Opinionista Ivo Vegter 7 May 2018

Ethical Pharmacists: Responding to a pharmacist and a homeopath

Last week, I argued for an “ethical pharmacist” certification for pharmacists who do not sell quack remedies, miracle diets and detox cures. This week, let me consider two of the responses I’ve had; one from a pharmacist, and one from a homeopath. One makes a good point, the other does not.

The brilliant economist Thomas Sowell once wrote: “When your response to everything that is wrong with the world is to say, ‘there ought to be a law’, you are saying that you hold freedom very cheap.”

This is a principle to which I hew closely, whenever I seek solutions to problems. In last week’s column, for example, I didn’t propose banning quackery from pharmacies, but rather, leaned towards a private sector solution that would inform consumers about pharmacists who could be trusted not to endorse homeopathy, natural quackery and miracle cures.

When you see something wrong with the world, not only shouldn’t you say “there ought to be a law”, but you should also consider that there probably already is a law, which causes the wrong you’ve identified.

A pharmacist responded to last week’s column by saying that they do see my point, and agree in principle, but that their business could not survive removing quackery from the shelves. It makes up about half of their business, and importantly, it is not price-regulated. By contrast, prices and profit margins on real medicine are strictly controlled by government.

Pharmaceutical manufacturers are required to sell their products at a “single exit price”, which is set by the Minister of Health. This means that prices cannot respond to market forces, which distorts the allocation of production resources, which inevitably leads to shortages.

This is not just economic theory. This is borne out in practice, with chronic shortages of many medicines in South Africa. Such shortages have been reported again, and again, and again, and again, and again, and again, yet astonishingly, nobody points to price controls as a likely reason for the shortages.

The government, of course, says it isn’t the fault of incompetent government, but the fault of profit-seeking pharmaceutical manufacturers. Apparently, they’re all supposed to be obedient, charitable drones, diverting resources from profitable ventures to instead produce low-margin medicine for governments on demand.

Not even Stop Stockouts, an NGO that highlights medicine shortages, particularly for South Africa’s HIV/Aids patients, refers to price controls as a possible cause in its most recent survey. All they hope for is a more competent government that more effectively controls the production and distribution of medicine. Their naïve ignorance of how government sabotages production would be funny, if people weren’t dying.

When medicines reach pharmacies, at the government-controlled “single exit price”, there is a simple formula that dictates what a pharmacist may charge. According to the Government Gazette of 29 December 2017, pharmacists may charge a “dispensing fee” of no more than 30% on medicines below R120, and no more than R36 on medicines that cost R120 or more.

This is, of course, no basis for running a business. If pharmacists were limited to selling real medicine, all but the largest few corporations – like Clicks and Dis-Chem – would find something better to do to earn a living. Those large incumbents, of course, welcome all this price control nonsense. They know that it drives or keeps smaller competitors out of the market.

In a survey of pharmacists, reported in a research report by Wits MBA candidate Daleen Pretorius, 73% said they were reacting to price controls in medicine by identifying alternative opportunities where prices are not regulated. That, inevitably, means selling “alternative health” products. Whether or not they work is not important to the survival of the pharmacist; what matters is that they can sustain the business now that the government has destroyed the profitability of real medicine.

Chronic medicine shortages, destruction of small pharmacies in favour of large chains, and a plague of profitable quackery, are the results of government’s ill-advised intervention in the market to make medicine more affordable and accessible to the poor. As always, good intentions pave the road to hell.

The pharmacist, for whom I have a lot more sympathy now, suggested that pharmacies might be convinced to create aisles with preparations that are “not endorsed” by the pharmacist in their professional capacity. This would enable them to sell profitable rubbish to counteract the disastrous impact of the government’s medicine price controls, without implicitly endorsing quackery. I think that’s a great idea.

Another reply came from a homeopath in private practice, who took up the defence of homeopathy. He suggested I visit a website that would set me straight, “in the interests of balanced journalism”.

My first reaction was that there is no need to seek a balance between fact and fiction, science and magic, medicine and quackery. Homeopathy is so obviously anti-scientific nonsense that it does not merit being taken seriously as an alternative.

But he kept at it, saying, “It is understandable that homeopathy is difficult to explain in terms of biochemistry, but the following pharma drugs have unexplained mechanism of action.”

He also quoted Arthur C. Clark: “Magic’s just science that we don’t understand yet.”

Well then. Should we accept all claims of magic as science we just haven’t got around to understanding yet? Shall we classify astrology, telekinesis, auras, palm reading, psychics, reincarnation and religious miracles as science?

This is obviously absurd. Clark was exceedingly curious and open-minded, as befits any scientific mind. He not only speculated about future technology (about which he said, “any sufficiently advanced technology is indistinguishable from magic”), but also about the paranormal. However, his investigations turned him into “an almost total sceptic”. He would have been appalled to find his words employed to justify credulity about pseudo-scientific claims.

It is true that there are pharmaceuticals with unexplained mechanisms of action. But first, unlike homeopathy, their action is well-founded in rigorous, large-scale, randomised, double-blind, placebo-controlled trials, which strongly suggests that there actually is a mechanism of action. And second, their mechanism of action might not be explained, but it is not unexplainable.

With homeopathy, by contrast, the claimed mechanism of action is not explainable in terms that are consistent with the great body of science that humanity has developed. It requires believing that increasingly weak dilutions actually make a compound stronger, that water has a structure that remembers the shit that’s been in it long after it is gone, and that disease is caused by “miasms”.

It isn’t just a case of not knowing how it works. It cannot possibly work as described, and many of the claims about homeopathy are, demonstrably, provably false.

As with any other pseudoscience, practitioners of homeopathy try to pass it off as scientific, but just not well understood. But that does not accurately describe it. To discover why, let’s go to that website the homeopath recommended, for the Homeopathy Research Institute (HRI).

The main purpose of this website is to highlight research that appears to support the effectiveness of homeopathy, deploy clever rhetoric against the most common criticisms of homeopathy, and attempt to counter major studies that find homeopathy is ineffective.

Consider, for example, their answer to the frequently-asked question, “Scientists say homeopathy is impossible.”

Like every other “FAQ” on the site, including the one with a double question mark for emphasis, it isn’t actually a question. Who cares about the accurate use of language when you’re promoting a pseudo-science?

They appeal to a single scientist, Luc Montagnier, who did jointly win a Nobel for discovering HIV, but also did some extremely controversial work on “electromagnetic signals from DNA”. Although some of this work appears to support ideas in homeopathy, and he appears to support the ludicrous idea that water has memory, Montagnier himself said one “cannot extrapolate [his work] to the products used in homeopathy”. None of his research on this subject is supported by any accepted scientific theories, and none of his experiments have been replicated. He most likely is an example of a scientist who is wrong. It’s not unheard of, you know.

The homeopaths might have defended themselves against claims that this is just a single crank by citing a whole lot more cranks, but instead, they appeal to surprising results in science, such as the theory that ulcers are caused by bacterial infection, which at first was ridiculed.

They ignore, of course, that it was not ridiculed because there is no known mechanism of action, or because the theory contradicts existing scientific principles. It was just believed to be wrong. When it was proven to be right, science turned on a dime, and showered the scientists with praise.

What made the ulcer bacteria discovery so notable is that this sort of thing happens rarely. It doesn’t mean that every claim that contradicts accepted science can be assumed to be a great discovery that has yet to be recognised.

In answer to the question (or rather, statement), “You can’t explain it”, they argue that a known mechanism of action is not a prerequisite for using a medicine. This is, of course, trivially true, and there are indeed (as we’ve seen) medicines for which we do not know a mechanism of action. But with homeopathy, unlike conventional pharmaceuticals, nobody knows how any of it works. That is an entirely different class of problem than the fact that we didn’t know how aspirin worked in 1900.

In answer to the claim that homeopathy is unproven, HRI retorts that some regular medicines are unproven too. To the extent that this is true, it is not a defence of homeopathy. It is, rather, an indictment of some conventional medicines. Whether or not those medicines work is not relevant to whether or not homeopathy is effective.

The HRI goes on to say that unlike conventional medicine, homeopathy is a “relatively new field”. It repeats this claim several times on the website. However, this is outrageous nonsense.

Homeopathy is 222 years old this year. It predates modern pathology by 60-odd years. If after more than two centuries in the modern scientific era you cannot prove that something works, or how it works, you’re probably selling quackery that doesn’t work at all.

In answer to the criticism that homeopathy research is of poor quality, it cites a 2005 study that finds shortcomings in conventional medicine trials too. Again, this is hardly a defence of homeopathic research.

Amusingly, however, it neglects to add the interpretation the authors give of that study, which totally undermines homeopathy:

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.”

The HRI website contains a database of over 1,000 clinical trials that, supposedly, support the use of homeopathy. I do not have the time, the inclination, or the expertise to evaluate them all critically. But others do, and have done so. This is why the HRI website prominently features “The Australia Report”, because it does not like that report’s anti-homeopathy conclusions.

The Australia Report is a comprehensive investigation by that country’s National Health and Medical Research Council, published in 2015, into whether homeopathy is effective as treatment for health conditions.

It concluded: “Based on the assessment of the evidence of effectiveness of homeopathy, NHMRC concludes that there are no health conditions for which there is reliable evidence that homeopathy is effective.”

The HRI criticism amounts to complaints that it was unfair to exclude small trials, or trials that could not be replicated, or trials that were of insufficient quality. Its rebuttal is full of rhetoric and irrelevance, but devoid of substance.

Notably, the very study cited above, which the HRI claims supported the use of homeopathy when it explicitly did not, also found that “smaller trials and those of lower quality showed more beneficial treatment effects than larger and higher-quality trials”.

This was not the first study to conduct a systematic review of the evidence. In 2010, the UK House of Commons Committee on Science and Technology concluded:

In our view, the systematic reviews and meta-analyses conclusively demonstrate that homeopathic products perform no better than placebos.”

An earlier paper was published by Edzard Ernst, the world’s first professor in complementary medicine, in the British Journal of Clinical Pharmacology in 2002. It reviewed all the existing systematic reviews, and found that a single positive result that had been touted by homeopaths was not supported by any of the other results. A notable conclusion, pre-dating the 2005 study cited above, is that the more rigorous the trial is, the smaller the effect size it finds.

Collectively they failed to provide strong evidence in favour of homeopathy,” wrote Ernst.

In particular, there was no condition which responds convincingly better to homeopathic treatment than to placebo or other control interventions. Similarly, there was no homeopathic remedy that was demonstrated to yield clinical effects that are convincingly different from placebo. It is concluded that the best clinical evidence for homeopathy available to date does not warrant positive recommendations for its use in clinical practice.”

So we have two responses, one by a pharmacist, and one by a homeopath. One makes a good point in defence of selling quackery, even while it admits that it is quackery. The other claims not to sell quackery at all. I know which one I find more credible. DM

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