Mesmerizing the populace

Updated: Apr 30



The Indian Parliament recently approved the National Commission for Homeopathy Bill (2020) even as the opposition appealed for reconsideration. This bill seeks to further legitimize the pseudoscience of homeopathy putting the lives of more than a hundred million people in danger.


The homeopathy product market in India is a valued at over $ 1 billion and projected to grow at the rate of 25% annually [2][3]. The ministry of AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy) has repeatedly trumpeted unfounded claims about the efficacy of the homeopathic drug Arsenicum Album-30 in preventing COVID-19. In keeping with the recommendations of AYUSH, many Indian states are distributing homeopathy medicine to citizens. The Government of Gujarat distributed the drug to half its population (35 crore people), even though "a clinical trial related to the prophylaxis nature of Arsenicum Album-30 for coronavirus in the state (did) not yield any conclusive result" (reported by The Times of India).


A Cautionary Tale


In early teenage I started developing recurrent infections of the tonsils that I continued to suffer from for more than a decade. Sometimes, the inflammation rendered me mute for days. A spoonful of ice cream or a bit of rain reliably aggravated the condition and often brought me down with fever. Earlier this year, I got my tonsils removed through a surgical procedure that would have been less painful and considerably easier to recover from at a younger age.


Why did I go a decade without proper treatment for an illness that is not uncommon? I was not oblivious. In fact, I was told by numerous doctors that a tonsillectomy was a good bet after antibiotics failed. But, I heedlessly resorted to alternative medicine. The popular choice in the family had been homeopathy for generations. Homeopathic doctors, on average charge less than half the consultation fee of an actual doctor and homeopathy purports to cure diseases, even chronic ones with sugary pills that come in pretty little bottles. Claims of no side effect add to its allure. Among its many charms is an utter disregard for modern medicine and a frivolous, widespread belief in the community that the human body has untapped self-healing potential.

All other claims of homeopathy pales in comparison to the truly farcical central tenets of the practice that dates back to 1790. The American Institute of Homeopathy lists several "guiding principles", all proposed by Samuel Hahnemann, the founder-patron saint of homeopathy. Samuel Hahnemann was a physician who according to the book The Science of Homeopathy [5] gave up practice saying "It is not I who is at fault, it is the art of medicine which is wrong". True to his egomaniac self, he went on to invent a new system of medicine that he believed could cure all diseases based on some fixed laws.


The first law or guiding principle, attributed to the Greek physician Hippocrates is similia similibus curentur or "let likes cure likes". The idea was reportedly [5] precipitated by Hahnemann's observation that the Cinchona bark, widely used in his time to cure malaria, produced malaria-like symptoms in a healthy person. If only he knew (as another mad theorist observed) that sometimes, a cigar is just a cigar.


The second law, called the Principle of Potentiation states that higher dilutions of an active ingredient has higher potency. Surprisingly, practitioners to this day tout this laughable idea, while attesting to the fact that the sugary medicine in homeopathy is just mostly sugar. The skeptic James Randi compared this serial dilution technique to "taking one 325 milligram aspirin tablet, throwing it into the middle of Lake Tahoe and waiting two years for the solution to be homogeneous".


Here is the TED Talk by James in which he overdosed on homeopathic sleeping pills.



There are other principles of homeopathy like the Doctrine of Vital Force and the Principle of Single Remedy but, they are too outdated to merit any serious discussion in the 21st century.


If you are a believer in homeopathy, you are by now irritated by my apparent ignorance. Maybe you, or someone you know has been cured of an illness by a homeopath and can bear witness to the miraculous healing powers of homeopathy. I too was apparently cured of tonsillitis several times; in fact, at least half a dozen times every year for a decade until I realized I never was.


The Power of Expectation


Expectation has physiological, sometimes therapeutic consequences. Due to this effect called placebo, even fake medicine can have real effects on the brain and body, caused by the belief that one is being treated. Although, people have known about this for a long time, the neuro-physiological mechanisms of the placebo effect have only recently been discovered.


"The average patient listens with much more interest to the prescription of his physician than to his directions about hygiene. Expecting good results from the drug, he often imagines that he feels them. So great is the power of hope that, even in incurable diseases, a temporary improvement often follows each new prescription. This power of hope … is sometimes used by the educated physician, who calls it ‘expectant attention."
- Nichols JTG, 1893, The misuses of drugs in modern practice [re-quoted from (8)]

At least two mechanism have been implicated in the Placebo response (Amanzio and Benedetti, 1999). Expectation, the first mechanism, can have a range of physiological effects, the best studied of which perhaps is pain reduction. In a paper published as early as 1978, Jon Levine and colleagues suggested that Placebo Analgesia - the reduction of pain caused by an inactive drug might be due to the release of Endogenous Opioids (pain-killers produced within the body). This hypothesis, based on the observation that Naloxone (a drug that counteracts the effects of Opioids) reduces Placebo Analgesia, has now been validated through other studies [9] [10]. Further evidence for physiological consequences of expectation comes from the study of reverse placebo or Nocebo. A subject given an inactive substance but told that it will increase pain, will sometimes experience an increase in pain in the right setting (like a hospital) [11].


LOCATION OF SUBSTANTIA NIGRA (MARKED IN GREEN)

Placebo response in Parkinson's disease has also received a fair amount of attention. Parkinson's disease is caused by the degeneration of dopamine producing neurons in a part of the brain called Substantia nigra and the resultant lack of dopamine (which is an essential neurotransmitter).


Raúl de la Fuente-Fernández and colleagues discovered that placebo response in Parkinson's disease patients is due to endogenous release of dopamine, which is surprisingly strong. In their study, placebo (an inactive substance) produced effects comparable to that of actual medicine (Apomorphine) due to the expectation of benefit.


The other mechanism is conditioning [10]. Subjects who are given a real pain-killer like morphine for a prolonged time show a (conditioned) physiological response and experience pain reduction when given an inactive look-alike intermittently. Placebo responses due to conditioning has been shown to mimic the effect of growth hormones, insulin, immunosuppressants and antihistamines [13]. This type of placebo response is also mediated by expectation [14]. Placebo has both conscious and unconscious aspects and is not unique to humans. Fabrizio Benedetti, a leading researcher in the field has suggested that the placebo analgesic response in animals is similar to that in humans [15].


Stuff Happens

FABRICIO BENEDETTI

There are some aspects of recovery that can neither be attributed to treatment nor to placebo response. Many at times, people get better on their own having needed no therapeutic intervention. Such spontaneous remission, is often spuriously attributed to the treatment subjects received prior to recovery [16]. Treatments also receive undue credit due to a statistical phenomenon called Regression to the Mean. Assuming that a doctor was consulted at the time of peak illness, it is more likely that the patient's condition will revert to the average state (mean) shortly after, in this case, a state of comparative normalcy.


The Trial of Homeopathy


Homeopaths often say that their practice has stood the test of time and unfairly accuse their critics of intolerance or reluctance to keep an open mind. But the truth is that numerous studies have looked at whether there is anything more to homeopathy than placebo effect and the effect of chance.


A "systematic review of systematic reviews" by Edzard Ernst looked at 17 systematic reviews on the efficacy of homeopathy. The review found no evidence to support the claim that homeopathy is better than placebo. Perhaps the more important observation from the study was that, more rigorous experiments were associated with insignificant or negative results [17]. Indeed, there is a disproportionately large number of low quality studies that come out in favour of homeopathy.


A meta-analysis by M Cucherat and colleagues on the efficacy of homeopathy initially considered reports from 118 Randomized Control Trials. About 102 of them either failed to report primary outcome or had methodological defects. This meta-analysis found that among the homeopathic medicines tested at least one (out of 16) was more effective than placebo but, issued an important caveat. The authors observed that studies of high methodological quality were associated with negative results [18]. Another study by Klaus Linde and colleagues arrived at the same conclusion [19].


In what can only be described as an attempt to overwhelm anyone who wants to take a look at the relevant scientific literature, the internet is filled with volumes of low quality studies on homeopathy. Head on over to the Indian Journal of Research in Homeopathy to read some fine specimens. It is worth mentioning that at least one article that I came across titled A review on the role of Homoeopathy in epidemics with some reflections on COVID‑19 (SARS‑CoV‑2) listed as its primary source "you tube recordings and webpages".


Any scientist worth his or her salt and indeed any student of science (who are often scolded for using unreliable sources of information in their scientific work) will find this a mockery of the whole scientific enterprise. This is also a blatant violation of the taxpayer's trust in scientific institutions of the country.


"Let us keep our minds open, by all means, as long as that means keeping our sense of perspective and seeking an understanding of the forces which mould the world. But don’t keep your minds so open that your brains fall out! There are still things in this world which are true and things which are false; acts which are right and acts which are wrong, even if there are statesmen who hide their designs under the cloak of high-sounding phrases."
— Walter Kotschnig [quoteinvestigator.com]

Placebo and Ethics

If saline solution or sugar pills can have the effect of actual medicine due to placebo response, why should doctors not deceive patients? Some experts, like Fabrizio Benedetti have argued that placebo could be a useful addition to the doctor's toolkit while maintaining that it is hard, if not impossible to justify deception on the part of medical practitioners [20]. In fact, a significant proportion of doctors are using (or have used in the past) placebos to treat pain, insomnia, anxiety or pacify patients who demand medicine, although sparingly [21]. This is also, strictly speaking, unethical but somewhat justifiable on the grounds that doctors do it to help patients avoid side-effects of the actual drug (pain and insomnia medicine sometimes cause drug-dependence).


Prescribing placebo to avoid conflict with patients or because all treatment options have been exhausted [21] is less justifiable. Some doctors should rightly be criticized for the injudicious use of antibiotics and giving homeopaths ammunition with which to attack modern medicine. But, having criticized modern medicine for it's shortcomings and having given placebo its due, let us turn our attention to homeopathy.


The cult of homeopathy with its generalized laws is a far cry from any scenario of optimal placebo use and its claims are anything but justifiable. Placebo has its limits and is incapable of curing any serious illnesses. Many people like me, who have subscribed to homeopathy in the past have gone through avoidable suffering. In the case of fatal illnesses, treatment with alternative medicine in a bid to reduce medical expenditure could rob you of precious time. Some diseases progress fast and modern medicine has a better chance of curing patients during the initial critical window. Thus, our over-reliance on alternative medicine can also lead to avoidable deaths.


Homeopathy has not been proven to be effective in treating any disease and is therefore, a pseudoscience. Any ambiguity in the matter is irrational and more importantly, due to propaganda perpetuated by people who stand to lose a lot of money if people know the truth. It is deplorable that elected officials believe or pretend to believe in this quackery and can pacify themselves by giving sugar pills to millions of citizens during a pandemic. They are either incompetent, or complicit in the homeopathy fraud.

FURTHER READING

  • Fabricio Benedetti, Ask the Experts: Is there a place for placebo analgesia in everyday clinical practice?. Pain Manage. (2011) 1(3) [read @ futuremedicine.com]

  • Baum, M., & Ernst, E. (2009). Should We Maintain an Open Mind about Homeopathy? The American Journal of Medicine, 122(11), 973–974. [read @ amjmed.com]

  • Edzard Ernst, Standing up for the truth about homeopathy and nazi medicine. [read @ irishtimes.com]

REFERENCES

  1. https://www.ndtv.com/india-news/parliament-approves-bills-ensuring-homeopathy-indian-system-of-medicine-2295281

  2. https://www.chameleon-pharma.com/the-indian-homeopathic-market-an-orchestra-of-growth

  3. Prasad R. Homoeopathy booming in India. Lancet. 2007;370(9600):1679-1680.

  4. https://timesofindia.indiatimes.com/india/homeopathic-drug-given-to-half-of-gujarat-population-since-march

  5. Vithoulkas, G., The Science of Homeopathy (2002), B. Jain Publishers. [Read here]

  6. de la Fuente-Fernández R, Ruth TJ, Sossi V, Schulzer M, Calne DB, Stoessl AJ. Expectation and dopamine release: mechanism of the placebo effect in Parkinson's disease. Science. 2001;293(5532):1164-1166.

  7. Nichols JTG. The misuses of drugs in modern practice. Massachusetts Medical Society, Medical Communications. 1893;16:3–46.

  8. Shorter E. (2011). A brief history of placebos and clinical trials in psychiatry. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 56(4), 193–197.

  9. Levine, J. (1978). The mechanism of placebo analgesia. The Lancet, 312(8091), 654–657.

  10. Amanzio, M., & Benedetti, F. (1999). Neuropharmacological dissection of placebo analgesia: expectation-activated opioid systems versus conditioning-activated specific subsystems. The Journal of neuroscience : the official journal of the Society for Neuroscience, 19(1), 484–494.

  11. Benedetti, F. (1997). The Neurobiology of Placebo Analgesia: From Endogenous Opioids to Cholecystokinin. Progress in Neurobiology, 52(2), 109–125.

  12. de la Fuente-Fernández R, Ruth TJ, Sossi V, Schulzer M, Calne DB, Stoessl AJ. Expectation and dopamine release: mechanism of the placebo effect in Parkinson's disease. Science. 2001;293(5532):1164-1166.

  13. Benedetti, F., Carlino, E., & Pollo, A. (2011). How placebos change the patient's brain. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology, 36(1), 339–354.

  14. Montgomery GH, Kirsch I. Classical conditioning and the placebo effect. Pain. 1997;72(1-2):107-113.

  15. Benedetti F. Placebo responses in animals. Pain. 2012;153(10):1983-1984.

  16. Benedetti, F., Piedimonte, A., & Frisaldi, E. (2018). How do placebos work?. European journal of psychotraumatology, 9(Suppl 3), 1533370.

  17. Ernst E. (2002). A systematic review of systematic reviews of homeopathy. British journal of clinical pharmacology, 54(6), 577–582.

  18. Cucherat M, Haugh MC, Gooch M, Boissel JP. Evidence of clinical efficacy of homeopathy. A meta-analysis of clinical trials. HMRAG. Homeopathic Medicines Research Advisory Group. Eur J Clin Pharmacol. 2000;56(1):27-33.

  19. Linde K, Scholz M, Ramirez G, Clausius N, Melchart D, Jonas WB. Impact of study quality on outcome in placebo-controlled trials of homeopathy. J Clin Epidemiol. 1999;52(7):631-636.

  20. Benedetti F. Ask the Experts: Is there a place for placebo analgesia in everyday clinical practice?. Pain Manag. 2011;1(3):211-212.

  21. Fässler M, Meissner K, Schneider A, Linde K. Frequency and circumstances of placebo use in clinical practice--a systematic review of empirical studies. BMC Med. 2010;8:15.