public profile of homoeopathy– the evidence base for homoeopathic prescribing

The Public Profile Of Homoeopathy– The Evidence

Base For Homoeopathic Prescribing

Presented at the Biannual Congress of Homoeopathic Association of South Africa at Durban on 28-9-14

Gyandas G. Wadhwani MD(Hom)

Chief Medical Officer (Homoeopathy), Directorate of AYUSH,

Government of National Capital Territory of Delhi. India.

homoeopathygyan@gmail.com

drgyanwadhwani@yahoo.co.in

When you sing, sing at the door so that the child passing by may learn wisdom.

African proverb

National Campaign on Homoeopathy

• The national campaign on “Homoeopathy for Mother and Child Care” was launched by the Department of AYUSH, Govt of India, in 2007. Pursuant to this, state level campaign was launched in Delhi on 24/09/2009 by Hon’ble Chief Minister of Delhi and Hon’ble Minister of Health & Family Welfare, Govt. of NCT of Delhi.

• The campaign was designed to increase the awareness of potential role of homoeopathy in ‘Mother and Child Health’ care and involved sensitization of policy makers and practitioners of different medical systems.

DELHI GOVERNMENTTEAM DELHI MAKING THINGS HAPPEN

Govt. of NCT of Delhi

Directorate of ISM & Homoeopathy

(Homoeopathic Wing)

CSC-III, B-Block, Preet Vihar, New Delhi-110092

www.delhihomeo.com, www.homeo.delhigovt.nic.in

e-mail : ddhomeo.delhi@nic.in

AYUSH(Ayurveda, Yoga & naturopathy, Unani, Siddha & Homoeopathy)

• The complementary and alternative medicinal systems (including Homoeopathy) in India enjoy both Public and Government patronage.

• This stems from the fact that all these systems follow holistic philosophy, which appeals to the indigenous culture and beliefs of people.

• However, the scenario is different globally!

• As a specialized system of therapeutics and pharmacology, homoeopathy, has withstood all possible criticism, from quackery to witchcraft and placebo to nocebo.

• Attempts have been made to curb the rising popularity through various publications and data analysis, disproving homoeopathy, especially published in ‘the lancet’, over last few decades.

• In spite of numerous publications, reviews and researches condemning all that is known as homoeopathy, the financial sector has seen a boom in business worldwide.

• In dollars the world homoeopathy market according to ASSOCHAM is $5.35 billion.*

• But is it a bubble about to burst?

*http://johnbenneth.wordpress.com/2011/10/06/worlds-fastest-growing-medicine/

The public profiling of homoeopathy

• Lately the pro-homoeopathy researchers/ scientists are throwing weight behind the works of Archibald Leman Cochrane, widely regarded as the father of ‘Evidence based medicine’.

What is

“Evidence Based Medicine (EBM) ?”

What is the purpose of medicine?

Public health promotion and education (awareness)

Disease prevention

Patient cure and care

Research and improvisation

Science Medicine Art

Deterministic Evidence based Open ended

What guides our decisions?

• Dogma: “Natural is best”

• Tradition: “We have always done it that way”

• Convention: “Everyone does it this way”

• Empiricism: “Experience as well as sensory perception”

• Evidence-Based: “Evidence (read ‘research’) supports this way”; “Nullius in verba”

What is EBM?EBM is the conscientious, explicit and

judicious use of current best evidence in making decisions about

the care of individual patients.

It's about integrating individual clinical expertise and the best

external evidence from systematic research.

Sackett, et al. BMJ 1996; 312:71-72

Clinical

ExpertiseBest research

evidence

Patient

Concerns

EBM

EBM – a short history…

• In ancient China, during the reign of Emperor Qianlong, the method of "kaozheng" ("practising evidential research") was used to interpret ancient Confucian texts (Woodhouse, personal communication, 1998)

• And during the late-renaissance era, the French Pierre Louis rejected the pronouncements of authorities that venesection was good for cholera and sought the truth in systematic observation of patients

EBM – a short history…

• JAMA 1992

“EBM: a new approach…”

• JAMA 1993 – 2000

“Users' Guides to the Medical Literature”

• 1990s – 3 trends

– Systematic reviews

– Search engines

– Knowledge distillation and “push” services

An example of EBM practice

• Experimental data to prove the safety of most practices is still sparse.

• It took more than 20 years and repeated huge clinical trials to establish the efficacy of single procedure, CABG, costing much much more than 50 million US dollars!!*

• *Leape LL, Berwick DM, Bates DW. What Practices will most improve safety? Reprinted JAMA, July 24/31, 2002-Vol 288, No 4, pp504

P.I.C.O.

– Patient/ Population/ Problem

– Intervention/ exposure

– Comparison

– Outcome

Question Evidence best provided

Cost • Cost-effectiveness study

Diagnosis • Diagnostic validation studies• Prospective studies/ blind comparison to a gold standard

Etiology/Harm • Cohort study• Case control study

Prognosis • Cohort study• Case control study

Quality of life • Qualitative studies

Therapy • Systematic review of Randomized Controlled Trials (RCTs)• Single RCT

1 Heneghan, Carl, and Douglas Badenoch. Evidence-Based Medicine Toolkit. 2nd ed. Malden, Mass.: BMJ Books/Blackwell Pub., 2006.2 Glover, Jan, and Lei Wang. Find it Fast: The Clinical Question : www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/

Evidence: systematic observation

Meta-Analysis

Systematic reviews

Randomized Controlled Trial

Cohort studies

Case control studies

Case Series

Anecdote or a single case report

Integrating evidence & practice

• Now I may be accused of ‘cherry picking’..

• One thing you could measure is how much of medical practice is evidence based. This is not easy. From the state of current knowledge, around 13% of all treatments have good evidence, and a further 21% are likely to be beneficial.*

• *Goldacre B. Bad Science- Is mainstream medicine evil. Fourth Estate, London; 2008; pp 199

SORT

The Trial of Homoeopathy

• Post hoc ergo proctor hoc….the fallacy of homoeopathy

• From the ‘assumed-accidental’ appearance of chills after intake of ‘china’ by Hahnemann to the ‘conjuring-up’ of the law named similia similibus curantur!

The Trial of Homoeopathy

• Could be an idiosyncratic adverse reaction!

• However, Hahnemann (or homoeopathic physicians) never claimed that China off produces the malarial parasite in blood.

• The proving merely suggests it to be one of the many remedies for certain kinds of intermittent fevers, one of which is malarial fever.

The Trial of Homoeopathy

• And unlike the quinine (which high doses of china officinalis contains), which most of malarial parasites have become resistant to, if indicated as per homoeopathic materia medica, china off shall cure cases of intermittent fever (even malaria), without fail.

• Moreover China is also a remedy for various kinds of intermittent diseases (refer to aphorism 234)… in which it may serve to break the intermittency.

The Trial of Homoeopathy• The placebo effect… the role of meaning in healing…

placebo explanations / placebo diagnosis/ placebo treatments

• History and numerous clinical studies are full of genuine examples how good bedside behaviour and reassurance can be highly effective.

• If truly speaking, placebo effect is so strong, why even waste so many resources and public money into drug researches for functional diseases or routine indispositions. Placebo treatment or explanation shall certainly suffice.

The Trial of Homoeopathy• Dr Steward Wolf took the ‘placebo effect’ to the

limit…two women suffering with nausea and vomiting (one of them was pregnant) were assured of a treatment; through a naso-gastric tube ipecac was adminstered; contrary to worsening, not just symptoms improved but stomach contractions also disappeared. Unconscious homoeopathy, as all homoeopathic physicians shall agree.

• Wolf S. Effects of suggestion and conditioning on the action of chemical agents in human subjects: the pharmacology of placebos. J Clin Invest, Jan 1950;29(1): 100-109

The Trial of Homoeopathy

• Moreover, now, the the placebo controlled trials are frowned over by the EBM community medicine!

• A treatment or therapy is only considered scientific if it performs better than the accepted methodology, already available.

The Trial of Homoeopathy

• Regression to the mean

• Which means that in homoeopathic treatment if it is not the ‘suggestion therapy’ working, then surely it is spontaneous healing or the disease would have ‘timed-out’

• As Voltaire said…..

The art of medicine consists in amusing the patient, while nature cures the disease.

Voltaire

The Trial of Homoeopathy

• It certainly can’t explain the 100 plus patients visiting daily the various (nearly 100) Delhi Government homoeopathic primary health centres, situated in the various parts of Delhi with residents full of poor socio-economic status. For these persons every day of sickness or absence means depletion of their meager sources of income or loss of jobs!

• And most of these dispensaries are co-located with allopathic set-ups, under the cafetaria approach of the Delhi Govt.

• IT CAN’T BE A MERE COGNITIVE ILLUSION!

The Trial of Homoeopathy

• Championing the ‘empirical data’

• The medicine of experience, and experience alone, of Hahnemann, or his faithful disciples: the guardians of homoeopathy

• The scientific medicine (read research based) completely distances itself from the epistemological approach of empiricism.

The Trial of Homoeopathy

• However, it is certainly believed that EBM is based on current best evidence. This evidence, however may vary from time to time.

• Homoeopathy, on the other hand, as a medicine of experience, has withstood the test of time. For us over two centuries, none of the drugs gone off the counter and banned from usage; for us the bryonia patient is as thirsty in arctic regions as near the equator and pulsatilla the opposite!

The Trial of Homoeopathy

• Where are the RCT/ SR/ Meta-Analysis?

• Now this is one area, wherein barring the few specific remedies viz. arnica, staphysagria, bellis perennis in post-operative/ post partum conditions, hekla lava in certain dental conditions, phytolacca in mammary conditions and a few others, it shall be exceedingly difficult to conduct these trials

• Considering the doctrine of individualisation in homoeopathy

The Trial of Homoeopathy

• Where are the RCT/ SR/ Meta-Analysis?

• Even in simple injury, arnica, ruta, bellis, hypericum, staphysagria, conium, calendula, rhus tox etc. can be indicated, depending upon the symptoms.

• Finding a specific remedy for the diagnostic condition hence dimnishes the chances of exact reproducibility in this ‘patient-centeric’ system of medicine called homoeopathy.

The Trial of Homoeopathy

• Cherry picking evidence/ studies/ data/ stitch up

• The ‘stitch’ up in a study explains the oddly good Jadad score

• Jadad score is a standardised tool that measures the quality of a study

The Trial of Homoeopathy

• Ernst E, Pittler MH. Efficacy of homoeopathic arnica: a systematic review of placebo controlled clinical trials. Arch. Surg. 1998 Nov; 133 (11): 1187-90

• The scientific men could not understand how or why the few studies could achieve 5 Jadad score! Of course, the studies were stitched up or tailored to produce certain results!

§ 53, Organon of the Art of Healing

…the pure homoeopathicmethod of healing is the onlycorrect one, the only onepossible to human art; it is themost direct one, just ascertainly as there is but onepossible straight line betweentwo given points…

THE ROAD AHEAD……..

Edmund Lee, On the successes of Lippe & Hering in curing many chronic cases which other physicians could

not help in the least

“These men had no secret methods of practice,no secret remedies; they had nothing morethan the humblest of us may acquire, aprofound knowledge of Hahnemann ’ sOrganon, of his Chronic Diseases, and of thehomoeopathic Materia Medica. Cannot we allobtain that knowledge also, and having it,cannot we, too, use it to cure these scourges ofthe human race as they did?’

RETURN TO THE INNOCENCE

• MASTER ‘ORGANON OF THE HEALING ART’

James Tyler Kent, An address preliminary to the study of

homoeopathics. Homoeopathician 1912; 1:6

..the masters of these living doctrines and the materia medica have been constant readers of this great work. Not one of the great prescribers has ever claimed a discovery not fully set forth in this work, but in all their greatest accomplishments have said that they based their success upon the Organon… …

James Tyler KentAn address preliminary to the study of

homoeopathics. Homoeopathician 1912; 1:6

….It is the first book for the student to read and the last for the old and busiest physician to ponder over. When Lippe, Wells and scores of others advocated a continuous reading of this book during their long careers, should we not likewise look upon it with a feeling of profound respect? ….

James Tyler Kent, An address preliminary to the study of

homoeopathics. Homoeopathician 1912; 1:6

…. Should we not crave for the hidden truths that has made these faithful followers of law so successful? To whom would a rational man apply for light when desiring to follow law in healing the sick and measuring out uses to man? Naturally to Hahnemann and his faithful adherents, and not to those who smile at what they choose to consider ravings of an aged man…

IT IS POSSIBLE TO FIND IN ORGANON,

THE HIGHEST WISDOM OR FOLLY AS

PER THE NATURAL TENDENCY OF

THE READER!

August Karl Gustav Bier (1861-

1949)

German surgeon & Pioneer of

Spinal Anaesthesia

RETURN TO THE INNOCENCE

• STUDY ‘TEXTBOOKS OF MATERIA MEDICA’ OR THE ‘ROOTS OF MATERIA MEDICA’

– MATERIA MEDICA PURA

– THE CHRONIC DISEASES

– THE ENCYCLOPEDIA OF PURE MATERIA MEDICA

– THE CHRONIC DISEASES

– A DICTIONARY OF PRACTICAL MATERIA MEDICA

– CYCLOPEDIA OF DRUG PATHOGENESY

Earnest Albert Farrington

You must acknowledge, that Materia Medica is themost important of all branches. You cannotunderstand it unless you have a thorough knowledgeof the others. You must learn symptoms and notmere words, and you cannot put any idea into themuntil you know their meaning; and unless you caninterpret symptoms, you can never learn the genusof a drug.

RETURN TO THE INNOCENCE

• COMMIT OURSELVES THROUGHLY BEFORE ‘ADDING ON’ TO MATERIA MEDICA

§ 144, Organon of the Art of Healing

…that all conjecture,everything merely asserted orentirely fabricated, must becompletely excluded from sucha materia medica; everythingmust be the pure language ofnature carefully and honestlyinterrogated.…

• Hahnemann has completely condemnedany way of ascertaining the power ofmedicine by looking, tasting, feeling or

guessing.

In his essay on a new principle he talksabout doctrine of signatures and gives itup thoroughly, with abundant reasons.

Cooper, however, contends that homeopathsshould "fall back upon experiences deduced fromacquaintance with disease and its treatment,”.He feels at the outset that "the doctrine ofsignatures…[ought to be brought] into accordwith modern thought,” especially consideringthat "the appearance of the roots or other partsof plants very often serve as a guide to theiradministration in disease, owing to…[their]resemblance to the diseases they cure,”

• In his quest for therapeutic enlightenment, Cooperpersonally resolved "to throw aside all provings andrepertories and to rely simply upon the action of theuninterfered-with curative principle of plants, which Ibelieve to be none other than growth-force.

These include the "virtues of Hydrangea in Diabetes,”which everybody knows is "the thirstiest shrub known,especially in the act of flowering,”;

The leaves of Ledum palustre are "somewhat spear-shaped,”, and thus its use for "penetrating wounds, beeand wasp stings, must have been guided…by a specialmorphological feature of the plant,”.

But Cooper was extremely gifted and intuitive. Considerhe prescribed mother tinctures in drop doses andwaited without repetition!!

It doesn’t take long to understand that Cooper wasn’tright in his claim that provings do not give information.

Try getting the FOLLOWING SYMPTOMS OF CHINA ORCINA JUST from doctrine of signatures or going intohistory of plant/ species or mythology.

…will hardly ever be found curative when there are not present disturbances of the night’s rest similar to those the medicine causes in the healthy… (Introduction)

Footnote to Symptom no 904: 904, 905, 933, 938, 946. Restlessness sleep at night, with anxious, frightful dreams, after which on waking consciousness is not quite perfect, or the anxiety they cause continues (934, 935) are quite peculiar to china, see 936, 937, 939, to 947

CHINA OFFICINALIS

293. The child is very lachrymose and complaining. 294. Weeps piteously when one attempts to touch or lead him (aft. 3 h.). 295. Great seriousness and sensitiveness; he takes the slightest joke on bad part. 297. Restlessness.298. Incessant restlessness.299. Longs for many different things. 300. Refuses everything offered to him, even what he used to like best. 301. Cannot be quieted by any persuasion; insensible to caresses.

CINA

§145 Footnote

• At first, about forty years ago, ………Butwhat shall we not be able to effect in theway of curing in the whole extent of theinfinitely large domain of disease, whennumbers of accurate and trustworthyobservers shall have rendered theirservices in enriching this, the only truemateria medica, by careful experiments onthemselves! The healing art will then comenear the mathematical sciences incertainty.

…The homoeopathic materiamedica is the basis ofhomoeopathic practice. Withouta pure materia medica there canbe no homoeopathic practice.Therefore the purity of themateria medica is simply aquestion of life and death to alltrue homoeopaths…

Dr. Walter James & Dr. Edmund Lee, Editor, Homoeopathic Physician, 1887

RETURN TO THE INNOCENCE

• HOMOEOPATHIC DRUG PROVING, BASED ON GUIDELINES OF ORGANON

Hahnemann was helped by 50 provers informulating his Materia Medica Pura, apart fromhimself and the referencing from Old SchoolAuthorities.

In spite of all turbulances, frequent travelling, fightinglitigations, seeing patients, reading stuff (researching),writing his observations (without computer orinternet), delivering lectures, fighting apothecaries,Hahnemann still managed to prove about 99 (pluspsorinum, published in Stapf’s archives, making it a 100remedies) remedies in his 53 years as a homoeopathicphysician!

Provers furnished Hahnemann with a writtenstatement of the symptoms they observed, onwhich Hahnemann examined them, carefullygoing over all the symptoms, and correctingor altering them so as to make them, as far aspossible, the exact sensation or pain observedwith all its conditions and concomitants.

It is these painstaking efforts that gave usinvaluable Materia Medica Pura, viz….

148. Shuddering on one side of the face. f.n. The occurrence of symptoms on only one half of the body is a frequent peculiarity of pulsatilla. Comp. 906, 921, 1073, 1074, 1077, 1098, 1099, 1100, Rhus, belladonna, cocculus show something similar.

PULSATILLA

F.n. to 199: The so-called tearing pains of pulsatilla are mostly a transient drawing tension, which always changes into a twitching like tearing-somewhat as if a nerve were painfully drawn out and stretched, and then let loose with a sudden, painful jerk. Hence the expression. "single tearing twitching," 167, "drawing twitching," 208, &c.

PULSATILLA

RETURN TO THE INNOCENCE

• USE REPERTORY WHEN REQUIRED; EVERY CASE DOES NOT REQUIRE REPERTORISATION IF YOU ARE WELL AQUAINTED WITH ORGANON & MATERIA MEDICA

RETURN TO THE INNOCENCE

• In actual practice there are two kinds of cases that come to every physician. One is the case that may be prescribed for with great certainty of success on the symptoms that are styled characteristic and peculiar(Organon § 153.) The other is where in all the case there are no such symptoms appearing; then there is only one way, viz, to hunt for the remedy that, in its pathogenesis, contains what is called the "tout ensemble" of the case. The majority of the cases, however, do have, standing out like beacon lights. Some characteristic or key note symptoms which guide to the study of the remedy that has the whole case in its pathogenesis.

RETURN TO THE INNOCENCE

• DOCUMENT YOUR CASES: BESIDES THOROUGH CASE TAKING, INVESTIGATIONS AND DISEASE ACTIVITY SCORES

• A FEW EXAMPLES:

CT Chest dated 148-08

CT Chest dated 5-3-09

CT Chest dated 4-2-10

DVT

• A 46 years old lady visited In May 2013 with Venous doppler report showing Rt side DVT.

• She received Argentum nitricum in LM potencies over an year.

• The Venous doppler repeated on 1-5-14 showed no DVT traces, only superficial varicosities.

OBJECTIVES

•To observe the effect ofHomoeopathic drug therapy inChikungunya fever and in PostChikungunya Chronic Arthritis in aprimary health care setup.

STUDY DESIGN

•A prospective observational without control was conductedon non-randomised subjects at Delhi GovernmentHomoeopathic Dispensary Aali Village (DGHDAV).

STUDY SETTINGS

Your faith is your fate, your devotion your destiny, yourdetermination, your goal, your desire shapes your life.Homoeopathic career is not for the weak, the timid,the vacillating and the sheltered cows but for therebel, the determined, the strong and courageouslions. It is for them who want to win. The survival andsuccess do not depend on certificates and courses buton strength and will power in you. The blessings of allwho suffered for homoeopathy and all who will benefitfrom it is waiting to bless you. Choose. Stay for ever orgo today, now.

Dr B. K. Bose