Homeopathy: what does the “best” evidence tell us?

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.