St John's Wort and why it scares me, despite the fact that it works.

Hi all,

It's lovely for once to be able to write about something that works, instead of something which has little to no evidence of it working. However, I wanted to share with you some reasons why I would tend to steer people away from a "natural" remedy, despite the evidence being positive. Why St John's Wort today? Well, my RSS feed today popped up with:

31/12/2012
Daily Telegraph
By: Presswatch
GPs prefer herbal remedies to Prozac, says survey
A survey by Schwabe Pharma found that GPs are increasingly likely to prescribe herbal remedies such as St John's wort for depression rather than Prozac.	(

(http://www.presswatch.com/health/index.php?d=2012-12-31#3)

I haven't been able to find the actual story, or the press release from Schwabe Pharma (who, incidentally, produce St John's Wort, so wouldn't be without bias), but it got me thinking anyway.

Is it because of a big pharma conspiracy? Is it because I'm in cahoots with the evil drug companies and all I want is money? Is it because I'm just too close-minded to be able to accept anything other than conventional medicines? Is it because I love seeing patients suffer? Well, in short no.

I find herbal medicines really interesting. Unlike homeopathy, which has no theoretical possibility of working, herbal medicines contain plant material with high enough levels of chemical constituents to cause a pharmacological effect. There's something quite beautiful about the concept of using plants for medicinal purposes. The problem with them lies in the fact that there just aren't enough studies done for us to be able to say whether they work, or more importantly, whether they harm. Whilst herbal remedies have enough "medicine" in them to make them work, this also means they have enough in them to cause adverse reactions, to interact with other herbs, medication, illnesses and so on. Without Big Pharma funding, though, its not that likely that large, well designed trials will be undertaken on them, so using herbal medicines can be a bit like shooting in the dark. Even if we don't find any documented issues with a herb, this doesn't mean none exist, it may just mean that nobody has looked at (or published) any issues yet.

St John's Wort is different. There is now a pretty large body of evidence to suggest that it works, and that it works better than placebo and as well as conventional antidepressants like the SSRIs. We also know a fair bit about its interactions and its adverse drug reactions... So that's great then, yes? That means healthcare professionals should all consider it as a better choice than the conventional medicines, with all their nasty side effects etc, right?

Well, in my opinion: not always. Whilst we know a fair amount about it, the problem here lies with production, and the inherent variability in herbal medicines. Because they're made from plant materials, there can be a huge amount of variability in what each tablet contains.. Even if you're using a product licensed under the Traditional Herbal Registration scheme, there can still be variability between each batch, depending on where the plant was grown, the time of year/ day it was harvested, and what it was treated after it was harvested. So, if you get stabilised on one batch of medicine, the next batch may contain differing amounts of active ingredients, which could mean a whole host of things might happen: it might work better, it might start interacting with your other meds, it might trigger a side effect etc. Then, just when you're getting used to that batch, the next one is different too, etc etc.

I've come across a few enquiries where a patient wants to use St John's Wort as add-on therapy along with their antidepressants. It maybe doesn't occur to the patient or their GP/pharmacist etc that it actually works in a very similar way to a conventional antidepressant. Combinations of antidepressants are usually only done under specialist care (with a few exceptions) because combining them increases the risk of some very severe side effects such as serotonin syndrome- the same applies to St John's Wort. The fact it's "natural" seems to blindside people into forgetting the usual principles of how medicines work.

This is before we even get into the territory of risks associated with self-treatment of what can be a very, very serious disease. Would I exclude use of St John's Wort entirely, for everyone? No, because it does appear to work. But do I treat it with as much (if not more) caution than I would an SSRI? Yes, because there's still not that much information about its safety in the grand scheme of things. So this sort of negates the point of it, to be honest.

Hopefully that explains a bit about why I'm cautious about herbal medicines.

Have a lovely New Year's Eve folks, see you again in 2013. 

Halotherapy: the return

Ages and ages and ages ago I wrote an initial blog post on halotherapy (salt cave therapy), and i promised you a follow up once I have looked at the available data for it.

In short, I always meant to get round to following it up, but kept forgetting or getting embroiled in something else instead. So here, dear friends, is the follow up post.

As you may recall, www.saltcave.co.uk were claiming their clinically tested, drug free treatment meant that many of their patients stopped taking their medications becuase they because symptom free. They claimed it would work for asthma, COPD, and sinusitis. So, I thought I'd test their claim for COPD, particularly since this illness can be particularly devastating and debilitating.

So here's what I did: had a look at their website, which attempts to helpfully provide a list of published studies. I the proceeded to ignore this entirely, and did my own search of Medline and Embase, the two leading medical literature databases in the world. If there was going to be any robust evidence, I would find it in those.

Now I'm interested in human clinical studies mainly as a starting point, because these are the ones that can actually tell us best whether or not something works. So I limited the searches to human trials: after all, The Salt Cave are claiming that it's a clinically tested therapy, right? I then combined the results for halotherapy, with results for chronic obstructive pulmonary disease, to see what would come up.

In Embase, I found one study. Unfortunately, it was in Russian, so I have to rely on the abstract. The study included 29 patients, and that's pretty much all that we know. The authors claim a significant positive effect, with no other information or data reported in the abstract. But frankly, a study with 29 patients in is neither here nor there- it's far too small to use to make any claims of benefit.It's worth noting, by the way, that these patients were in a "sanatorium" setting, which is likely to be a rather different setting to the middle-class-Ikea-£35 a go-UK based version that is being sold here. What other treatments would be given in a Russian sanatorium setting? How would any of this affect the patient's condition? How has this been controlled for in this study? Unfortunately, there's no way of knowing given how badly presented the abstract is.  

Okay, so what did I find in Medline? Well, in short, nothing. No results at all.

So then I went back to the references provided by www.saltcave.co.uk and found very little to add. Another Russian-based sanatorium study, in abstract only, providing no data at al. Likewise, the study that they use on the "results" page of their website only include 26 patientswith COPD: again, too limited to draw any secure conclusions from.

So my conclusion? The evidence for the use of salt cave therapy in COPD is far too limited to claim any benefit at this point in time. More research needs to be done in this area to be able to claim that it works. And this evidence base certainly doesn't justify £35 per hour. They can put as many testimonials as they like on their website but it still doesn't add up to good, robust clinical evidence.

Hopefully this is a step to debunking some of the claims they are making on this website. Whilst there is a possibility that it might work, at the moment we just don't have enough information to justify the claims- and the cost.

Further reading on halotherapy can be found at The 21st Floor and Sceptical Letter Writer

For transparency, here's my search terms:
EMBASE: halotherapy.ti.ab AND Chronic obstructive ling disease/ 
MEDLINE: halotherapy.ti.ab AND Pulmonary disease, chronic obstructive

Christmas Dinner Conversation: An Anecdote

Hi all,

Hope you all had a lovely festive period, whatever religion (or lack of) you may follow.

I spent christmas day with my parents and remaining grandparents, and thought I'd regale you with the tale of part of our christmas dinner conversation.

Having been asked what I was doing in life at the moment, one of the things that was mentioned was the Newcastle Skeptics in the Pub talk that my good friend and Helper Dog Nancy and I are doing in February. This prompted Mum to state that she thought that homeopathy might work, after all plants had been used for many years in medicine. Now, I have written before about the case of the magic crystals, and do remember mum trying homeopathic remedies on me as a child (out of desperation due to my awful car sickness. Out of interest, I also remember them not working) when I was a bit older, so this stopped me short. I do have a suspicion that the majority of users of homeopathy have little knowledge of how it is made, and therefore no idea how unreasonable it is to expect it to work. And here was living proof that this was, indeed the case. Dad was aware of the like-cures-like principle, but they had no idea at all of the serial dilutions used in homeopathy.

Cue a demonstration (involving wine), and an explanation that beyond 12C there is virtually no likelihood of any molecules of the "active" ingredient appearing, and the general consensus was that they were amazed at this turn of events, and couldn't understand how on earth it could work and how anyone could possibly be taken in by such nonsense.

And so it seems to me that a general lack of good information about what homeopathy is, and what the principles of it are, may well be responsible for the majority of people who may believe it still works.

What do you think? I wonder if there is any way to measure this? If you have any ideas, do give me a shout.

H x

A Call To Arms: Pharmacists should call for Open Data

Pharmacists of the world, unite and take over.

Pharmacy has been hit hard over the past few weeks. We've had MPs accusing us of being smartie counters, and a badly written BBC News expose implying that we are all merrily dealing benzo's to make a quick buck. (I may attempt another blog post on this at some point)

I believe that historically, pharmacy has drawn the short straw. In my opinion. our professional body, the Royal Pharmaceutical Society, seems to lag behind other bodies when it comes to media savviness, and it often feels like we have very little impact or voice when it comes to the healthcare profession as a whole. Even now, its still a rare occastion that a pharmacy-related story will actually have a pharmacist commenting on it in the news- GPs, doctors and nurses are simply much more vocal and recognisable to an audience.

But here is an opportunity, and it has been handed to us on a silver platter by Ben Goldacre and the BMJ. I'm sure you may have heard by now, but there is a pretty large campaign on the go to allow for more transparent reporting of clinical trial data. This has been prompted by the case of Roche's Tamiflu, but its wider implications on patient safety and care are huge.

All the information you need about the BMJ's Open Data campaign can be found here. 

Today I tweeted Ben Goldacre to ask what involvement there has been from the pharmacy bodies. The answer? A big fat zero. There has been no involvement at all, from any of them.

So here is my call to arms. If you are a pharmacist, or if you are affiliated with the pharmacy profession, lets contact the RPS, the GPhC, NPA, PSNC, and anyone else who will listen. Lets tell them how important this is to us and how we want them to represent us and get our voice heard.

After all, to be experts in medicine, we need to have access to information about medicine. And that information has to be accurate, reliable, accessible, and unbiased. Without open data, we simply cannot do our jobs properly or with the degree of safety that we would like to. It may seem like a trial not being published is far removed from handing over a prescription to a patient over the counter, but the fact of the matter is that patients are dying due to the lack of transparency. How can we counsel a patient on side effects, for example, when patient level data from trials has been withheld? How can a patient be prescribed the best medicine for their condition when most of the trials involving the drug haven't been published?

Moreover, what a great way to represent ourselves as a profession who, more than anything, care about the health- and safety- of our patients, and who are willing to speak up when it counts. What a fantastic opportunity for our professional bodies to prove what they can do.

H xxx

The importance of being human

The more I talk to homeopaths and other alternative medicine practitioners, the more I realise that the distinction between in vitro and in vivo testing is unclear to many.

It may be due to ignorance, or it may be in a desperate bid to pad out the lack of real-life clinical evidence, or to stun us all into silence with impressive looking sciencey stuff, but it seems that alternative medicine supporters are desperate to throw in vitro studies my way as "evidence" that their treatments work. But here's the thing: it's not evdience that it works at all. In fact, for the purposes of informing treatment decisions, any in vitro data might as well be discarded before you even bother reading it.

Why do i say this? Well, the easiest way to explain this is in picture form (drawings are courtesy of my marvellous friend Haymond Lam) :

Figure 1: A Petri dish, with some cells in it. (in vitro)

Figure 2: A human being  (well, okay, I know some people might think scientists aren't quite human beings but, y'know, we thought we'd still use one as an example). (in vivo)

As you can see from these pictures, a few cells in a petri dish actually look (and act) rather differently to a functioning, whole human body. So positive (or negative) results in an in vitro study actually bear very little resemblance to real life clinical situations. What  in vitro testing is great for is as preliminary evidence- to make new discoveries and to guide further research, and to find out the all-important details of how something may work. But we can't use some cells in a petri dish to say "Yes, this will definitely work for this or that illness". The only sort of evidence that we can use to decide if a drug is effective in any particular illness is a robustly designed clinical trial, and even then we can't use that as a cast iron guarantee.

I'm hoping that you will forgive me for this horrendous oversimplification, but it is hopefully a useful point to make. So, the next time you come across some in vitro studies being used as "evidence" that homeopathy works, you know that they're actually scraping the barrel, particularly gievn the fact that homeopathis is supposed to have been around for 2000 years. I'd expect after that amount of time that they'd have more than cell culture studies to their name.

H x

Alternative medicines and brain tumours

There's been a lot of press attention in recent days about the case of  Neon Roberts, whose mother had apparently ran away with him in order to avoid him being given post-surgery radiotherapy.

I will admit at this point that I haven't looked too closely into the case. I'm writing this on my lunch break so don't have time to go into all the details, but it appears that after being found, Neon has been taken into foster care and has been given the treatment he requires.

If the press reports are to be relied upon (and bear in mind my main source is the Daily Fail), this seems like a striking case of the sort of harm misinformation about alternative medicines can cause. Reportedly, the mother only wanted him to receive "natural remedies" as he recovers from his surgery. The implication is that natural remedies would be safer for the child, whereas conventional treatments like radiotherapy and chemotherapy are evil, toxic poisons.

And yet this distinction between "natural" and conventional medicines is highly blurred, particularly when it comes to chemotherapy. Some of our most powerful (and potentially toxic) chemotherapeutic agents are derived from plants- the taxols for example. Ultimately, the main difference between these agents and alternative medicines is that they have been tested and have been proven to work. If other natural, alternative medicines went through the same testing processes and also had positive results, they too would cease to be alternative and would become conventional medicines. Radiation, similarly, is an ultimately natural process. So how do the public at large decide what constitutes a "natural" remedy? We can see from this case the potential consequences of such misinformation.

Another thought that occurs to me is the distinction between complementary and alternative medicines. I think we can all agree that there is a potential benefit from some natural remedies for some cancer-associated symptoms or problems. So as an example I have no problem with a patient who decides to try a herbal remedy to treat say anxiety alongside their conventional treatment, providing they are doing so with a knowledge of the pros and cons of the treatment, and with their healthcare provider's knowledge. Complementary therapy, in other words. What's infinitely more worrying is the concept of alternative therapy, e.g. where a patient makes a decision to not use conventional medicine but to use a herbal remedy(or homeopathy, or acupuncture etc) instead. The evidence base for alternative medicines is absolutely nowhere near the level required to justify a patient using them instead of conventional medicines for something as serious as cancer.

And this brings me on to homeopathy. Yes, homeopathy again. I'm not going to cover how homeopathy works, as its been done much better at this site: http://www.howdoeshomeopathywork.com/ . What is particularly worrying about this modality is the advice given that conventional medicines need to be avoided to allow the homeopathy to work. This is bandied about in an inocuous sort of a way by websites such as this. So, by recommending a homeopathic treatment for a serious condition, homeopaths are directly harming their patient by encouraging them to not take conventional medicines (which may have a chance of working at least) and to replace them with Magic Woo Memory Water Sugar Pills (which have zero chance of working). One of the most heart-breaking things i have ever read on the internet are the letters of Penelope Dingle to her homeopath, who treated her pancreatic cancer. If you haven't seen this already, I highly recommend that you have a look, but warn you that it is likely to induce tears, then rage.

I've noticed that a few homeopaths on twitter have already picked up on the story of Neon Roberts, and are gleefully tweeting things like "UK Boy to Be Forced Into Chemotherapy" (forgetting the fact that it's actually radiotherapy that he will be receiving). Of course I'm Not Actually A Doctor Nancy Malik is involved. So I thought I'd have a look at what evidence there is that homeopathy can treat brain tumours, before they all start claiming that it can. So I've checked Medline and Embase, the leading medical literature databases in the world. My search stratedy was: Search for homeopathy. Search for brain tumours, and limit to therapy or treatment. Add the two together. See what comes out.  Makes sense, right?

So here are the results for EMBASE (links are only available to athens users):

	1	EMBASE	*HOMEOPATHY/	4263
	2	EMBASE	BRAIN TUMOR/dt, th [dt=Drug Therapy, th=Therapy]	7758
	3	EMBASE	1 AND 2	0

And here are the results for MEDLINE:

	1	MEDLINE	HOMEOPATHY/	3941
	2	MEDLINE	BRAIN NEOPLASMS/th [th=Therapy]	7433
	3	MEDLINE	1 AND 2	0

Now, you don't have to be an expert in literature searching to realise that that's a bit fat zero.

I'm Not Really A Dr Nancy Malik, however, has other ideas, and has helpfully sent me links to 4 sources that she claims are evidence that homeopathy can work in brian cancer treatment. Three of which are studies looking at  tissue cell culture, and one of which is for treatment of side effects (ergo as complementary, rather than alternative therapy, and which bears no resemblance to whether or not it could actually treat a brain cancer). The in vitro studies are very interesting i'm sure, but to use them as evidence that homeopathy can treat brain cancers in humans is an enormous stretch. With something so serious, would you really be willing to base a treatment decision on what happens to a couple of cells in a lab? Or would you rather base it on what happens to thousands, if not millions of other people in real-life? I know which one I would go with.

One other footnote to this news story is one which I fear may have been forgotten about. Imagine being a child, who has just undergone surgery for a brain tumour. Imagine the fear this poor boy feels on a daily basis, not to mention how physically ill he may be. Now imagine being taken by your mother on a trip elsewhere, then being taken into foster care and having to be given radiotherapy, whilst a court case battles on around you. I can't even begin to imagine what this child is feeling. This time would have been bad enough for him as it was, without any of this being added onto his trauma. 

A quick thought on some complementary medicine modalities

Hi folks,

I'm working on a little project about complementary and alternative medicines- a quick reference guide to the most common modalities, and how they differ in effectiveness, safety, theories etc. I've been using the Natural Medicines Comprehensive Database- a great (but unfortunately rather expensive) site for balanced, evidence-based information on alternative medicines- for information on different modalities, and I came across a statement that I hadn't considered so far, but one which I think may actually be quite persuasive to some when it comes to alternative medicine. It's quite simple, but the thought just simply hadn't occurred to me before.

This is the fact that  a lot of modalities were developed prior to any sort of scientific knowledge about how the body works, or pharmacology. For example, homeopathy was developed at a time where it was thought "humours" were to blame for illness- a time where blood-letting was treatment of choice for much sickness. And as for Traditional Chinese Medicine (TCM), developed over 2000 years ago:

"At that time there was no scientific concept of disease or pharmacology in terms that can be related to our modern understanding of medicine. Therefore, the principles of TCM were formed based more on philosophy than on science"

The same goes for Ayurvedic medicine as well.

So, on this basis, why should we believe that any of these modalities are scientific, or likely to work? How can homeopathists, for example, claim that it is "science-based medicine" when it fact it predates the science of medicine?

Why, in days where calculators are easily available, should we be expected to believe that using an abacus will be more effective and safer?

H xxx

Thoughts on a child-free life

In my initial post, I said that I would mainly be blogging about skepticism in healthcare. Well, it turns out that I'm actually more able to churn out random nonsense about other -occasionally rather deep- aspects of my life more easily. And, as i'm getting more involved in skepticism as a whole, it's amazing to me how it's touching all the other aspects of my life as well, reinforcing vaguely held ideas and making me much more able to express my views to other people.

The other night I was at a bit of a 'do at a friend's house, and I had a conversation with one of my friends who I think is absolutely brilliant but I don't see that often in which I found myself employing some skeptical skills unexpectedly. The conversation was about the thorny issue of children.

So, here we go. I don't want children. Here is the standard conversation that I am used to pretty much every time these words leave my mouth:
Other Person:  "Oh.... OH?! REALLY?"
Me: "yes, really"
Other Person: "what, ever?"
Me: "no, never. At least I can't see myself ever having a space or need in my life for them in the future"
Other Person: "But you don't know what you're missing!"
Me: "yes, yes I do, thank you very much."
Other Person: "but it's different when it's your own"
Me:  "I'd rather not take the chance that it isn't"
Other Person: "oh, I knew someone (or alternatively, I used to be) just like you. And they (I) went on to have 20 kids and they (I) love them to bits."
Me: "umm, right. Well I don't think that's going to happen here"

And so it goes on, time after time, as if one day, during one of these generic conversations, I'm going to go "actually, do you know what, you're RIGHT!, I'm off to procreate RIGHT NOW"

I actually believe that the idea that you'll have children is very similar to religion, in that it sadly often doesn't even occur to people that there is an alternative option. It's just accepted as routine that you'll grow up, you may get married, and you'll have kids. I doubt many people ever think to challenge this notion, and as a result I think a lot of people don't address their own concerns about becoming parents before they do, and I'm sure this is a source of great angst and sadness in the world today.

I'm often confronted with a momentary look of blatant hatred when I confess that I don't want kids to people, before they get the chance to rearrange their face.  I sometimes get the feeling this may be a "hey, damn, I wish I'd thought of that!" reaction. Sometimes I see people over-enthusiastically posting on Facebook about how marvellous their kids are and I really can't tell who they are trying to convince.

My friend has found herself having to think about whether or not she wants children, because other people are constantly forcing her to think about it. Because she's been with her boyfriend for a prescribed amount of time, the "when are you getting married, when are you having kids" conversation is being thrown at her regularly. We talked for a while and it seems she's inclined to think she doesn't want them, but its such a social norm that she almost can't believe that this could be an option for her.

As you'll know from my previous post about atheism, I agree very much with Alom Shaha's notion that atheism needs to be more visible as an option to stop a lot of misery. I think similarly about not wanting children. I'm told I'm selfish for not wanting them, that I'm abnormal, that I'm somehow doing my gender and humanity a disservice. And I am selfish, but is it not more selfish to have a child because its simply what you do, then potentially spend a lifetime suppressing low-level regret and resentment? I could start on about overpopulation, blah blah blah but that's usually just too much effort for these types of conversation.

It strikes me that, like a lot of things in life, most people take this decision on face value instead of examining it with skeptical principles. And, after questioning yourself and your deeply held beliefs and societal norms, you still want to go ahead, then fine, I sincerely wish you all the best. It seems to me that a healthy dose of skepticism- in all aspects of life- is always worthwhile.

Like atheism, I've confronted my lack of desire for children, and I accept and embrace it, even in the face of some moments of fairly serious pressure to the contrary. I have no need or space for a child in my life, and I can make my own purpose and legacy without having to create and drag a new life into the equation. I'm comfortable with my decision, I just wish that everyone else was as comfortable with it as I am. Comfortable enough that the sort of conversations above- that I and many other child-free people (by which I mainly mean women) have to go through all the time- don't have to happen anymore. Comfortable enough that its an accepted life decision and not seen as an eccentric quirk.

I could rant on for days about this subject, and I may well revisit it in future posts. I hope that's not too boring for you.

H xxx

A childhood story

I was a fairly robust, risk averse nipper. But, like all kids, I got the odd sniffle and sickness now and then. And, like most parents, my Mum would usually take me to see the doctor when I was poorly.

I have a really vivid memory of going to see the doctor. He was a kindly, soft-spoken chap who, as I recall, had a caring manner. And what I remember more than anything was his large leather case, filled with pastel-coloured vials of what he described as "magic crystals".

Depending on what was wrong with me, I was able to choose from a selection of colours of "magic crystals", which were then administered to me and which, in my head, made me feel a bit better. I think I only got one dose, when I was there in the surgery. Neither my mother nor I have any recollection of me taking home any "magic crystals" or having repeated doses.

Now, here's the thing. At no point did my dear darling mother actually bother to ask what the "magic crystals" were. We now assume (hope!) that they were some sort of homeopathic thing. They definitely looked like coloured sugar crystals and tasted like sugar. Or were they some sort of elaborate placebo designed to soothe children into believing they felt better? Or were they some suspicious hallucinogens? The point is, at no point did my mother think to question the doctor: he was in a position of caring authority and he knew best what would make me better, right? And from my perspective, a nice, caring man who my mother had trust in was letting me pick pink sweet-tasting crystals so YAY GIVE ME THE SUGAR!

Out of interest, my memory is that yes, magic crystals did make me feel momentarily better. But this is a vague memory, which may well have been clouded by nostalgia and the many years that have since gone by. why could this have been? Well, power of suggestion and placebo. As a child I knew doctors made me better: ergo, I felt better when I was at the surgery seeing the doctor.

We hear a lot about patient choice in debates about homeopathy. I guess my point here is that this doesn't always come into the conversation with patients or their carers, and that's worrying. Admittedly it was longer ago than I care to admit, but I'm pretty sure similar practices go on today. I really do hope that medical homeopathists do allow their patients more informed consent, and I also sincerely hope that all homeopathists do the same. But they can't offer them full informed consent because the data isn't there to back up their claims, or they have misunderstood the data that is there, and most importantly, the science and theories don't make sense. What sort of benefit vs risk decision can happen for a patient when they simply pick up a pack of arnica 30C from the shelves of Boots?  What kind of choice was my mum able to make when it didn't occur to her to ask any questions, and no explanation was forthcoming?


Health care professionals have a duty of care to their patients. A large part of this is about communication. What homeopathists (and herbalists, and traditional chinese herbalists, and halotherapists, and anyone else who purport to change people's health) need to realise is that, in the eyes of the public, they hold the same amount of trust and duty of care. And even if regulatory bodies aren't in place to take you to court if you harm someone, your personal morals should step in before you sell a remedy made merely of hope for monetary gain.

The air is nice up here on the moral high ground.Of course, it could always be the case that it's actually just the mind-altering effects of whatever mind control agents were in the magic crystals....

H xxx

Domestic Abuse? Treat it with Magic Water!

Its safe to say that quacks, by the very definition of what they do, just love a vulnerable person. But even so, it makes me incandescent with rage every time I see an example of it occurring.

Tonight, my naively skeptic self has been utterly taken aback by a tweet I've seen. It was retweeted by "I'm-Not-Really-A-Dr" Nancy Malik, who I have had some dealings with in the past. These previous dealings basically revolved around a discussion about what constitutes high impact journal evidence (i.e. pointing out that books are not actually journals). This culminated in me (rather generously) offering my evidence retrieval services for any future posts she wanted to write. Homeopaths, don't say I never offer you anything.

So tonight, what's made my blood boil is this post. Homeopathy for domestic violence. HOMEOPATHY for domestic violence. Homeopathy for DOMESTIC VIOLENCE.... etc etc.

I count myself very lucky that I have never personally had any experience of domestic violence. I don't pretend to know how it feels for the many men and women who do experience it, and whose lives are relentlessly ruined by such a crime. And a crime it is, there's no two ways about it. It may have multifactorial causes, some of which may be illnesses, but, certainly in the UK, it is very definitely considered a crime. 

I'm going to attempt to be as systematic as possible here, but frankly I'm so furious I think I'm going to find it hard to collect my thoughts in any sort of semblance of order. But anyway, here goes:

So how can homeopathy help, according to "I'm-also-a-fake-Dr" Binal Master? Well, first of all: "It involves a detailed case history, which serves as ray of hope to both the patient- i.e., the one who is abused, as well as the offender. The patient has an opportunity to be heard and understood from her own perspective"

Ok, do you know what? I sort of agree with some of this. The opportunity to raise concerns in a safe place to someone who is listening is great. However, that safe place should be with someone who a) isn't being paid for a consultation b) isn't likely to make money from any recommendations they make c) is properly trained in dealing with domestic violence and d) ideally should be the police, or a specialist service who are able to give protection to vulnerable people.

Apparently, anger management (along with yoga, meditation etc) are available as adjuncts to homeopathy. ADJUNCTS?! Don't you think that anger management therapy would be rather more important than an add-on? This suggests to me- and it could be how i'm reading it- that homeopathy ON ITS OWN can feasibly be used to treat both victims- and perpetrators- of domestic violence.

The article goes on: "Some cases are due to psychiatric disorders such as antisocial personality, bipolar disorder or schizophrenia. Homeopathy has been found effective in such cases also, where it gives people a second chance to adapt to society and live within the community ."

Agreed, some cases can be due to a variety of mental health disorders. Has homeopathy *really* been found to be effective in these cases? I haven't checked right now, but I'm willing to bet there's no robust RCTs proving that homeopathy treats biploar for example. Are these sentences suggesting that homeopathy on it's own can treat these issues? Because I don't see anywhere suggesting that this is alongside conventional medicine. So now we've potentially got a situation where a person with a very serious mental illness is causing harm to another person (not to mention cases of self-harm), being treated with magic woo-water alone. This puts everyone in that situation at potential risk.

The post goes on to give handy tips for what people should do in the event of domestic violence, including not isolating yourself, asking for support, and seeing a doctor. Now, this is all very well and good, but I think we've missed out one rather important step here: what about the police? what about getting yourself out of a potentially dangerous situation as soon as possible? At no point is this suggested, and the general gist of the article appears to be "but it's happening for a reason, so let's treat the reasons and see if it stops". Actually, no. GET YOURSELF SAFE first. If there are reasons, then yes they should be treated, but this is secondary to the safety of anyone who is in this situation, for whatever reason. 

Summing up, "Dr" Master states:

"Homeopathy is a safe and effective way to treat the victims as well as the culprits of domestic violence. It focuses on the way patients have reacted to events and the personality of the patient. It helps to bring complete harmony of physical, mental and social well being."

It's safe, is it? It's safe to treat violent people with an inert substance, and to suggest that the victim treats themselves with inert substances in the meantime, in the vain hope that whoever is being violent will eventually change? Is it effective? What evidence is there for this effectiveness, because there are no references on this post and my word, you should be backing up claims like that. And what about the safety of the homeopathist, who most probably has no training in dealing with volatile and violent- or vulnerable people?

And here's the absolute worst bit: At no point in this article does it state that domestic violence is wrong.

On thinking about God.

I think I have probably always been an atheist. I can't remember having any revelatory moments in which I realised the idea of God was dead to me, and I also can't remember ever really, truly having a need for a god. I remember a few occasions, in those awful dark moments that pounce on you in life, that I wanted a church to go to. A physical place of comfort, which would surround you with warmth and love and knowledge that everything in the world would get better eventually. But I don't think that really had anything to do with an actual wish for a god. And in actual fact, I feel really quite uncomfortable in churches, like at any moment i'm going to be found out and burnt at a stake.

What I realised quite recently, though, is that this has never actually been a conscious decision to not believe in God. And how could I have been reasonably living as an atheist for so long without ever really confronting how I came to be this way?  I was actually quite startled about how little I knew about atheism (or agnosticism, for that matter)

I was so, so lucky in my parents, who I think both had a Catholic upbringing (I say think because I have literally no idea what religion my Dad is. We've simply never had that conversation). Their attitude was very much: "let her make her own mind up when she's ready". Though my Mum believes in God, she thinks that if he is so omnipresent, there's no need for her to traipse to a church when clearly she could be getting on with something more interesting. I'd never say it to them, but I'm so thankful to them for letting me just drift along pretty much ignoring anything religious. I went through a bit of a phase of deciding i might be Buddhist as an early teen (yes, yes- I was a bit of a hippy-goth type creature, and I refuse to be ashamed of it), and my Dad in that way which is typical of him showered me with leaflets for the Newcastle Buddhist Centre and even bought me a book about being a buddhist. Even now I'll claim occasionally to be a Buddhist, but this is only when I'm grasping for an excuse to make someone else kill a creepy crawly because I'm too scared to.

I'm also utterly unknowledgable when it comes to religions, including Christianity. I'd just much rather find out other stuff about people than their religion. I want to know if they're nice people, if they're funny, what they do for a living, and who they think will win the Great British Bake Off, rather than which church they go to or whether they believe in the right god or not. I figure my ignorance is bliss, provided I spread it liberally over all religions. Although offering a Jewish vegetarian some bacon brownies may not have been my best moment.

There is a reason that I've been thinking about my own lack of belief, and that reason is a Skeptics In The Pub talk by the (exceptionally charming) Alom Shaha. His talk was brilliant, and I found I was sat there thinking 'why have I never thought about any of this before and yet it all makes SUCH SENSE'. (I'm really not going to go into every thought I had during his talk, except to say... *swoon*). I bought his book, The Young Atheist's Handbook (whilst attempting and failing to not blush and make a stupid joke about only buying it so I can feel young) from him and voraciously read it over the following week. I found myself doing all sorts of thinking about my lack of belief.


Now, I would absolutely love to write an eloquent, concise review of his book but I doubt I'd do the genre of book reviewing justice. I'd just like to say that it's very beautiful, and that you all should buy it, if you haven't already. I've found that since reading it, I'm a whole lot more confident and vocal about not needing belief in god now and in discussing this with other people without having fear of offending anyone. At least I know my own lack of belief now stands up in the face of my own questioning. And, in the face of that, I started reassessing a fair bit about the rest of my life- how I feel about love in the wake of my divorce, for example. It sounds a bit far-fetched that one little purple book can do that sort of thing but I guess sometimes the most profound moments appear very unexpectedly.


Anyway, all of this is a very long-winded way of saying: I have thought about it, and I'm now very confident that I just don't have room or need in my life for a god. I'm fine (and actually weirdly comforted) by the thought that this is it: there's nothing beyond, no afterlife, no higher being, no destiny... Just this, and this is what we make of it ourselves.

Oh, and if you're wondering: I think Danny will win this year's Great British Bake-Off, but I want Brendan to win.

H xxx

The Magazine Of Doom

Today, I and several others have sent strongly worded emails to W.H. Smith's.

The reason? A magazine they are stocking which is frankly disgraceful. Encased in a glossy, brightly coloured cover, this is clearly such a blood-pressure-raising piece of crap it's ridiculous.

However, to the untrained eye, it's another helpful glossy magazine, packed with useful hints and tips for how to stay healthy. Look at that nice, smiling, benign healthy looking lady. And it is a sad fact of life that patients and the public really do respond to these sorts of publications more than they do to advice from their healthcare practitioners. I can't tell you how many patients have stormed into my pharmacy with a piece of paper cut from a newspaper, demanding to know why they have been given this horrifically dangerous drug. Goodness only knows how many would turn up at their doctors. I would often spend a lot of time with these patients and explain to them what i could about the limitations of these sources, but to be honest I often felt that i had neither the resources or time to be able to do so properly. Some would change their mind, some would be marching off to their GP, usually demanding  more expensive newer drugs whose safety record we know even less about.

To be honest, even the title of this publication upsets me: What Doctors Don't Tell You. As if they are willingly sat in their surgeries or their hospital wards, giggling evilly about all of the suckers that they are going to see who are in pain, or depressed, or generally feel sick and vulnerable, rubbing their hands together, and all the while they are thinking "I could CURE you within a second, but I'm not going to, I'm going to sit here and watch you SUFFER! MWAHAHAHAHAAAA!". Actually, doctors (and any other healthcare professional) are usually people whose primary aim is to help people. They're usually overworked and under-resourced, and I suspect that many (like me, when I worked in community pharmacy) constantly feel guilty that they aren't able to help as much as they would like, because of their lack of time and resources. Yes, there is the odd Shipman character here and there, but I suspect very few people actually go into front line health care purely for money, or for the kicks of withholding various cures and treatments from their patients. Doctors, pharmacists, nurses, and other healthcare professionals may not get everything right every time, they may not be as up to date with evidence as they would like, and they may not make exactly the right decision for every single patient. But my word, I bet they really, really would like to.

The fact of the matter is: What The Doctors Don't Tell You about are usually overly hopeful health claims based on little evidence, and peddled by people who DO have the intention to make money. What they don't usually tell you about is unicorn tears and magic water and rooms made of salt and badges with unicorns drawn on (listen to Skeptics with a K podcast episode 45) because they very probably DON'T WORK, and your doctor wants more than anything to make you better. No doctor is going to advise that you try to avoid a hysterectomy with diet (Front Page of What The Doctors Don't Tell You)  if you are in a lot of pain now and a hysterectomy would improve your quality of life for you quickly, as an example. A nutritional therapist, though, as an example, may advise you to delay surgery and try diet instead, causing you to suffer for longer than is necessary.

I know this has turned into a bit of a rant. It's hardly evidence based, but it is based on genuine emotion from someone who, despite all my cynicism and negativity, just wants to do whats best for patients. I know that most of my health care professional colleagues feel the same, and this sort of sugar coated nonsense is actually rather offensive. I used to lie awake at night worrying about the patients i had seen through the day. I had many episodes of private tears for the ones that i couldn't help, and my whole week would be lifted when I had made someone's life a little bit easier. I wonder how many purveyors of woo could say the same.

Anyway, the general gist of this post is: email W.H. Smith and tell them to get this nonsense off their shelves, 

Am I the World's Worst Skeptical Pharmacist?

Yesterday, I had a cold.

We all joke about Man-Flu, and how rubbish men can be when they have a cold. But even the worst of Man-Flu sufferers is nothing compared to me. I am the Queen of Minor Illness related whinging.Instead of merely having a simple cold that makes me feel slightly rubbish, I have some sort of TB-Ebola crossover which makes me the illest person alive at that particular time.

I'm feeling a bit better today, but I'm left with a cough. Not a particularly bad cough, but a cough nonetheless. So this morning, I found myself buying Buttercup syrup.

Now, I know fine well that there is no good evidence for any cough preparations. I know that squill, the main active ingredient, has insufficient evidence to rate its efficacy. I know that capsicum is just going to give me a little bit of a warming sensation and that's it. I know that, for a couple of seconds after a swig, my throat may be thinly coated with a viscous substance which will feel nice, but will soon be washed away by all the other goo encased in my body. And yet, I still spent some of my hard earned money on it.

So, I suppose the question is: why? Surely, with knowledge that there is no evidence, and all of my new found skepticism, I should be steering away from products that I know won't work? Am I really just a poor excuse for a skeptic, and a poor excuse for a pharmacist? After I'd finished hanging my head in shame, I thought about this a bit.

And my primary answer is probably: Hope. I know it wont work, but I hope that it will because I may have a date-type thing on Saturday and I don't particularly think hacking up a lung is a great way of selling myself (and no, I probably can't fall back on my charming personality as I doubt that is much better than lung-hancking). The secondary answer would be that it tastes nice, and it has teensy tiny amount of alcohol in which makes me feel slightly smug about alcohol intake at work.

I find myself wondering (ugh, this sounds like a SATC storyline now) how many people who turn to woo and quackery as a treatment option think similarly. I wonder how many blindly accept that, say, homeopathy is going to work for them, and how many go along with it in the vain hope that something good may happen. I also wonder how many peddlars of woo think like this themselves, and how many think "haha, suckers!" when practising fake magic on people.

Anyway, back to whinging profusely and coughing up parts of various organs.

Halotherapy: a pinch of nonsense?

My first subject on this blog is a result of an enquiry we encountered a while ago at work. I had never in my life heard of halotherapy, or "salt cave therapy" as its also known.

What does halotherapy involve? well, at first glance it appears to be mainly sitting on an Ikea chair in a room for an hour. Actually, on second glance, it appears to be the same. For the privilege of doing this, you pay £35 a hour.

I'm over simplifying, of course. According to The Salt Cave's website:

"The healing microclimate of a natural salt mine is recreated  inside a therapeutic salt room using the Breeze Tronic Pro medical device pharmaceutical grade salt is finely milled and accurately mixed with a regulated current of air, which is then evenly dispersed throughout the salt room.Breeze Tronic Pro is programmed to synchronise particle size, concentration, room temperature and humidity and to maintain the optimum, therapeutic environment for each client."

The website then helpfully goes on to tell us about all the other conditions that halotherapy can be used for: asthma, COPD, acne, ADHD, and various other ailments. It's packed with testimonials using words like 'miracle' and recommendations, but sadly lacking in anything like useful clinical information. We are told that: The clinical state of 85% of the patients with mild and moderate bronchial asthma, 75 % with severe bronchial asthma, 98%- with chronic bronchitis, bronchiectasis and cystic fibrosis improved after Salt Therapy. The patients were examined 6 and 12 months after the first Salt Therapy course.
But of course there is no reference cited to have a good look at where they've gotten their figures from.

So let's think about this. I'm not that hot anymore on inhalation formulations (university was a long, long time ago folks), but i do remember than inhalation therapy was quite a complex area. Could sitting in a room with some salt on the walls really have all these health benefits? I can see the point of a steam room type situation (especially as I sit here typing with a cold, thinking how lovely a steam room would be), but a dry room?

I'm going to have a bit of a look into it, and get back to you. (That's how we medicines information pharmacists roll). In the meantime... Those Ikea chairs... I just can't take it seriously. I could always be wrong, of course.

Helper Dog Blogs

Just a quick little post to recommend another shiny new blog to the skeptical circuit, written by one of my greatest friends and aforementioned Helper Dog:

Evidence Based Skepticism

Favourite it now. Or, if you haven't yet favourited this one, do it after you've favourited mine, pretty please

H xxx

What skepticism means to me

Hi all,

Welcome to my new humble little blog about skepticism. It's going to be mainly based on healthcare because, as a pharmacist, that's what I come across the most in daily life, but there may well be the odd few other bits and pieces that creep in also.

So about me:
My friends call me Simple Dog, because I'm generally useless at life, in particular electrical items and computers confuse me. I'm easily distracted by pretty coloured things, sparkly things, cake and other baked goods, and have a tendency to make high pitched noises when I get excitable about something.

I started off my professional life as a hospital pharmacy pre-reg. I then worked in community pharmacy for a good few years, in a supermarket pharmacy then an independent chain. I now work in medicines information, but still do regular locums around about.

During my time in community, I used to regularly sell things that i had no idea about, or that i knew had very little if any benefit. I used to tell patients this, but on many occasions they would go ahead and buy it anyway. I'll even admit here to ordering homeopathic products to fill the shelves of a pharmacy I managed. At the time, I vaguely knew it was a load of old tosh, but didnt have the time or the inclination to bother doing anything about it.

This job in Medicines Information has opened my eyes a hell of a lot. I started having a poke about on various different skeptical blogs. The Miracle Mineral Solution Saga and the Burzynski Hoohah piqued my interest further.  And when my good friend and Helper Dog Nancy suggested we go to something called Skeptics In The Pub, I was hooked. The nerdy part of my loves learning new stuff, and I'm a proper beer drinker, so combine the two and I'm a happy girl. I find myself thinking about a whole load of things that I would never have bothered devoting any time to before, and I think I'm much better off for it. I've also met some wonderful new people.

Something I've noticed from all this skeptical activity is that I'm now able to do my job much better. I used to think I was rubbish at critical appraisal, which is a very dry subject that always really bored me. However, put it into the context of woo and quackery and I've found its much easier to grasp. I'm hoping to use this knowledge to try and promote skeptical ideas and critical thinking to pharmacists. At the moment I have a few vague ideas floating around my head.


Skeptics get a bad rap in a lot of cases. It seems that believers (in whatever area it may be) are ready and eager to just dismiss them out of hand. But I believe (There's that word again) that a healthy dose of skepticism can only do good. Either it strengthens a cause if the belief is proved right, or it can be used to change beliefs to something more evidence-based and worthwhile.

This is my little contribution.

H xxx