Honesty is the best policy

As I write this, I am convalescing following an important (albeit minor) but painful diagnostic procedure.  There is no need to go into detail save to mention it is now apparent to me, that despite several thousand years of perceived wisdom it is, after all, possible to pass an object which feels roughly the size of a camel through something roughly the size of the eye of a needle providing sufficient lubrication is employed.

To distract myself from these delicate proceedings I began to dwell on the events and the reasoning that had led up to this day, the final stage in the investigation of this particular medical problem.  Making decisions about medical matters is not easy.  There are strong emotions to contend with - fear of the unknown, fear of pain, worry about family and friends.  There is denial; would I prefer not to know the full picture, just in case it’s something serious?  Also anger; I still consider myself young (don’t we all?), what have I done to deserve this, it’s not fair?

Fortunately my doctor was all you would hope for; extremely pleasant as well as knowledgeable and professional.  He was obviously experienced in this area of medicine and in dealing with this type of (not so patient) patient.  Aware of my worries he took time to explain carefully what was going to happen, the risks involved and the benefits to be gained in the way of good diagnostic information.  He was able to give me an idea of how I might feel during the procedure based on first hand reports he had had from previous patients undergoing the same thing.  He was also able to call on scientific studies to give an idea of the suitability of other routes of inquiry open to me.  From studies in larger patient groups he was able to advise that more invasive means of investigation probably weren’t called for at this stage given the risk of complications and the likelihood that, since all other tests had so far proved normal, little extra would be learned.

He explained, between my nervous interruptions, about the drugs that would be used.  Local anaesthetic with its familiar, predictable mode of action, well understood by those who use it and supported by decades of research allowing scientists to modify and improve the drug to give better pain relief and a varying duration of action, depending on requirements.  Antibiotics too, since their discovery in the 1930’s have been studied in sub-microscopic detail and classified, catalogued, refined and improved upon resulting in the saving of uncountable millions of lives in the few decades they have been around.  Pain killers also have come a long way since their beginnings as willow bark infusion taken through pursed lips to treat a headache.  Thanks to diligent research they are now more effective yet safer than ever before.

Of course it is the way of the world that most useful things in life have drawbacks as well as benefits.  Take mobile phones for example.  They save lives in disaster situations but when you’re next to a person ostentatiously broadcasting the more inane half of their high decibel conversation they are a complete pain and if used inappropriately, such as when driving a car, can be lethal.  In minor medical procedures such as mine the “risks” are equally minor; some pain or discomfort, the possibility of a little bleeding, all of which would be expected to resolve of their own accord within a day or two.  In other cases however where the stakes are higher the risks of treatment may be proportionately increased too.  This is the so called risk-benefit analysis which is core to any sensible decision in modern medicine and surgery.

Crucial to such an analysis is a full and honest understanding of how medicines and surgical procedures work and of all their actions on the body, not just the desirable ones we are hoping for.  The key word here for me is “honest”.  We live in a fast moving technological world containing many wonders which only a few decades ago would have seemed almost magical and some wonders which to many people, myself included, appear magical right now.  But they aren’t magic, they are made possible by an understanding of the way the world works and how the things in it from galaxies to quarks interact.  There is so much to know we can’t all understand everything, that is to be expected and it’s why, sometimes, we have to rely on experts who we can trust.  I haven’t a clue how the computer I am typing on at this moment works but I know that somewhere there is someone who does and what’s more could explain how and demonstrate it to me (and hopefully ignore my vacant look and silly questions).

Similarly in medicine, both human and veterinary, advancing technology means that today we are able to do things which, only 20 years ago would have been prohibitively expensive or dangerous if not downright impossible.

It behoves us though to be honest with ourselves about this technology from which we all benefit.  There is no place for head in the sand denial.  Problems such as side effects won’t go away if ignored; these inevitable if uncomfortable facts need to be recognised and dealt with in a mature and realistic way.  In short we need to admit that some breaking of eggs will be required when making omelettes.  Flat denial is of little consolation to Humpty Dumpty as you approach casually, whisk in hand, mouthing platitudes about the nutritional benefits of your finest cherry tomato and mozzarella frittata.  Humpty Dumpty would in fact be very well advised to run a mile from such advice.  Similarly we should all be extremely suspicious of anyone promising us something for nothing in any area, particularly medicine.  If something sounds too good to be true, whether it’s a “Humpty-friendly” omelette or a side effect free miracle cure, it probably is.  You don't get something for nothing in this life, particularly in the world of medicine and anyone who tries to convince you otherwise is at best labouring under a delusion and at worst, lying.

There is nothing more important than honesty when it comes to making health decisions for those family members who show us unconditional trust and who know we will act on their behalf and do what is best for them; our pets.  It is they who make being a pet “owner” such a special and difficult privilege and it is to them, for their trust and loyalty, that these writings are dedicated.

Miasms - I'm preparing for enlightenment

Miasms as Practical Tools: A Homeopathic Approach to Chronic Disease - the book is on its way - John Saxton's magnum opus. Can't wait! Having forked out large amounts of spondooliks on this apologia for the power of invisible & otherwise undetectible energies on health and well being I'm looking forward to reading it; to be fair, he rarely disappoints.

John Saxton BVetMed, MRCVS is also a VetFFHom, which is to say a fellow of the faculty of veterinary homeopaths and a CertIAVH - your guess is as good as mine on that last one. He has previously stated that pet booster vaccinations are a fraud and that vets who give these vaccinations (myself included) are fraudsters while on the other hand believing that his practice of radionics where diagnosis and cure are effected by hand waving and communing with a black box with some wires in is entirely genuine, above board and completely trustworthy. He was a founder member of the august British Association of Veterinary Homeopaths and the first veterinary surgeon to hold the office of President of the Faculty of Homoeopaths, so who am I, a mere allopath, to argue.

Laughter is the best medicine

So, Radovan Karadzic, alleged war criminal and concentration camp enthusiast has been arrested, posing as an alternative healer.

According to the BBC Mr Karadzic (or rather his alter ego Dragan Dabic) was a pleasant, long haired, bearded gentleman given to wearing black and entertaining the clients of the Madhouse Bar which he frequented by singing while playing the traditional one stringed Serbian gusle. He had a girlfriend, grandchildren and was cultured, tolerant and polite, according to a friend.

He wrote for a health magazine during his 10 year undercover life and earned his money from practicing alternative medicine claiming to be an expert in “human quantum energy”. He ran his own web-site and gave lectures, billing himself as a "researcher in the fields of psychology and bio-energy" at which he would distribute business cards.

His pseudonym probably came from a civilian man, a construction worker killed, along with 12,000 others, by Karadzic’s forces during the siege of Sarajevo in 1993. As Radovan Karadzic he stands accused of war crimes and genocide, particularly the 1995 massacre at Srebrenica when 7,500 innocent Muslim men and youths were massacred by pro-Serbian forces. He is also charged with unlawfully deporting civilians based on national or religious identity and destroying homes, business and sacred sites. It was during Karadzic’s reign of terror the phrase “ethnic cleansing” was coined to describe the activities of those he commanded.

The subject of Karadzic’s arrest came up recently during a discussion with fellow sceptics and inevitably there was some, fairly heated, debate (this is sceptics we’re talking about after all). Some felt a strong sense of comic irony in the fact of a brutal mass murderer turned kindly healer, others felt such levity was ill placed, particularly since on occasions there have been examples of people masquerading as conventional health care workers which is certainly not a subject for humour, so why should a similar situation involving an alternative practitioner be amusing. In my view this is missing the point and this story is funny on several levels, the brutal nature of the subject not withstanding. I believe we are allowed to laugh in this instance.

To many sceptics the concept, under any circumstances of a 'fraudulent' alternative practitioner is funny. The idea that some people may be able to talk to the dead while others just pretend or that some people are genuinely channelling the spirit of a long dead North American Indian shaman or a dolphin while others are making it up is hilarious. The possibility that some homeopathic sugar tablets work whereas others don't is truly laughable. All these things are bogus, any effects existing purely subjectively in the minds of practitioners and proponents. There is no way of policing such people. How can there be such a thing as a fraud when none of it works anyway?

In the case of someone acting as a bogus vet, doctor or nurse the situation is most definitely not funny in any way shape or form. This is someone using real medicine as a cover to prey on weak and vulnerable people for their personal gratification. The possibility of causing patients harm whether through ignorance or intent is real. Drugs have real effects and can cause real harm. Someone going to a channeller is no more likely to be harmed by one who is 'bogus' than by one who is 'real'; someone given 'fake' sugar pills by a bogus homeopath can rest assured that the effect will be identical to that which they would get from the 'real' thing. Someone given drugs by a bogus doctor on the other hand is much more likely to come to harm than when treated appropriately by a real doctor.

There is a difference between CAM and real medicine when it comes to fraud. The two modalities do not have equal standing or deserve equal respect and gravity. A 'fraudulent' CAM practitioner is a joke and will be laughed at, a fraudulent doctor is a criminal and will be locked up.

When talking with alternative practitioners there is often an air of smugness about them. In their view, as a rule, it is they are the enlightened ones. They portray themselves as caring, hands-on, intuitive, holistic, empathic - always with the implication that science based practitioners are none of these things and, furthermore are cold, clinical, hurried and detached, seeing patients as diseases, not individuals. Having been personally exposed to this type of bigotry for years, hearing that a genocidal maniac had joined the ranks of the touchy-feely, caring-sharing alt med brigade is wonderfully ironic and, I am afraid, extremely funny.

This is sick, graveyard humour and this man is a monster but it is humour nevertheless and it certainly doesn't mean that a sceptic caught smirking at this news item believes that all alt med practitioners are mass murderers. It's human nature and I make no apologies for it.

As a sceptic pal said, “it's too bad it wasn't an herbalist posing as a genocidal maniac. That would have been funnier”!

Homeopathy in animals.

(this article was originally published in the excellent Skeptical Intelligencer journal)

Is its apparent effectiveness in animals proof of homeopathy's effectiveness?

Many reasons are offered as to why homoeopathy has not been accepted by the mainstream. The arguments range from alleged institutional apathy or lack of understanding to an active conspiracy excluding homoeopaths from mainstream medicine (Coulter, 1980). It is claimed that conventional practitioners are too lazy or incompetent to acquire the disciplines necessary to practice homoeopathy (Coulter 1980, Kent 1900). Pharmaceutical companies are accused, largely without evidence, of suppressing homoeopathy as they allegedly fear competition from a medical modality offering an inexpensive direct-to-patient mode of therapy. Underlying all these arguments is the tacit conviction that homoeopathy is effective; all that is needed is for people to understand it better.

To support this conviction evidence of variable quality is offered ranging from selected therapeutic trials to a vast range of equally selective anecdotal case reports.

A common argument against homoeopathy is that, given its implausible mode of action, many perceived responses to homoeopathy must be due to the placebo effect. Knowing this it is claimed by proponents that apparently positive results in groups such as very young children, or animals, where the placebo effect cannot operate, offer particularly compelling evidence of its validity. This article will show that the argument that apparent success in veterinary cases constitutes proof of the effectiveness of homoeopathy is simplistic and false.

Why bogus Veterinary therapies appear to work

According to Dr Harris Coulter “the use of homoeopathy in veterinary medicine is of particular interest because the psychosomatic factor in treatment is largely excluded” (Coulter 1980); Peter Adams states that, in the case of animal treatment, “the patient is not even aware of receiving any medication so the placebo effect can be discounted” (Adams, 1996); Gerhard Koehler asserts that responses in animals associated with the use of homoeopathy “…show how ridiculous it is to call homoeopathic treatment ‘suggestive’… it is the objective result which counts in this field” (Koehler 1986). If these (non-veterinary) authors are incorrect in their certainty and homoeopathy is no more effective than placebo whereas this might be of some occasional benefit in human medicine it offers no benefit to animals under treatment who, in reality, would be receiving no treatment at all. This has serious implications for animal welfare.

In his 1997 article Barry Beyerstein gave examples of errors & bias which could give the (false) impression that homoeopathy was able to successfully treat disease in humans. Many of the points he makes are equally valid when applied to veterinary medicine. So what are the explanations that may help counter the homoeopathic argument which usually goes along the lines of, “we had a dog with a rash which was cured by homoeopathy and he didn’t know what sort of treatment he was having so it can’t just be mind over matter, can it”?

1. The disease may have run its natural course.

The body is perfectly capable of dealing with the vast majority of illnesses without external assistance. Evolution has gifted us a powerful immune system and a variety of mechanisms to ameliorate or resolve a variety of diseases. Many organs are capable of regeneration following injury. The skin will grow into large deficits to heal with minimal scarring, the liver will regenerate to full function following massive damage, certain fractures will knit, often giving a functional result, without any form of fixation, the heart can maintain its output and function despite defects such as valvular insufficiency. Animals’ lack of the psychological problems associated with trauma in humans and their apparent resistance to pain mean that, in some instances, even major injuries and disease will resolve themselves naturally in time if medical or surgical intervention is withheld or unavailable.

Examples of conditions which can present as severe yet may resolve without active intervention include gastro-enteritis, cystitis and lower urinary tract disease in cats, certain types of pelvic fracture, vestibular disease (a profound but often temporary disturbance of the balance centre, often erroneously referred to as a ‘stroke’ for convenience), lameness caused by sprains or bruising, some abscesses in cats, upper respiratory tract infections (cat ‘flu’ and kennel cough) and mild spinal disease. In uncomplicated cases spontaneous recovery can appear almost miraculous. If homoeopathic remedies are given during the course of the disease it can be very hard to convince an observer that the homoeopathy was not directly responsible for the final outcome.

Not every case will resolve unaided however and many of the above conditions require veterinary treatment. The correct treatment of diseases known to be self limiting is geared towards offering palliative support, particularly pain relief. Clearly, if homoeopathy is used to the exclusion of conventional drugs although the end result may be similar because of the natural healing process, the animal will have undergone considerable suffering in the interim having been denied proper analgesia.

2. Many diseases have a waxing and waning course.

Allergic skin conditions are common in the dog and if due to environmental allergens will naturally have a seasonal course; for instance signs associated with a pollen allergy will improve during the months when the relevant plant is not in flower.

Addison’s disease results from an under active adrenal gland and is notorious for symptoms which are be extremely variable ranging from vague lethargy to haemorrhagic enteritis and which often improve temporarily without treatment.

The mast cell tumour is a skin cancer in dogs taking the form of initially small skin lumps which appear dormant for many months. If traumatised these lumps will produce large amounts of substances such as histamine resulting in a large, local swelling many times the size of the original tumour. Although spectacular in appearance these reactive zones will usually resolve spontaneously although the original cancer remains.

Juvenile lamenesses in dogs are a special group of conditions which can appear minor in the first year or so of life. Eventually after a series of relapses and remissions they may appear to resolve but if left untreated can lead to serious, even disabling joint disease in middle age.

Often treatment is sought by owners for their pets when signs are at their worse and this is often just the time in cyclical diseases when temporary remission occurs naturally. Intervention by a homoeopath at this stage will coincidentally be associated with improvement in symptoms creating a false impression of cure and possibly delaying early investigation and appropriate treatment to a stage when such treatment is too late to be effective.

3. Use of a provisional or working diagnosis.

Much as we might wish otherwise, inevitably, in veterinary medicine standards of diagnostic investigation are not always as rigorous as in the human medical field. Cost restraints and finite resources are limiting factors in many cases. This means that in general practice vets may make a presumptive, working diagnosis or short-list a number of possibilities based on limited evidence and treat accordingly.

So, for instance a lump between the toes of a dog could be either a cyst, an abscess or a tumour. If detailed diagnostics are not an option a practitioner may treat with antibiotics since a cyst will resolve spontaneously, a tumour will show no response, thus justifying the cost of investigation and an abscess may respond to antibiotics. So the treatment will be effective, appear to be effective or be ineffective depending on the true nature of the condition. The use of antibiotics in a case where infection is not confirmed is far from the ideal of evidence based medicine but is a practical necessity in some cases.

It can be seen that in the same case a completely ineffective remedy such as homoeopathy will also have a reasonable chance of being associated with a resolution thus creating the false impression that a cure has been effected, even that homoeopathy has cured cancer. The difference again, as in the previous section is that very often a conventional vet will provide pain relief while awaiting the outcome whereas no pain relief is afforded by homoeopathy.

4. Mis-diagnosis by Veterinary surgeon, owner or owner’s friend.

Interpretation of the clinical examination, imaging techniques or laboratory analysis is not always cut and dried. There are very few conditions for which there is one completely certain diagnostic sign, most diagnoses rely on a multitude of tests as well as one’s clinical impression. So even trained professionals will occasionally make a mis-diagnosis. A good practitioner will work with this possibility always in mind, continually reviewing the case in the light of new information and re-appraising the diagnosis accordingly. A recent case of mine involved the removal of several suspect skin masses in a dog. Initial laboratory analysis suggested cancer. This didn’t concur with my clinical impression and following a conversation with the pathologist the findings were reinterpreted in the light of more detailed information as being the result of harmless inflammation. The owner, however, having had the provisional results, had self-referred to a Veterinary homoeopath who set about treating the cancer and incidentally a self limiting post-operative swelling called a seroma homeopathically. Needless to say treatment of the seroma was completely “successful”; whether, having been informed of the revised laboratory report, he also claimed a cure for cancer I don’t imagine I will ever know with an certainty.

The tendency of owners to self diagnose or to trust the diagnosis of acquaintances who may have had a pet with similar symptoms greatly adds to the potential number of mis-diagnoses and consequently to the number of apparent ‘miracle cures’. For instance a dog with a cough due to a viral infection may present very similarly to a dog in the initial stages of heart disease. If the owner of the dog with the viral infection is told by the owner of the dog with heart disease that their dog has the same condition and will deteriorate rapidly, requiring extensive investigations and treatment and the viral dog is treated homeopathically then, when the viral infection self cures in a week or two; behold, a miracle, homoeopathy has cured a failing heart.

5. Concurrent use of conventional medicine

This, so called “complementary medicine”, can be the most galling of all to the genuine practitioner when homoeopathy, used concurrently with conventional medicine, is credited entirely with the cure. This is particularly likely in the case of a condition that is slow to respond to treatment. After some time on conventional treatment the owner, concerned about the apparent lack of response will turn to a homeopath who initiates treatment which is immediately followed by a cure. Again, once this course of events has taken place it is well nigh impossible to persuade someone that the homoeopathy was irrelevant to the outcome and had they simply allowed further time the final result would have been the same.

6. A desire to believe on the part of owner and homeopath

Even when there are few if any improvements in the homeopathically treated animal, owners who have a strong psychological investment in alternative medicine can convince themselves they and their animal have been helped. To have received no relief after committing time and money to, and having a deep, personal belief in alternative treatment is difficult to admit to oneself and others so there is strong pressure to find some redeeming value in the treatment and avoid losing face. There may also be an unspoken complicity between owner and practitioner with neither party willing to disappoint the other with negative findings or comments. Of course an animal cannot make an informed choice and plays no part in this cosy conspiracy; it will either get better in spite of or suffer as a result of their owner’s dogma.

Conclusion:

The veterinary profession has a reputation for being a caring one, I feel this reputation is deserved. The vast majority of vets that one meets are deeply committed to their clients and patients, human and animal, and have a strong desire to do their best for them, occasionally at personal cost.

It is a subject of continual debate amongst veterinary sceptics as to why colleagues who have had a scientific education and who might be expected to know better have turned to a treatment modality that has more to do with religious faith than rational medicine.

The more charitable among us will argue that in some cases this desire to help in the face of limited resources and failure to keep up with current thinking may be a reason why some have abandoned the uncertainties of the scientific path in favour of the more prescriptive homoeopathy. Possibly also a lack of humility makes it difficult for some people to admit they may have been wrong and to review their work critically. After all it is easier to tell oneself and one’s client that the skin condition is getting worse because of a ‘healing crisis’ rather than because of an error in diagnosis or, worse still because the medical modality you have invested so much of yourself in is completely false.

Others will argue that, given a veterinary education and even a basic knowledge of statistics and research, veterinary homoeopaths are guilty of at best turning a ‘mental blind eye’ to the inconsistencies of their calling and at worst of a disingenuous misinterpretation of the facts particularly by the blurring of the distinction between an improvement being associated with and being caused by a particular treatment.

Whatever the reason it is a great deal to expect homoeopathic practitioners with deep seated faith in homoeopathy with its quasi religious overtones to suddenly admit the error of their ways and change overnight. The effort is worthwhile however, my patients have no say in the matter of medical dogma, they are “dumb” animals and are entirely dependent on their human masters to make the right decisions for them. When the good sense of their carers is distorted, lacking or simply ill informed it is our duty to try to persuade and educate, gently and patiently, until reason prevails.

References:
Adams, P., (1996) Natural medicine for the whole person (reissued 1998), Element books ltd, Shaftesbury
Beyerstein, B.L., (September/October 1997) Why bogus therapies seem to work, Skeptical Inquirer magazine
Coulter, H. L., (1980) Homoeopathic science and modern medicine, North Atlantic books, California.
Kent, J.T., (1900) Lectures on homoeopathic philosophy (1990 reprint of 1954 edition), B. Jain publishers ltd, New Delhi
Koehler, G., (1986) The handbook of homoeopathy, Thorson’s publishing group, Wellingborough

Useful reading:
Renan Moritz V. Rodrigues Almeida, (Federal University of Rio de Janeiro) Revista do Hospital das Clínicas vol.58 no.6 São Paulo 2003 (http://tinyurl.com/2sfbq).
Kleijnen, J., P. Knipschild and G. ter Riet. 1991. Clinical Trials of Homoeopathy. British Medical Journal; 302: 316-23
Hill, C. and F. Doyon. 1990. Review of Randomized Trials of Homoeopathy. Review D'Epidemilogie et de Sante Publique; 38: 139-147
Linde, Klaus, Nicola Clausius, Gilbert Ramirez, Dieter Melchart, Florian Eitel et al. 1997. Are the Clinical Effects of Homoeopathy Placebo Effects? A Meta-Analysis of Plecebo-Controlled Trials. Lancet, 350: 834-43
Ernst, E. and M.H. Pittler, Journal of Clinical Epidemiology 53 (2000) 1188, Re-analysis of previous meta-analysis of clinical trials of homeopathy
Linde et al, Impact of Study Quality on Outcome in Placebo-Controlled Trials of Homeopathy, J Clin Epidemiol Vol. 52, No. 7, pp. 631–636, 1999
Boissel, J.P., M. Cucherat, M. Haugh and E. Gauthier. Critical Literature Review on the Effectiveness of Homoeopathy: Overview of Data from Homoeopathic Medicine Trials. In Homoeopathic Medicine Research Group. Report. Commission of the European Communities
Cucherat M, Haugh MC, Gooch M, Boissel JP Eur J Clin Pharmacol 2000 Apr;56(1):27-33 Evidence of clinical efficacy of homeopathy. A meta-analysis of clinical trials.