Thursday, 14 October 2010

Homeopathy for the 21st Century


The lobbying charity Homeopathy: Medicine for the 21st Century (H:MC21) recently shelled out for two adverts
in the New Statesman. (The adverts are available here and here.)


The advert in my possession appeared in the 11th October issue under the title

"Homeopathy Cares"

The general thrust of my epic complaint to the Advertising Standards Authority (ASA) - which weighs in at a mammoth fifteen pages - is

"...but not enough"

It's worth highlighting a few of the arguments the a
dvert makes - and why these arguments are wrong. (Apologies to everyone for whom an explanation isn't necessary.)



According to the advert,

"At Bristol Homeopathic Hospital 70.7% of 6,500 patients with chronic conditions benefited from homeopathic treatment and had reduced need for conventional medication."

The claim refers to a 2005 study published in a New York-based magazine.

Alas, the study's conclusions are meaningless - it is essentially a large collection of anecdotes, which painful experience has taught us is too unreliable to be taken seriously as scientific evidence.

(Image credit - recent edition of The Lancet)

The advert continues,

"...more randomised controlled trials [studies of homeopathy] are positive than negative."

In other words, of the many studies which have been done on homeopathy, a majority say that homeopathy works.

The problem with this claim is that many of the studies are of poor quality, and we cannot confidently rely on their conclusions.

Luckily, we have a series of "meta analyses" to rely upon - formal reviews of the available scientific evidence. The most recent one, published in The Lancet in 2005, concluded

"...the clinical effects of homoeopathy are [compatible with] placebo effects."

In English, this means that homeopathy is no more effective than any other sugar pill. The advert claims

"Homeopathy has a history of success in chronic illness"

In fact, the opposite is true - homeopathy has no history of success in treating any kind of illness. (If I'm wrong - show me the evidence!)


The advert claims,

"In Cuba an integrated approach to healthcare has lead to homeopathy being used to enable 2.3 million people, including the elderly, to be cheaply and effectively protected against endemic Leptospirosis."

The underlying problem with the above claim is that it is bollocks.

(Image credit - Frank Gable cartoon)

Here, then, is my complaint to the ASA. Although it's slightly on the long side, I hope it covers every base.

If anyone is tempted to submit their own ASA complaint (the address is new.complaints@asa.org.uk, by the way), you're welcome to copy mine - but you should change paragraphs 23 and 28, which refer to me personally.

(A great number of people assisted me in preparing the complaint. As always, I am grateful to them.)

"I write to complain about an advert appearing in "New Statesman" magazine ("Special Issue", 11 October 2010, "Policy Report No 9" supplement, p15).

The advert, entitled "Homeopathy Cares", is for the charity "Homeopathy: Medicine for the 21st Century" (H:MC21).

I suspect that the advert may be in breach of several sections of the British Code of Advertising, Sales Promotion and Direct Marketing (CAP) code (2010). I can provide the original advert by post, if necessary.

1. The first section of the advert is titled "Homeopathy has a history of success in chronic illness".

2. (i) The advert claims:

"At Bristol Homeopathic Hospital 70.7% of 6,500 patients with chronic conditions benefited from homeopathic treatment and had reduced need for conventional medication."

(ii) Many of the advert's claims are supported by references on the advertiser's website, www.hmc21.org. I will repeat the references here when relevant.

(iii) The statement above is supported by a 2005 study [1] published in the New York-based "Journal of Alternative and Complementary Medicine".

(iv) The Journal describes itself [2] thus:

"The Journal of Alternative and Complementary Medicine includes observational and analytical reports on treatments outside the realm of allopathic medicine which are gaining interest and warranting research to assess their therapeutic value. It includes current concepts in clinical care, including case reports that will be valuable for health care professionals and scientists who are seeking to evaluate and integrate these therapies into patient care protocols and research strategies."

(v) A free copy of the latest edition of the Journal is available on its website. I consulted the issue marked Volume 15, Number 12 [3].

(vi) Of the eleven "Original Articles" in this issue, there is one systematic review whose "results should be interpreted cautiously", another systematic review whose conclusions "[need] to be verified by more high-quality trials", and a single randomised controlled trial (RCT) studying the possible benefits of massage. (All the quotes in this paragraph were taken from the text of the articles themselves.)

(vii) The remaining articles are a collection of surveys, case studies, non-randomised trials and pilot studies.

(viii) Returning to the study in question, "Homeopathic Treatment for Chronic Disease", the study describes its design thus:

"Design: This was an observational study of 6544 consecutive follow-up patients during a 6-year period."

(ix) The study's conclusions are:

"Homeopathic intervention offered positive health changes to a substantial proportion of a large cohort of patients with a wide range of chronic diseases..."

3. Under Section 3.7 of the CAP Code (2010), I challenge whether the claim that "6,500 patients with chronic conditions benefited from homeopathic treatment and had reduced need for conventional medicine" can be substantiated; under Section 3.1 I challenge whether the claim is misleading; and under Section 3.3 I challenge whether the claim omits material information that the consumer needs to make informed decisions about homeopathy. The rationale for my challenge is:

(i) The study was published in a journal which appears to contain very little rigorous clinical research, and whose main business seems to be the publication of surveys and pilot studies

(ii) The study is not a RCT; it appears to be nothing more than a collection of anecdotes

(iii) Because of its systematic design failings, no part of the study appears to offer substantiation of the claim

4. (i) The advert continues:

"Other clinical outcome studies indicate similar levels of benefit, and more randomised controlled trials are positive than negative."

(ii) The claim is supported by the non-specific text, "For more see www.britishhomeopathic.org". The link is the home page of the British Homeopathic Association.

5. (i) I am unaware of any rigorous RCT that has ever demonstrated the efficacy of homeopathy.

(ii) A 2005 meta-analysis published in the Lancet [4] discussed the quality of the available research:

"110 homoeopathy trials and 110 matched conventional-medicine trials were analysed...21 homoeopathy trials (19%) and nine (8%) conventional-medicine trials were of higher quality. In both groups, smaller trials and those of lower quality showed more beneficial treatment effects than larger and higher-quality trials..."

(iii) The meta-analysis concluded:

"Biases are present in placebo-controlled trials of both homoeopathy and conventional medicine. When account was taken for these biases in the analysis, there was weak evidence for a specific effect of homoeopathic remedies, but strong evidence for specific effects of conventional interventions. This finding is compatible with the notion that the clinical effects of homoeopathy are placebo effects."

(iv) In response to this meta-analysis, "the Lancet ran an editorial entitled 'The End of Homeopathy' in which they argued that 'doctors need to be bold and honest with their patients about homeopathy's lack of benefit'". [5]

(v) Earlier meta-analyses such as the 2002 study by Ernst [6] reached comparable conclusions.

6. (i) Under Section 3.7, I challenge whether the claim "Other clinical outcome studies [of homeopathy] indicate similar levels of benefit" can be substantiated.

(ii) Under Section 3.1, I challenge whether the claim "more randomised controlled trials are positive than negative" is misleading, in that it fails to take into account of the poor quality of such "positive" studies, as documented by the studies I have discussed.

7. (i) The advert continues:

"In Cuba an integrated approach to healthcare has lead to homeopathy being used to enable 2.3 million people, including the elderly, to be cheaply and effectively protected against endemic Leptospirosis."

(ii) The claim is supported by a reference to an unpublished paper from the "Finlay Institute" of Cuba [7].

8. (i) Leptospirosis is a bacterial disease. The bacteria is spread by many mammals, most commonly by rats. It usually enters humans when infected water is drunk. Occurrences of Leptospirosis are rare in the West, but sporadic outbreaks do occur in Cuba [8].

(ii) The standard preventative measures against Leptospirosis are better hygiene, elimination of rats, and vaccination. The effectiveness of the vaccine vax-SPIRAL in controlling the disease in Cuba has been clinically proven [9].

9. The study's methods are described thus:

"METHODS: Forecast models were used to estimate possible trends of disease incidence. A homeoprophylactic formulation was prepared from dilutions of four circulating strains of Leptospirosis. This formulation was administered orally to 2.3 million persons at high risk in an epidemic in a region affected by natural disasters. The data from surveillance were used to measure the impact of the intervention by comparing with historical trends and non-intervention regions." [7]

10. Under Section 3.7, I challenge whether the claim that "2.3 million people...cheaply and effectively protected against endemic Leptospirosis" can be substantiated. My rationale for the challenge is:

(i) According to its entry in Pubmed [7], checked on 11th October, the study does not appear to have been published in any peer-reviewed clinical journal

(ii) The study, being apparently unpublished, is of unknown reliablity

(iii) The study does not appear to have any kind of control group

(iv) The study's results appear to have been measured against estimated baseline levels of infection - not actual baseline levels which the researchers could, and should, have taken the trouble to measure

(v) Incidence of Leptospirosis infection is highly variable, and without a control group, it seems impossible to distinguish the effects of homeopathy from natural variations in infection rates and the effects of clinically-proven vaccinations

(vi) As discussed above, homeopathy has never been shown to be efficacious against any condition; rigorous clinical trials would be required to substantiate the claim

11. (i) The advert continues:

"About 6 million people in the UK choose homeopathy despite the fact that for the vast majority this means that they have to pay for their treatment."

(ii) The statement refers to a response to a question in the House of Commons Science and Technology Committee's "Evidence Check: Homeopathy (2010)" report.

(iii) However, the statement appears in the advert's section entitled "Homeopathy has a history of success in chronic illness".

12. (i) Under Section 3.7, I challenge whether the claim that "Homeopathy has a history of success in chronic illness" can be substantiated.

(ii) Furthermore, under Section 3.1 I challenge whether the statement "About 6 million people in the UK choose homeopathy despite the fact that for the vast majority this means that they have to pay for their treatment", appearing as it does in the section called "Homeopathy has a history of success in chronic illness", is misleading.

(iii) My rationale for the challenge is that the two statements together imply that six million people are denied free medicines of proven efficacy on the NHS. If the efficacy of homeopathy is, in fact, unproven (as demonstrated by the meta-analyses mentioned above), the implication is misleading.

13. (i) The advert continues:

"The NHS spends £11 billion annually on conventional drugs out of a budget of £100 billion, and this cost keeps rising, as there is an increasing need to treat long-term conditions...Only 0.001% of the NHS drugs budget is spent on homeopathic medicines, but these are mainly used to treat patients with chronic health problems who have not been helped, despite great cost, by conventional means."

(ii) Under Section 3.7, I challenge whether the claim that homeopathy can "be used to treat patients with chronic health problems who have not been helped...by conventional means" can be substantiated.

(iii) Under Section 12.2, I challenge whether the same claim might discourage "patients with chronic health problems" from seeking essential treatment.

(iv) 0.001% of £11 billion is £110,000 [11].

(v) The Society of Homeopaths estimates that the NHS actually spends at least £4 million annually on homeopathy [12].

(vi) Therefore, under Section 3.7, I challenge whether the claim that "Only 0.001% of the NHS drugs budget is spent on homeopathic medicines" can be substantiated, and under Section 3.1 I challenge whether an attention-grabbing number like "0.001%" is misleading, when the actual spend amounts to many millions of pounds.

(vii) Under Section 3.1, I challenge whether the comparison between evidence-based medicine, which is expensive but frequently effective, and homeopathy, which may sometimes be a less expensive treatment but which is clinically unproven, is a misleading one.

14. (i) The advert continues:

"The NHS also spends £2 billion annually on treating the adverse side effects of conventional drugs. Homeopathy has no side effects."

(ii) This is the essentially the same argument that I challenged in paragraph 13 (vii). Under Section 3.1, I again challenge whether the comparison is misleading, since of the two methodologies, the one which is portrayed as being more expensive is also the only one which clinical studies show is effective.

(iii) I also challenge whether the statement "Homeopathy has no side effects" is misleading, as it omits the inconvenient fact that the only clinically proven "effect" that homeopathy can demonstrate is a placebo effect.

15. The advert continues:

"Even a small increase in spending on homeopathy could produce dramatic benefits, reducing care needs and increasing patient quality of life."

16. Under Section 3.7, I challenge whether any of the following claims can be substantiated by rigorous clinical trials conducted on people:

(i) Homeopathy "produce[s] dramatic benefits"
(ii) Homeopathy can "reduce care needs"
(iii) Homeopathy can "[increase] patient quality of life"

17. (i) The second section of the advert is entitled "Homeopathy offers a caring alternative".

(ii) Under Section 3.7, I challenge whether the claim that mainstream, evidence-based medicine is less "caring" than homeopathic medicine can be substantiated.

(iii) Under Section 3.1, I challenge whether the claim that homeopathy is a satisfactory "alternative" to evidence-based medicine is misleading.

18. (i) The advert continues:

"Opposition to homeopathy is based on propaganda"

(ii) Under Section 3.1, I challenge whether this claim is misleading, given that opposition to homeopathy is at least partly based on the two meta-analyses mentioned above.

19. (i) The advert continues:

"Homeopathy has a growing evidence base, but according to the British Medical Journal, of the 2,500 most commonly used treatments in the NHS, 51% have unknown effectiveness, and only 11% have been shown to be beneficial."

(ii) The statement refers to a page on the BMJ's website [13] containing a pie chart. The chart indeed describes 51% of treatments as being of "unknown effectiveness".

20. (i) I think the claim is extremely misleading, and on four counts.

(ii) The chart takes no account of the frequency with which treatments are used. Thus, fifty-one unproven treatments, each used once a month in the UK, would occupy equal space with forty-nine proven treatments used hundreds of times every day. In the context of attacking the effectiveness of evidence-based medicine, the conclusion that 51% of treatments in use in the UK are of unproven efficacy would clearly be entirely misleading.

(iii) The chart classifies treatments according to the number and quality of RCTs supporting them. However, this is not the whole picture, as RCTs cannot be used in some circumstances. In these "self-evident interventions" - such as blood transfusions, starting the hearts of heart attack victims, or antibiotics for meningitis victims - not only would RCTs be unnecessary to demonstrate the effectiveness of the treatments, but the use of a control group in which patients with immediate life-threatening conditions were denied treatement would be unethical [14].

(iv) The data on which the chart is based has been compiled in an effort to identify new areas of clinical research. Using it for another purpose - to portray evidence-based medicine as some kind of pseudo-science - is misleading.

(v) In fact, the web page referenced by the advertisers [13] includes a warning of this nature:

"Dividing treatments into categories is never easy hence our reliance on our large team of experienced information specialists, editors, peer reviewers and expert authors. Categorisation always involves a degree of subjective judgement and is sometimes controversial. We do it because users tell us it is helpful, but judged by its own rules the categorisation is certainly of unknown effectiveness and may well have trade offs between benefits and harms."

(vi) It would be easy to accuse the advertisers of cherry-picking, since other estimates of the extent of evidence-based medicine are wholly different.

(vii) Edzard Ernst has written [15] about this very issue. He writes:

"One often-voiced argument against evidence-based medicine is that clinical practice is, in fact, not evidence-based. The origins of this argument lead us to a BMJ editorial of 13 years ago [16], referring to a remark made by David Eddy, at a conference in Manchester, that only 15% of medical practice was based on any evidence at all."

(viii) Ernst continues [17]:

"The most conclusive answer comes from a UK survey by Gill et al who retrospectively reviewed 122 consecutive general practice consultations. They found that 81% of the prescribed treatments were based on evidence and 30% were based on...RCTs. A similar study conducted in a UK university hospital outpatient department of general medicine arrived at comparable figures; 82% of the interventions were based on evidence, 53% on RCTs. Other relevant data originate from abroad. In Sweden, 84% of internal medicine interventions were based on evidence and 50% on RCTs. In Spain these percentages were 55 and 38% respectively. Imrie and Ramey pooled a total of 15 studies across all medical disciplines, and found that, on average, 76% of medical treatments are supported by some form of compelling evidence, the lowest was that mentioned above (55%), and the highest (97%) was achieved in anaesthesia in Britain. Collectively these data suggest that, in terms of evidence-base, general practice is much better than its reputation."

(ix) Therefore, under Section 3.1 of the code, I challenge whether
the claim "...of the 2,500 most commonly used treatments in the NHS, 51% have unknown effectiveness, and only 11% have been shown to be beneficial" is misleading, and under Section 3.7 I challenge whether it can be substantiated.

21. (i) The advert continues with an attack on the author of the 2002 meta-analysis mentioned above:

"The leading so-called ‘expert’ and critic of homeopathy, Professor Edzard Ernst, has admitted that he has no qualifications in homeopathy."

(ii) The statement refers to Edzard's earlier career in which he practised "alternative" medicine, and in particular an interview he gave to a German magazine this year [18]. An English translation which the advertisers provide on their website [19] seems to me to be accurate.

(iii) Under Section 3.1, I challenge whether the attack is misleading in that it implies Ernst's opinions on alternative medicine cannot be trusted because his academic credentials, among them hundreds of published papers in peer-reviewed scientific journals, do not include "qualifications" in pixie dust filtration, unicorn psychology - or homeopathy.

22. The advert continues:

"The leading organisation opposing homeopathy, Sense About Science, is funded by pharmaceutical companies and relies on a strategy of propaganda stunts rather than scientific research."

23. (i) According to their website [20], Sense About Science (SaS) "is an independent charitable trust promoting good science and evidence in public debates. We do this by promoting respect for evidence and by urging scientists to engage actively with a wide range of groups, particularly when debates are controversial or difficult."

(ii) The trust's policies on funding disclosure are available on their website [21], as are a summary of their most recent accounts. The trust's full accounts are also available from the Charity Commission [22].

(iii) According to the trust [21], income from the year ending 5 April 2009 totalled £260,792, of which contributions from "Companies and Trade Associations" totalled £46,000 (about 18% of the total).

(iv) The same web page [21] discloses the identity of the trust's donors. It is striking to compare the list of pharmaceutical companies who are among the donors with the list of other contributors.

(v) The list of other contributors is:

"The Association for Clinical Biochemistry, the Biochemical Society, Biotechnology and Biological Sciences Research Council, British Toxicology Society, British Institute of Radiology, British Pharmacological Society, the Genetics Society, Institute of Biomedical Science, Institute of Food Research, Institute of Physics, Institute of Physics and Engineering in Medicine, John Innes Centre, Medical Research Council, Motor Neurone Disease Association, Multiple Sclerosis Society, Natural Environment Research Council, NESTA, Physiological Society, Research Councils UK, Royal Academy of Engineering, Royal Astronomical Society, Royal College of Pathologists, Royal College of Radiologists, Royal Meteorological Society, Royal Pharmaceutical Society of Great Britain, Royal Society of Chemistry, Royal Statistical Society, Society for Applied Microbiology, Society for Endocrinology, Society for General Microbiology, University of Brighton, University of Cambridge, University of Dundee, University of Edinburgh, University of Glasgow, University of St Andrews, University of Stirling, University of Sussex, University of The West of Scotland, the White Rose Colloboration Fund Wiley-Blackwell, Elsevier, Science Careers.org, Amberstone Trust, Esmee Fairbairn Foundation, John Ellerman Foundation, John Innes Foundation, the Kenneth Miller Trust, the Lawes Agricultural Trust, Paul Hamlyn Foundation, PHG Foundation, Rayne Foundation, The Wellcome Trust"

(vi) The list of pharmaceutical companies, in its entirety, is:

"AstraZeneca plc, ClearCast, GE Healthcare, Unilever"

(vii) Therefore, under Section 3.1, I challenge whether the claim "Sense About Science is funded by pharmaceutical companies", implying that the trust is wholly or mainly funded by pharmaceutical companies, is misleading.

(viii) The advertisers accuse SaS of relying "on a strategy of propaganda stunts rather than scientific research".

(ix) I am having difficulty identifying any publicity stunts organised by SaS in their opposition to homeopathy. I have examined the basis for the advertiser's claim [23] without success.

(x) I think, perhaps, the advertisers are confusing SaS with the "ten:23" event organised by the Merseyside Skeptics [sic] Society in January 2010 [24]. (I am comfortable in describing the event as a "publicity stunt", since I took part in it.)

(xi) Given that Sense About Science describe their methodology as "promoting respect for evidence and by urging scientists to engage actively with a wide range of groups, particularly when debates are controversial or difficult", under Section 3.7 I challenge whether the advertisers can substantiate their claim by identifying two publicity stunts that were organised by Sense About Science in their opposition to homeopathy.

24. (i) The advert continues:

"The leading popular book critical of homeopathy (Trick or Treatment?) has been shown to be scientifically unreliable. It was co-authored by Simon Singh (a trustee of Sense About Science) and Professor Ernst."

(ii) The claim "shown to be scientifically reliable" refers to the thesis of a "book" by William Alderson, "Halloween Science", which is available for download from the advertiser's website [25].

(iii) William Alderson is, in fact, the "Chair and Treasurer" of the advertisers H:MC21. According the advertiser's website [26], he "was elected to the Board of Directors of the Society of Homeopaths in 2010. He trained at The London School of Classical Homoeopathy."

(iv) The site's biography seems to indicate that Alderson does not possess any scientific qualifications (such as a BSc). Two other people listed on the same page have PhDs.

(v) I cannot find any indication that the "book" is currently in print [27].

(vi) The "book"'s conclusions are [25]:

"Ernst and Singh have failed to provide a secure theoretical or evidential base for their argument, and have used analytical tools inadequate (in this context) for achieving objective and reliable conclusions. The result of these weaknesses is that their argument relies heavily on preconceptions, variable definitions and opinion, a problem exacerbated by a tendency to confirmation bias on the authors’ part. As a result, Trick or Treatment? has no validity as a scientific examination of alternative medicine."

(vii) The advertisers claim that "Trick or Treatment" has "been shown to be scientifically reliable". Because of the word "scientifically", I would expect the claim to be supported by articles in peer-reviewed scientific journals, or at least a published work by a qualified scientist.

(viii) Therefore, under Section 3.7 I challenge whether the claim "[The book, 'Trick or Treatment'] has been shown to be scientifically unreliable" can be substantiated.

25. (i) The advert continues:

"The recent Science and Technology Committee report on homeopathy was voted for by only three MPs. Of these only one attended the hearings and he has strong links to Sense About Science (Dr Evan Harris)."

(ii) The Committee's report was passed ("...Ordered, That the Chairman make the Report to the House") by a margin of three votes to one on 8th February 2010. [28]

(iii) At the time, the committee had a membership of fourteen MPs drawn from all parties.

(iv) The 8th February meeting was chaired by Phil Willis. Evan Harris, Ian Cawsey and Doug Naysmith voted for the report. Ian Stewart voted against. Tim Boswell was present, but is not recorded as having voted. The remaining eight members of the committee did not attend the meeting.

(v) As the advertisers report, Evan Harris does indeed have strong links with Sense about Science. He is a member of their Advisory Council [29].

(vi) The advertisers note that only three MPs voted for the report, but omit to mention that only two others (beside the chairman) were present. Of these, only one MP voted against.

(vii) Under Section 3.1, I challenge whether this omission of the number of votes against, taken together with the word "only", misleadingly implies that the report's supporters were in a small minority.

(viii) Before entering politics, Evan Harris trained as a doctor, specialising in acute medicine and surgery. It is not hard to imagine why he might have an interest in clinical evidence.

(ix) Therefore, under Section 3.1, I challenge whether the advertiser's statement that "...only one [of the report's supporters] attended the hearings and he has strong links to Sense About Science" is misleading by omitting this rather pertinent fact, focusing solely on Harris' membership of SaS.

26. (i) The advert claims "H:MC21 represents thousands of homeopaths and patients..."

(ii) I note that advert does not say "H:MC21 represents the views of thousands of homeopaths and patients...", which would be reasonable, given the "28,000 signatures" they claim to have collected "in support of homeopathy".

(iii) I have examined the advertiser's website and publicity materials for evidence that it has thousands of members, or thousands of registered supporters, without success.

(iv) Therefore, under Section 3.7 I challenge whether the advertisers can substantiate their claim that they "represent thousands of homeopaths and patients".

27. (i) The advert appears on the inside back page of a supplement within the magazine (but stapled to it). The supplement is titled "Social care: who pays?".

(ii) The supplement contains a number of opinion pieces by named authors (such as Andy Burnham, who was Secretary of State for Health until May 2010) who are obviously not employees of the magazine.

(iii) The advert does not seem to contain a clear indication that it is an advert.

(iv) Given the advert's position on the back page, adjacent to a non-advert page entitled "Further Information" (which introduces ten "leading organisations and pressure groups"), and given the lack of indications that the advert is an marketing promotion, under Sections 2.1 and 2.4 I challenge whether the advertisers have complied with their responsibility to make their marketing communications obviously identifiable as adverts.

(v) I include a scan both of the advert, and of the adjacent page I have discussed.

28. (i) I have no connections with any of the people, organisations or publications mentioned in this complaint, with one exception: as I have already mentioned (para 23 viii), I took part in the "ten:23" event in January, though I am not a member of the Merseyside Skeptics Society who organised it.

(ii) The advert mentions a prominent former MP. For the sake of clarity, I am not a member of any political party.

(iii) I have no connections with the magazine, or the publishing industry in general.

(iv) I have no connections with the advertisers, or with the alternative medicine industry in general.

Footnotes:

[1] D.S. Spence, E.A. Thompson, S.J. Barron, ‘Homeopathic Treatment for Chronic Disease: A 6-Year, University-Hospital Outpatient Observational Study’, JACM, 2005, 11:793-798. Available at http://www.ucl.ac.uk/Pharmacology/dc-bits/spence-jacm-05.pdf

[2] http://www.liebertpub.com/products/product.aspx?pid=26

[3] http://www.liebertonline.com/toc/acm/15/12

[4] Shang, A et al., "Are the clinical effects of homeopathy placebo effects? Comparitive study of placebo-controlled trials of homoeopathy and allopathy", Lancet 2005; 366:726-32

[5] Singh, Ernst, "Trick or Treatment? Alternative Medicine on Trial", First American Edition 2008, p137

[6] Ernst, E., "A systematic review of systematic reviews of homeopathy', Br J Clin Pharmacol 2002; 54:577-82.

[7] Bracho, G. et al, "Large-scale application of highly-diluted bacteria for Leptospirosis epidemic control." Available at http://www.ncbi.nlm.nih.gov/pubmed/20674839

[8] "The Leptospirosis Information Center", http://www.leptospirosis.org/

[9] Martínez R. et al, "Efficacy and safety of a vaccine against human leptospirosis in Cuba" (in Spanish), Rev Panam Salud Publica. 2004 Apr;15(4):249-55. Available at http://www.ncbi.nlm.nih.gov/pubmed/15193180

[10] Professor Kent Woods, Chief Executive of the Medicines and Healthcare Products Regulatory Agency (MHRA), response to Q211, House of Commons Science and Technology Committee, Evidence Check: Homeopathy (2010), p. Ev 70, at

[11] In case my mathematics is flawed, my calculation was 11000000000 x 0.00001 = 110000

[12] http://www.homeopathy-soh.org/whats-new/research/evid/cost-benefit-studies.aspx

[13] http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp

[14] http://www.veterinarywatch.com/CTiM.htm

[15] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314867/pdf/15160706.pdf

[16] As of 2010, actually 19 years ago: Smith R., Where is the wisdom... the poverty of medical evidence. BMJ 1991; 303:798-799.

[17] Source for the quoted figures can be found at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314867/pdf/15160706.pdf

[18] http://www.dzvhae.com/portal/pics/abschnitte/300410102802_hn168april10.pdf?PHPSESSID=273eb20b3c19d743c6c106bbd56fd1dc

[19] http://www.hmc21.org/#/edzard-ernst/4543212059

[20] http://www.senseaboutscience.org.uk/index.php/site/about/6/

[21] http://www.senseaboutscience.org.uk/index.php/site/other/130

[22] http://www.charity-commission.gov.uk/SHOWCHARITY/RegisterOfCharities/CharityWithoutPartB.aspx?RegisteredCharityNumber=1101114&SubsidiaryNumber=0

[23] Advertiser's reference #12: "Strategy information from the ‘Memorandum submitted by Sense About Science’ (HO36), Evidence Check, pp. Ev 7-8."

[24] http://www.1023.org.uk/the-1023-overdose-event.php

[25] http://www.hmc21.org/#/halloween-science/4535659799

[26] http://www.amazon.co.uk/s/ref=nb_sb_noss?url=search-alias%3Daps&field-keywords=halloween+science&x=0&y=0

[27] http://www.hmc21.org/#/who-we-are/4535743636

[28] ‘Formal minutes’, Evidence Check, pp. 48-50. http://www.publications.parliament.uk/pa/cm200910/cmselect/cmsctech/45/45.pdf

[29] http://www.senseaboutscience.org.uk/index.php/site/about/27
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