To the Editor: I applaud the Medical Journal of Australia’s recent attempt to increase the evidence base of complementary medicine.1 However, it is disappointing that the Journal’s idea of doing so seems to be to import the same dogmatic and misinformed debate currently occurring in the United Kingdom.

Ernst makes little secret of his antihomeopathic agenda and engages in some “cherry picking” of his own, neglecting, for example, to mention the substantial methodological criticisms of some of the references he chooses to use to support his points.2 Further, expert testimony at the British House of Commons Science and Technology Committee’s evidence check on homeopathy identified 24 condition-based systematic reviews and meta-analyses on homeopathy, of which nine were positive, five were negative and 10 were inconclusive.3 As a system of medicine, this compares more closely with the evidence base for conventional medicine than many would care to admit.4

It has also long been observed that the complex and individuated nature of complementary therapies — and many conventional therapies, for that matter (including many surgical and psychological interventions) — makes clinically relevant evaluation with a placebo-controlled trial difficult.5 Cochrane reviews may certainly be “the best” at reviewing the trials, but this means little if those trials were not an appropriate evaluation tool in the first place. Rarely do these trials reflect the real-world settings in which patients, medicines and practitioners exist. The challenge is not simply to be better than placebo, but to produce the largest clinical effect possible in a real-world setting.

In his article,1 Ernst himself seems to acknowledge the potential broader real-world benefits that patients receive from homeopathic treatment, as confirmed by observational data,6 yet seems inclined to focus only on reductionist approaches to evaluation that are well known to be ill suited to homeopathic research, or focuses on the implausible nature of the medicine itself. We need to take a different approach and work out why it is that patients who choose to use homeopathy get better (as they quite often do). To do this, we need not just more basic and clinical research, but more health services and public health research on homeopathy — reviewing the reviews adds little if there is simply not enough to review in the first place.

Throwing out the baby with the bathwater helps no-one, least of all the patient. And the patient, not ideology, is what it should be all about.

In reply: Wardle’s letter raises several points that deserve comment. Wardle calls me dogmatic, misinformed and antihomeopathic. Such ad hominem attacks hardly promote a rational debate. When I started my job of scrutinising homeopathy 17 years ago, I was pro-homeopathy1 — I once worked in a German homeopathic hospital — and became more sceptical as the evidence base for homeopathy became more clearly negative.2 This, it seems to me, is the opposite of dogmatic.

Wardle cites the report by the House of Commons3 in the United Kingdom and claims that it “identified 24 condition-based systematic reviews and meta-analyses on homeopathy, of which nine were positive . . .”. In truth, it was a submission from homeopaths to the House of Commons that made this statement. The report itself found no positive evidence for homeopathy and even criticised how the homeopaths tried to mislead the inquiry.3

Wardle also thinks that clinical trials are “ill suited” to evaluate homeopathy because homeopathy is “complex and individuated” and clinical trials “rarely . . . reflect the real world”. The notion here is that, if the scientific method does not support our belief, it must be the former rather than the latter which is at fault. Adopting this attitude would take us right back into the Dark Ages. After discussing these issues for 17 years, I have the impression that most homeopaths are in favour of rigorous, reductionist science — insofar as it generates the results they want. Whenever this is not the case, they point to observational studies that are wide open to bias and confounding, and therefore show us precious little.

Finally, Wardle seems to imply that homeopathy works because patients like it and that this is what truly helps patients. The truth is that medicine has made huge advances only since we buried this attitude. It is time now that proponents of homeopathy do the same — not to conform with a dogma, but because patients would live longer and healthier lives.