At 10.23am on January 30, 2010, 400 homeopathy sceptics gathered across the UK to stage a mass ‘overdose’ of homeopathic remedies.
It was an attention-grabbing stunt but one that supporters of the 10:23 movement deemed necessary. The antihomeopathy 10:23 campaign – named in reference to the Avogrado limit, the point at which a substance is so diluted that there is likely to be nothing of it left – was targeting Boots on this particular occasion. Supporters rallied against the multiple for selling what it branded an “absurd pseudoscience”.
The stunt worked: no-one was harmed by taking the volume of medicines that, according to homeopaths, should constitute an overdose. It also raised public awareness of the issue – should a substance with so little apparent effect be sold by trusted healthcare professionals?
Five years on and the question continues to divide the sector. Boots and many other pharmacies across the UK still stock homeopathic remedies despite the Royal Pharmaceutical Society (RPS) rejecting the therapy method due to a “lack of scientific evidence”. It could be argued that patients are entitled to choice, even it is just a placebo – after all, there is flimsy evidence behind cough medicines and other over-the-counter products. But opponents argue that there is a much darker side to buying into the homeopathy industry.
“People have a basic expectation that products on sale at a pharmacy have some degree of evidence for their use, yet I’d wager the majority of pharmacists accept that homeopathic remedies are nothing other than placebo pills”
Michael Marshall, Vice-president, Merseyside Skeptics Society, creator of the 10:23 campaign
A flimsy evidence base
Firstly, it is important to understand exactly what homeopathy is. The treatment method was created by German doctor Samuel Hahnemann in the 1790s and works on the premise that ‘like cures like’.
For example, coming into contact with large amounts of an irritant such as pollen is likely to exacerbate hayfever. But homeopaths believe diluting the pollen with water until a minuscule amount remains and then shaking it will create a substance that can be used to alleviate the symptoms.
In contrast to conventional medicine, homeopathic remedies work on the theory that the more the solution is diluted, the more effective it becomes. Emma Wright, brand manager at homeopathic remedy manufacturer Nelsons, says homeopathy works with the body’s “natural healing processes to relieve symptoms, helping a return to good health”.
The problem is the lack of evidence behind these claims. Critics argue that the ingredients are diluted to such an extent that they no longer remain in homeopathic remedies. And scientific studies have largely supported the view that it is simply a placebo – in fact, an Australian government review of 225 research papers on homeopathy in March concluded there was no reliable evidence to prove its effectiveness.
The review has predictably caused a backlash among homeopathy supporters. Peter Fisher, director of research at the Royal London Hospital for Integrated Medicine in London and the Queen’s physician, is one of those. He believes the Australian government review used “unusual methods of analysis” to reach its damning conclusions about homeopathy – it assumed one trial showing its efficacy was negated by another trial deeming it to be ineffective. In a BMJ article published this month, Dr Fisher pointed to studies in France and Germany that showed GPs who integrated homeopathy into their practice had better outcomes than those who didn’t.
Nevertheless, it is generally accepted among the scientific community that homeopathy has a weak evidence base. Edzard Ernst, lecturer at the University of Exeter and co-author of Trick or Treatment? Alternative Medicine on Trial, has conducted extensive research into homeopathy. His trials failed to show that homeopathy was anything more than a placebo and his reviews of the available evidence led him to the same conclusion.
Professor Ernst accepts Dr Fisher’s argument that some homeopathy trials have produced positive results, but questions the reliability of these studies. “The totality of the reliable trial data fails to demonstrate that diluted homeopathic remedies are effective beyond placebo,” he insists.
Giving patients what they want?
Weighing up this lack of evidence, it prompts the question: why exactly are these remedies still sold in pharmacies? One potential argument – albeit not an ethical one – is the sheer size of the business.
According to the British Homeopathic Association, while it is “difficult to ascertain” how much the industry is worth in the UK, the figure was somewhere around £46 million in 2012. More than 10,000 homeopathic preparations were dispensed by the NHS in 2014, with a total net ingredient cost of £110,400, according to the Health and Social Care Information Centre. Homeopathy can also mean big bucks for those who practise it – an initial consultation with a specialist costs somewhere between £20 and £80, according to NHS Choices.
But supporters are quick to dismiss this image of money-grabbing homeopaths. In fact, Vidhi Patel, homeopathic doctor and research and development consultant at Minerva Research Labs, says many pharmacists are put off stocking remedies because they “can be quite expensive to invest in”.
Rather than financial benefit, Nelsons’ Ms Wright believes the argument for stocking the treatment all comes down to providing “the best care and choice for consumers”. Homeopathy and traditional medicine can be used together, Ms Wright argues – and it would be wrong to completely dismiss something that could help patients. “The high level of repeat purchase is a good indication that consumers believe them to be efficacious, otherwise why would they continue to buy them?” she asks.
There is also another side to this patient choice argument. Sceptics such as Dorset contractor Mike Hewitson (see Why I stock homeopathy, above right) sell the remedies due to patient demand, but use it an opportunity to intervene and suggest a more evidence-based alternative. “If I don’t keep it [homeopathy], then I drive the people straight into the arms of quacks and health food shops,” he points out.
Value of the homeopathy market
Homeopathic preparations dispensed by the NHS in 2014
Total net ingredient cost
The ‘shopkeepers’ debate
It’s a convincing argument, but one that fails to convince all homeopathy sceptics. Michael Marshall, vice-president of the Merseyside Skeptics Society – the organisation behind the 10:23 campaign – says selling homeopathy could jeopardise the profession’s reputation among patients. “People have a basic expectation that products on sale at a pharmacy have some degree of evidence for their use, yet I’d wager the majority of pharmacists accept that homeopathic remedies are nothing other than placebo pills,” he argues. “Until reliable, robust and replicable evidence exists showing a positive benefit of using homeopathy, it should not be given to patients nor sold to customers.”
The University of Exeter’s Professor Ernst also believes the lack of evidence makes it a dubious stock choice. He warns that selling these remedies risks degrading pharmacists to the role of “mere shopkeepers”. If they do choose to sell homeopathy, he stresses that they must avoid pretending it is effective or they will be perceived as “unethical and dishonest”.
The argument makes sense in principle but, in reality, there are many treatments with dubious evidence behind them on pharmacy shelves. So what makes homeopathy so different from, say, a sugary cough syrup?
The answer is the common misunderstanding of homeopathy among the public – as highlighted by the 10:23 campaign website. “Ask many people what they think homeopathy is and you'll be told ‘it's herbal medicine’ or ‘it's all-natural’,” it says. “Actually, it is neither of these. Few people realise that homeopathy involves diluting substances so much that there's literally nothing left in them.”
There is a dangerous side to these misconceptions. Patients may be tempted to buy homeopathic remedies for serious conditions – for example, asthma or high blood pressure – instead of using evidence-based treatment. The BMJ reported that one woman had relied on homeopathy for protection during a trip to Togo in West Africa, which resulted in a serious bout of malaria.
This isn’t necessarily an isolated incident. In Professor Ernst’s book Trick or Treatment? Alternative Medicine on Trial, he and his co-author, journalist Simon Singh, set out to find whether homeopaths would promote their remedies as an alternative to conventional medicine. The answer appeared to be yes. The authors sent an email to 168 homeopaths pretending to be a mother asking for advice about whether or not to vaccinate her one-year-old against measles, mumps and rubella in 2002. Of the 77 respondents, only two advised the mother to immunise.
Given these potential dangers, the debate over stocking homeopathy will remain contentious. The conflict between its advocates and its critics is unlikely to be resolved soon, and there are many complex reasons why pharmacists may stock the remedies.
Perhaps all pharmacists can do is to make an educated decision based on the potential risks and benefits to their patients. Each individual will have their own view on whether selling the products is a threat to their reputation or a tool for educating patients. Ultimately, just as it is for patients to review the evidence and decide what treatment option is right for them, pharmacists must also make a decision about whether they feel comfortable having homeopathy on the shelves.