Opinionista Ivo Vegter 2 May 2018

Ethical pharmacists should not sell quackery

Pharmacists often sneer at homeopathy and other natural health quackery. But they do sell it, which on the face of it contravenes the South African Pharmacy Council’s ethical rules. There should be an “ethical pharmacy” certification in South Africa.

My local pharmacy sells a product called Septoguard. On the box, it claims to be a “natural antibiotic”. Unlike other antibiotics, however, it is freely available, requiring no prescription.

Being a curious, scientific sort, I rummaged inside the box, where I found a package insert, just like you would with real medicine. Reading it, a few oddities struck me.

The pharmacological classification is “D: Unani-Tibb”. It is surprising that an antibiotic would not be classified under the usual “A.20: Antimicrobial agents” heading, or one of its sub-headings, because that is where antibiotics intended for use in humans go.

It is even more notable, however, that category D does not exist. Medicines Control Council (MCC) regulation 25, under the Medicines and Related Substances Control Act, says that there are three classifications of medicine: A, intended for use in humans; B, for stuff that doesn’t work on its own; and C, intended for veterinary use.

There is no category D. So the pharmacological classification is entirely bogus, designed only to make this snake oil look like real medicine.

For the meaning of “Unani Tibb”, we go not to some weird new-age holistic magic site, but, surprisingly, to the Western Cape University’s “School of Natural Medicine”. It flogs courses in alternative medicine, and belongs right up there with South Africa’s other schools of witchcraft and wizardry.

It claims that Unani Tibb is a “complete, scientific and natural system of medicine”. However, it also admits that two thirds of “natural medicines” have no published scientific literature supporting their use. That leaves one third, for which there is “some published literature”. That hardly sounds complete and scientific. Frankly, there is “some published literature” for almost anything.

Unani Tibb is based on “temperament”, and divides people into four broad categories: “sanguinous, phlegmatic, melancholic and bilious”. Ergo, it still believes in the four “humours”. It turns out that this is based on the 11th-century writings of Avicenna, a Persian scholar, who in turn took the ideas from the Greco-Roman writings of Hippocrates and Galen.

The problem is that all this humour claptrap was scientifically discredited and superceded in the mid-19th century by the “father of modern pathology”, Rudolf Virchow. Unlike with art, science does not improve with age, and ancient “science” is not very far removed from superstitious nonsense. Which is exactly what Unani Tibb is.

According to the UWC, Unani Tibb includes “regimental therapies” such as cupping and colour therapy, which have no basis in the credible medical literature. One journal, dedicated to colour research, treats the subject with sarcasm bordering on contempt, saying there is “compelling support for applying the caveat emptor principle to colour psychology and colour therapy claims found in non-academic sources”.

In other words, this stuff is unscientific bullshit, taught by a supposed “university”. They should be ashamed of themselves.

This antibiotic, Septoguard, says its “pharmacological action … is based on the Unani-Tibb philosophy”. That’s as vague and non-specific as saying aspirin’s pharmacological action is based on medical theory, except that it has even less credibility. This makes it clear that there is no science that explains its action, nor has it been subjected to testing, let alone to large-scale, randomised, double-blind, placebo-controlled trials.

Often viewed as a “gold standard” in medical testing, these trials are not as objective and distortion-free as one might wish, but they go furthest to eliminate sources of artefacts and bias in research. So-called natural remedies are rarely tested for quality, safety, or efficacy, because such testing would likely show the concoction to be ineffective, or have too many unwanted side-effects.

As a result of this lack of testing, Septoguard’s insert says there are no known side-effects, nor are there symptoms of overdose. This is unlike any real medicine ever. You can overdose on water, but not on this magic concoction! But it you do happen get side-effects, the manufacturers urge you to go see a real doctor.

The claims of no side-effects are also implausible because Septoguard does contain active herbal ingredients. These extracts are impure, containing everything and anything they can squeeze out of a plant. Sometimes, herbs do contain useful active ingredients for example, aspirin is derived from the bark of a willow tree – but they are also likely to contain ingredients that have unwanted side-effects.

That’s the difference between ancient herbal medicine (or “phytotherapy”, as the UWC likes to call it) and modern pharmacy. Modern pharmacy tries to identify active ingredients, provide them in a measured dose, and exclude ingredients that do not contribute towards the desired outcome, thereby eliminating unnecessary side-effects.

Herbal medicine, by contrast, can be harmful, because it has more ingredients, they are often toxic, and their composition and dose are far less rigorously controlled. The notion that herbal medicine is somehow safer than modern pharmaceuticals is logically nonsense.

By definition, an antibiotic, natural or otherwise, is supposed to kill bacteria and other microbes. This is why oral antibiotics are usually prescribed for a limited time, because they often cause gastro-intestinal complications: they kill essential gut microbes just as easily as they kill the microbes that cause infection.

For Septoguard, however, things are different. The package insert says you can use it to treat various infections, but primarily, you should take it as a “daily health supplement to boost the immunity”. If you’re taking an antibiotic that you can take every day, indefinitely, without prescription, you’re not taking an antibiotic. You’re taking a placebo with no known action.

The Septoguard insert says is has not been evaluated by the Medicines Control Council. Not that I hold much stock in government bureaucrats. Laws about medicine classification, evaluation and scheduling do not prevent quacks from selling industrial bleach enemas to the gullible mothers of children, who proceed to burn out the child’s intestinal lining, fish it out of the toilet, and post pictures to Facebook, believing them to be the parasites that supposedly cause autism.

But not having been evaluated by the Medicines Control Council (MCC) is an admission that Septoguard has not been tested for quality, safety and efficacy for its intended purpose. One might hope that the makers appealed to a private alternative for scientific testing, but there is no claim whatsoever about the product’s quality, safety or efficacy.

On the contrary. The insert concludes by saying, “This medicine is not intended to diagnose, treat, cure or prevent any disease.”

There we have it. The product’s own insert says it doesn’t work, and is not intended to work.

Of course, this statement exploits a legal loophole. By not claiming to be medicine, it avoids having to be registered as a medicine by the MCC. It does, however, suggest that the maker has no confidence that the substance would pass tests for quality, safety and efficacy.

Yet the University of the Western Cape will teach you all about its scientific underpinnings, and pharmacists will proudly display it on their shelves, lending it a veneer of respectability that real medical practitioners ought to be ashamed of.

Septoguard is, of course, far from the only quackery sold in pharmacies. There are all sorts of diet concoctions, supplements, and “natural” cures for everything that would otherwise cost a lifestyle change or the price of a doctor’s visit. Dis-Chem proudly advertises homeopathic remedies, despite the fact that they consist of nothing but fairy-dust and magic.

As a reminder, homeopathy is pseudoscience. It hasn’t just not been proven to work, it has been proven not to work any better than a placebo. Papers that appear to conclude the opposite (but were actually inconclusive) have been soundly discredited.

Homeopathy holds that “like cures like”. This is, of course, absurd on the face of it. Supporters like to compare it to vaccines (even though they’re typically anti-vaxxers) because vaccines appear to be a scientific case of “like cures like”. But they aren’t, and are nothing like homeopathy. Vaccines have active ingredients in meaningful concentrations. They work to help the body fight disease by training the immune system to respond effectively to pathogens. They cure nothing, and in fact sometimes cause the disease against which they’re meant to immunise. If you have polio, or smallpox, an additional dose of polio or smallpox isn’t going to cure you. It’s going to make it worse. A vaccine would only have helped if you received it before contracting the disease, not after, as a cure.

Homeopathic remedies are made from all sorts of poisons. The reason they rarely kill anyone, however, is because they are diluted so much that none of the original substance is likely to remain present in the solvent, which is usually water or ethanol. (The exceptions are cases in which the dilution was not done correctly.)

To make it effective, and counter-intuitively make each successive dilution stronger, homeopaths vigorously shake it to “potentise” it. This has something to do with the “structure” of water (it has none, on normal timescales), which gives it “memory”. If it did, of course, it would retain “memory” of a lot of stuff other than the ingredients the homeopath intended, like sewerage. If it had any potency at all, it would probably kill you.

There simply is no plausible scientific explanation for why homeopathy might work, and it has never been shown to work in large-scale, randomised, double-blind, placebo-controlled trials.

Herbal and other untested remedies can have actual harmful effects, but homeopathy’s harm lies exclusively in convincing people to forgo real medicine, and becoming sicker or dying when they might have been cured. It ought not to be sold by responsible pharmacies that claim to act in the best interests of their customers’ health.

It is ironic that proponents of various natural and alternative health products so often accuse the pharmaceutical industry of being craven, greedy corporations driven by profit above human health. Sure they are. But every business is driven by profit.

That is true for pharmacies, but also for naturopathic quackery. This junk gets sold to ignorant, gullible or desperate people, with no intention of healing them and every intention of parting them from their money. Most pharmacists will happily sell you both proven pharmaceuticals and untested quackery, because it makes a profit.

But they shouldn’t. When a pharmacist openly admits that some of the stuff on his shelves doesn’t work, and is overpriced to boot, it is unethical to continue selling it to ignorant people, desperate for a cure for whatever ails them.

In fact, the South African Pharmaceutical Council (SAPC), in its ethics rules, says a pharmacist may not advertise medicines “in any manner that is not factually correct; that is misleading; or that harms the dignity or honour of the profession”.

Most natural and alternative remedies, not to mention slimming products, muscle-building products, immune-boosting products, vitamins, and countless other products on the pharmacy shelves, cannot be called “medicine” without being factually incorrect and misleading. A tiny line in the package insert that says it isn’t really medicine is not sufficient to change that.

When there is no credible scientific evidence for the safety and efficacy of a product, and the package insert even admits this, it should not be on the shelves of a respectable pharmacist. It should be limited to the shopfronts of quacks and charlatans. At least when you buy from them, you know you’re not giving your money to someone who claims to uphold scientific standards.

Of course, one could make a law about this, but the law is a blunt tool. And it appears that the statutory SAPC is unable or unwilling to enforce its own ethical rules.

Instead, professional associations or patients’ advocacy groups might compete to issue “ethical pharmacist” certifications, which assure customers that pharmacies do not sell ineffective or even dangerous quackery. It might appear more profitable to do so, but only in the sense that fraud and misrepresentation are “profitable”. In the long run, most people will want to patronise honest professionals for their healthcare.

I, for one, find it deeply troublesome that my medicine gets selected from stock that includes snake oil and magic. This fraud harms people, and ethical pharmacists should see an end to it. DM

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