself, maybe what I learned at medical school isn’t entirely correct. Maybe the homeopaths have a point.

I stayed in this hospital for half a year and I was impressed. Although I have to say, if you speak to any doctor after their first time they get to treat patients, they are always very amazed. It is an overwhelmingly impressive feeling to be let loose and treat patients. So in retrospect, I don’t know to what extent I was impressed by homeopathy and to what extent by treating patients.

What lead you from practicing medicine to conducting scientific studies?

I followed a normal career path, changed hospitals, became a specialist in physical medicine and rehabilitation and spent quite a lot of time in a research lab. My time in the lab was quite decisive for my future. I started to think, actually think.

As a medical student, you are not really expected to think as much as learning and absorbing, but you don’t have time to think. Becoming a scientist who is publishing papers allowed me to see a different perspective on medicine.

Still, I kept an interest in homeopathy and other alternative methods such as acupuncture. When I became a head of my own department, I decided to do a few clinical trials on homeopathy.

What was the motivation to conduct the clinical trials? Were there no previous studies available at that time?
I thought one needs to have proper evidence, proper scientific evidence. At that time, there were very few good studies. I thought that is what homeopathy needs, but also what I needed. Why did my patients in the homeopathic hospital get better? I had a lot of questions.

Profesor Edzard Ernst přednáší v Praze o alternativní medicíně

Profesor Edzard Ernst during his lecture in Prague to the Czech society of sceptics (Sisyfos)

Would you say you were trying to prove homeopathy works? Or were you trying to disprove it?

At the time I had spent about ten years in basic research. I may not be a brilliant scientist, but I know the basics. To prove that something works, you first need to try everything possible to show that it doesn’t work. You need to try to disprove a hypothesis.

That is the whole setup of a clinical trial. When testing whether a treatment works or not, you do everything to disprove the hypothesis that the treatment is effective. Randomization, double blind, all these features are there to make the test as rigorous as possible.

How to determine what works and what doesn’t

It is easy to start believing a false narative. That is why scientists are using rigorous methods to test the effects.

Clinical trials are used to determine the effectiveness of drugs or treatments. In order to eliminate any biases, modern trials employ these tools:

  • control group – while one group is getting the experimental treatment, another is getting no treatment or placebo treatment (sham treatment)
  • randomization – people are assigned to the group at random to avoid any type of bias
  • double blind – neither the patients nor the doctors know who is getting which kind of treatment

Only this sort of rigorous experiment can reliably test whether the treatment is effective.

Were you wondering back then about why there were so few studies on the effectiveness of homeopathy?

Yes, it did occur to me. But I had worked in the only German homeopathic hospital – Germany is of course the birthplace of homeopathy – and I saw how totally uninterested homeopaths are in science. In their view, homeopathy is an art not a science. That has maybe changed now a little bit, but back then, science didn’t come into it.

As a head of a very large hospital department in Vienna, I kept homeopathy and other alternative medicine therapies as a hobby. And then I saw an advertisiement by the University of Exeter in the United Kingdom. It was an opening for a head of a Complementary and Alternative Medicine department, first position of its kind worldwide. I applied, got the position and then it was my full time job to research alternative medicine.

Since then, I stopped being a clinician. I never saw patients anymore. Instead, I built a team and we did nothing but research.

Homeopathy

Homeopathy is one of the most popular disciplines of complementary/alternative medicine. The beginnings of homeopathy date back to 1810, when German physician Samuel Hahnemann published his book and introduced the basic principles of homeopathy.

  1. “similar cures similar“
  2. “more diluted is stronger“
  3. special shaking (“potentization“)

Most clinical trials (review from 1998, review from 2015) concluded that homeopathy is no more effective than a placebo.

So you tried to test the alternative treatments against placebo to see if these treatments are effective. How did it go?

Our research interest in complementary medicine had two objectives. For any specific condition we first asked: does it work? When we ask “does it work”, we are asking, “does it work better than a placebo.” I don’t doubt for a minute that placebo works, we know that very well. So a treatment should be better than a placebo.

Second, we ask if for the specific condition the treatment causes any harm to the patient. If so, how much harm does it do? People often think that alternative and complementary medicine is harmless, and thus quite different from conventional medicine, which we know can do a lot of harm. But in the 1990s, there was virtually no research into the risks of alternative medicine. We were the first ones to actually research it, and it is still not represented strongly enough as a subject.

Part of the reason for that is the absence of a monitoring system for alternative therapies. When you take any regulated medicine, you know the effectiveness of that drug is backed up by a huge amount of post-marketing surveillance. People can read about the side effects in the little leaflet. If you take any alternative medicine, nothing similar exists.

People also often forget about non-direct adverse effects. Sometimes the alternative therapy itself might be harmless. But if, because of using the alternative therapy, the patient is declining a more effective treatment, they are harmed indirectly. In the most extreme case, a person declines an effective chemotherapy, uses homeopathy instead and dies. Therefore, we need to look at the balance between risk and benefit. There is almost no research on indirect risk because the practitioners of alternative medicine are often so uncritical. They hardly ever record the direct risks, but never the indirect ones.

When you started your complementary and alternative medicine unit, what were your first steps?
It was in 1993 and it was a big thing. I was the first head of complementary medicine and the papers devoted whole pages about it. I thought it would be a quiet life, but I was wrong. It was a big deal, I remember The Guardian dedicated a whole page to me.

Celostránkový článek z deníku The Guardian z roku 1993

Celostránkový článek z deníku The Guardian z roku 1993

I built a team because alone I couldn’t do anything. Once I had a group of five researchers, I instructed everybody to keep a low profile. We first want to be sure about what we are saying. We don’t want to pretend we’re clever. We have to have data.

In the first five years we were publishing in academic journals, but we weren’t trying to get in the press. I never contacted a journalist while I was there. The nature of my post meant that almost every other day a journalist contacted me with a question. Journalists found me attractive because I presented a view of alternative medicine that was not presented before.

What were the results?
I said publicly at the beginning: we are not going to make any statements we can’t prove. We are not going to study homeopathy as a whole. We are going to study what is most important for the UK. The next week there was a spiritual healer at my door: “I hear you’re studying spiritual healers.” Turns out spiritual healers were really the largest group of alternative healers in Great Britain. So we studied them. Overall we studied 48 different treatments.

Přehled účinnosti alternativních terapií

Přehled účinnosti alternativních terapií

How many of them did you find to be effective?
There were a few herbal treatments that were effective for specific conditions and some massage treatments. (For details, see the article in BJGP, PDF)

We also did four trials on homeopathy, none of them were positive. I oversaw another clinical test of a homeopathic remedy before in Vienna and that was a positive one. We tested a commercially available homeopathic remedy and the results were positive. Why were they positive? Because the homeopathic remedy was not diluted. You find that quite often. A company registers the remedy as homeopathic because it is easier. But it was a D1 dilution which is basically an herbal remedy. It was not a real homeopathic remedy, but legally it was.

But you didn’t keep a low profile forever. What changed?
I realized we also have a responsibility to the public. So we started publishing the results we were producing and also results from scientists around the world. I’ve built up a reputation with journalists and it snowballed.

I never once contacted a journalist while at Exter, but every other day a journalist contacted me. I was attractive to them because I presented a completely new perspective on complementary and alternative medicine.

The founder of homeopathy would not practice it today

Homeopathy is practiced not just by homeopaths. A lot of doctors dabble in homeopathy and prescribe homeopathic remedies to their patients. And I am sure they see it as being forward-thinking and patient-oriented.
Yes, that is the image they’d like to give themselves. They would like to see themselves as forward-thinking. But what they consider forward-thinking is actually already an old hat. There is no question that evidence-based medicine is the future. And that’s because evidence-based medicine has mechanisms to evolve over time.

But for some people, it can be appealing to choose homeopathy precisely because it has resisted virtually any changes and stayed the same. It seems cool.
A lot of bullshit can sound appealing, but it is still bullshit. I don’t care what looks cool and what doesn’t . Medicine is not about what looks cool, medicine is about effective and not effective.

Profesor Edzard Ernst přednáší v Praze o alternativní medicíně

Long history of homeopathy doesn’t mean it’s working, warns Prof. Ernst

Did homeopaths always try to stick to tradition?

Samuel Hahnemann (1755 - 1843)

Samuel Hahnemann (1755 - 1843), German doctor and the inventor of homeopathy

Homeopathy hasn’t really changed since Samuel Hahnemann, who invented it. However, Hahnemann himself was quite forward-thinking. He was, in my opinion, a great doctor. Of course I never met him, but I think if Hahnemann was a doctor today, he wouldn’t practice homeopathy.

Toward the end of his life, Hahnemann held to his ideas a bit too much. We all will probably do that at some point. But he was a forward-thinking doctor. He saved thousands of people with his treatment. In his time, bloodletting was the standard and his therapy was better – just by not causing harm. Remember this was a time of bloodletting, that practice alone might have killed millions.

Is homeopathy distorting the public’s understanding of how medicine works?
It is extremely difficult to give a science lesson to the public. It’s an impossible task to do it in one conversation. That is why I write books. It is a long process.

What is your most successful strategy when explaining to someone that homeopathy doesn’t work?
The simplest is to show that there is nothing in it. Most solutions are diluted so much that there is simple no trace of the original, not a single molecule of what it says on the label. Homeopaths know that and they say there’s some energy… it quickly gets into metaphysics, but it’s simply bullshit what they come up with. It’s unproveable.

So it cannot possibly work. But that is not the only way. Clinical data also show that homeopathy doesn’t work. We have five hundred trials. Of course, some of these show positive results and homeopaths like to point to these. But that is cherry picking; that is cheating. You have to look at the totality of the evidence. And looking at the systematic reviews of the evidence shows that homeopathy works no better than placebo.

So you have no mechanism how it could work and no proof that it actually works. That should be enough for any intelligent person to give it up.

I bet you were quite intelligent 40 years ago. Yet you also used to believe that homeopathy works. What changed your mind?
I am not sure if I was ever a true believer. I was very impressed by homeopathy. I definitely would have liked the idea that homeopathy works. Also, if I was able to prove that homeopathy works. If you do that, you get two Nobel prizes: one for chemistry and one for physics. It is attractive.

People imagine that something changed my mind and I suddenly realized that homeopathy doesn’t work. But that wasn’t the case. It was slow, drip by drip by drip: looking at all the evidence that already existed, contributing to the evidence with new research, conversations with homeopaths, all of these things.

Today I believe that lots of people are helped by homeopathy. But they misinterpret the mechanism. They are helped by the close contact with the kind and empathetic homeopath who gives them time and listens to them. They are helped by the placebo effect and other mechanisms. But it has nothing to do with the homeopathic remedy itself.

Modern medicine could learn some empathy from homeopaths

You mentioned homeopaths were not really interested in scientific studies. Were homeopaths skeptical of science, or were they worried they wouldn’t like the answers science has for their questions?
In retrospect, to be blunt, it is just stupid. As doctors, we have the ethical responsibility to find the best possible treatment for our patients. So giving homeopathy to people and see them getting better – and maybe they would get better anyway – is simply not enough. We need to ask, is this the best I can do for my patients?

If you do believe in homeopathy, you are not well informed. You don’t know what the evidence shows. That is unethical. You should base your treatment on evidence.

At the same time, evidence-based treatment wasn’t the standard even in conventional medicine, and only came to prominence in the last seventy years or so.
Well, I am not that old, but you’re right, the term “evidence-based” is even younger, maybe 35 years old. But the principle always existed. It is both a scientific principle and an ethical principle. 

So what could the practitioners of evidence-based medicine learn from homeopathy and alternative medicine in general?
We have to understand the popularity of alternative medicine as criticism of conventional medicine. When I go to my doctor, the appointment is 7 minutes 30 seconds on average. Out of that, the doctor looks at the screen for seven minutes. That is not good medicine.

Doctors need to listen to patients, investigate patients, touch patients. Doctors need to show empathy, sympathy and understanding. In Sweden, the average lenght of the appointment is around 25 minutes, that seems to be OK to me.

Some countries have systems that are not supportive of good medicine. Doctors must refuse to work in such systems. They must demand that the system changes to allow for proper medicine.

Přechod na DVB-T2

Od 27. 11. probíhá postupný přechod na vysílací standard DVB-T2. Proces by měl být dokončen do poloviny roku 2020. Diváci si tak musí pořídit televizi s podporou kódování H.265 (HEVC) nebo starší televizi doplnit vhodným set-top boxem.

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