Recently David Gorski and I felt compelled to respond to a misguided commentary by Dr. Vinay Prasad in which he flogged the long dead horse of ivory tower academics wondering out loud why anyone would bother communicating science to the masses, especially confronting pseudoscience, misinformation, conspiracy theories, and fraud (yuk!). This was especially disappointing because we should be natural allies, as we all advocate for increased science-based standards throughout medicine. He had two primary points, the first being that such topics are too easy and therefore beneath true experts. He misses the point, however, that while the underlying science may often be a slam-dunk, the social, cultural, and psychological phenomenon of belief in pseudoscience and how to confront it is very complex and challenging. His apparent ignorance of this entire field does not make it simple.
His second main point is that pseudoscience in medicine is not a big deal (the old – “what’s the harm” argument) – if, essentially, people are wearing copper bracelets. Ironically this second point mainly reflects his ignorance of the first point. He used homeopathy as one of his main examples, which does perfectly represent everything wrong with his argument. Yes, the science showing that homeopathy is probably impossible is a slam-dunk. Homeopathy uses fanciful ingredients based on magical thinking and then dilutes them in most cases out of existence, claiming that their “essence” is left behind. There are multiple ways to demonstrate the absurdity of these claims from a scientific point of view, although, there are some nuances that a novice might miss, such as the claims for “water memory”.
Prasad’s error is in thinking that, once we have explained the math, chemistry, and physics that renders homeopathy pseudoscience, we are done, and can move on to more important issues. But what about the clinical trial evidence looking at homeopathic treatment? This too is resoundingly negative, but this did not stop a Cochrane systematic review from claiming that in some cases homeopathic treatments are “promising” and deserve more study. In fact, homeopathy is a perfect test case, a real-world meta-experiment, that nicely demonstrates why we need science-based medicine rather than just evidence-based medicine, and also all the things that Prasad himself advocates for in clinical trials.
Further still, his apparent belief that pseudoscience in medicine is a small problem is demonstrably false, and also betrays a very American-centric view of medicine. I was recently reminded of this by an article by Edzard Ernst (someone Prasad can look to who models how an academic can confront pseudoscience and improve quality in medicine). The article is an update to one he wrote 17 months ago about homeopathy in Germany (I also wrote about this – in 2010 – so this process has been going on for a while). Homeopathy is deeply embedded in German mainstream medicine, part of medical training with the option to get additional licensure as a “homeopath”. Insurance companies reimburse for homeopathic treatments.
However, over the last decade or so this has been slowly changing. What Ernst noticed last year was that:
In the last few years, several individuals in Germany have, from entirely different angles, taken a fresh look at the evidence on homeopathy and found it to be desperately wanting. Independent of each other, they published articles and books about their research and insights. Here are 5 examples:
In Sachen Homöopathie: Eine Beweisaufnahme, Norbert Aust, 2013
Homöopathie neu gedacht: Was Patienten wirklich hilft, Natalie Grams, 2015
As soon as those ivory tower scientists starting paying attention, they started to realize that homeopathy just doesn’t deliver the goods. Even leaving the extreme scientific implausibility aside, the clinical evidence is not there. Homeopathy does not work. After 200 years homeopathy has nothing to show for itself scientifically, and it is hard to argue that this is due to bias against this practice when Germany considers itself the home of homeopathy, with a massive cultural bias in its favor.
Ernst also noted that the response of homeopaths, especially when their sales started to drop, was typical for CAM proponents – they did not marshal better evidence, look inward at their practices, or talk about reform. No – they went on a marketing blitz. Further, this marketing was largely framed around vicious personal attacks against the scientists who were simply pointing out that homeopathy is literally nothing. As Ernst points out, their personal attacks took familiar forms: “we are incompetent, we do not care about the welfare of patients, we are habitual liars, we are on the payroll of the pharmaceutical industry, we aim at limiting patient choice, we do what we do because we crave the limelight”. This is all ho-hum, just another day for skeptics.
Still, Ernst was optimistic because we have science on our side. He writes now to point out that recent developments have been moving away from homeopathy in Germany:
I have just received the news that the Board of the Bavarian Medical Association has unanimously decided in the meeting on 5.12. to remove the additional training in homeopathy from the medical training regulations. UNANIMOUSLY!!!
11 of 17 medical associations have kicked homeopathy. That leaves 6. The next decision is due in Berlin.
This means that in most German counties (there is hope that, sooner or later, the other 6 will follow suit), doctors will no longer be able to train in homeopathy and use the title ‘homeopath’.
This is great news, and hopefully this trend will continue. We also need to end insurance reimbursement for homeopathy. These trends also need to be exported to every country in the world.
I do differ a little from Ernst’s optimism – I do not think such victories are inevitable, simply because we have science on our side. As he points out, this progress took 200 years to come. It is also too early to say if this will be a long term trend, or if this is just a blip on the otherwise-endless commercial success of homeopathy. False beliefs and rank pseudoscience can become essentially permanently embedded in cultures. Look at chi/qi in Asian culture, or Ayurveda in India. Sure, the trained scientists may reject pseudoscience and superstition, but not the billions of people living in those regions. Homeopathy in Europe is similar, although arguably not buried quite as deep. We cannot be complacent and delude ourselves that it will be easy to permanently banish homeopathic pseudoscience from medicine.
We are also making progress against homeopathy in the US, UK, and Australia. But in these countries also, homeopathy is far from gone, and past experience is that such beliefs are like vampires, they keep rising from the dead. The bottom line is that there are billions of dollars to be made selling just homeopathy (let alone the rest of medical pseudoscience) and that is powerful motivation to keep it alive.
I will also point out that what progress has been made is largely due to dedicated skeptical campaigns. In some cases this is more obvious than in others (the UK is probably the most obvious example), but it seems clear that constant pressure from skeptics, especially skeptics within the medical profession, is what is slowly turning this ship. We cannot let up on this pressure now – the other side certainly won’t.
And this pressure from skeptics is by far most effective when it occurs in collaboration with mainstream doctors and scientists. This collaboration is critical, and is why tackling pseudoscience, fraud, and conspiracy theories should not be ignored, and should not be relegated to a small band of dedicated skeptics. It needs to be part of mainstream scientific activity.
The ideal situation is for there to be a recognized and respected specialty that combines the public understanding of science (traditional science communication) with an understanding of pseudoscience, science-denial, conspiracy thinking, the philosophy of science, and media literacy (i.e. scientific skepticism). But combined with this needs to be a recognition among academics of all stripes that science communication, critical thinking, and media literacy are important, and that as part of their regular duties they should collaborate with the experts, to combine their topic expertise with skeptical expertise to fight misinformation and pseudoscience in society.
Where we see exactly this type of collaboration is where we have had the most success, such as in pushing back against the pseudoscience of homeopathy. We can also clearly see the dire need for such collaboration while we are in the middle of a deadly pandemic and yet there is popular pushback and misinformation regarding the vaccines that are the only plausible path out of this pandemic. This is also why Prasad’s commentary is so toxic, and why he needs to seriously reconsider his position.