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HO 33
Memorandum submitted by Homeopathy: Medicine for the 21st Century (H:MC21)
H:MC21 is a charity which promotes homeopathy. Introduction 1. Karl Popper stated that: ... the belief that we can start with pure observation alone, without anything in the nature of a theory, is absurd ... Observation is always selective. It needs a chosen object, a definite task, an interest, a point of view, a problem.([i]) Any evidence in the field of health, therefore, should be considered in relation to the "point of view" which provides its context. In particular there is a need to ensure that scientifically valid definitions are used, and a theoretical framework capable of being tested scientifically. 2. A distinction also needs to be drawn between the use of science and technology.([ii]) The use of modern technology may not mean that a field is scientific, whilst scientific theory may be able to predict results without being wholly capable of explaining the details of how the results are achieved. The Empirical Approach 3. The practice of conventional clinical medicine uses technologies derived from scientific fields, but it operates within an empirical one: Clinical practice must not be regarded as applied biological medicine, and it is necessary to adopt the empiricist approach for the solution of clinical problems.([iii]) 3.1. The definition of illness. Disease categorisation is based on the following approach: Doctors have studied millions of sick people, and we must imagine that no two of these were ever completely identical as regards their clinical pictures and the underlying causal mechanisms, but in order to build up a medical science, it was essential to stress the similarities rather than the differences.([iv]) Though empirically useful, this is not scientifically sound, because: 3.1.1. Disease definitions change over time as symptomatology and causative processes are better understood. For example, the illness of pneumonia is now categorised as eleven illnesses.([v]) 3.1.2. Some diseases are essentially individual, or "idiopathic".([vi]) 3.1.3. Research and clinical evidence indicate that differences in individuals affect treatment (see 4.3). 3.2. The definition of effectiveness. There is no scientifically justified definition, and the "effectiveness" of treatments changes unpredictably. 3.2.1. The 'intention to treat' means that "effectiveness" is dependent on what symptomatology is chosen. 3.2.1.1. There is an arbitrary divison into "desirable" effects and side effects, despite the fact that the true effect of the drug is the combination of these. 3.2.1.2. Changing the 'intention to treat' changes the definition of "desirable" effects and side effects, and so changes the "effectiveness", as in the case of Viagra.([vii]) 3.2.1.3. The severity of side effects in clinical practice can lead to the withdrawal of a treatment shown to be "effective" in trials. 3.2.2. The time-scale of trials may be insufficient for establishing the effects of a treatment. 3.2.2.1. Effects which lie outside the time-frame will only be identified from clinical practice. 3.2.2.2. The "effectiveness" of drugs can be redefined as a result of experience in clinical practice, as in the case of Aspirin.([viii]) 3.3. Theory of health and disease. The absence of a theory means that processes of change in health cannot be distinguished from each other, such as: 3.3.1. The 'natural course' of the disease from a course affected by treatment.([ix]) 3.3.2. The effect of a 'placebo' from that of a curative agent. 3.3.3. Improvement in one part of the body cannot be readily and systematically related to symptomatology in other parts of the body. Evidence-based Medicine 4. In the face of these problems, medical practitioners have devloped the system of evidence-based medicine (EBM). This involves three elements, none of which is sufficient by itself as a basis for successful medical practice (our emphases): Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centred clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer. Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients.([x]) 4.1. Care of the individual. The purpose of medicine is successful treatment of the individual, so evidence of what is successful in individual cases is essential. One method of acquiring this information is outcome studies, but these cannot provide information enabling the development of new treatments. 4.2. Clinical expertise. Practitioners can acquire experience which enables them to assess the differerent effects of treatments across a range of individuals, and to target treatments based on that experience. The problem is that this knowledge is rarely quantified, let alone rigorously quantified, and therefore it is liable to be subjective. 4.3. External clinical evidence. Evidence about treatments gathered from RCTs can offer some degree of objectivity about treatments, but it cannot provide reliable information about the appropriateness of a specific treatment to a particular individual. Thus: There was still no guarantee that a treatment that had succeeded during a set of trials would cure a particular patient ...([xi]) As a result RCTs alone cannot enable medicine to fulfil its primary purpose. RCTs are also dependent on a scientific framework if they are to produce valid results. 4.3.1. RCTs can successfully produce reliable evidence of the harmful effects of a treatment because: 4.3.1.1. A scientifically valid definition of outcome is simply the increase in morbid effects or mortality rates. 4.3.1.2. Issues of homogeneity and generalisability are irrelevant since everyone is affected by harmful interventions, with only the extent and rapidity of harm being individual. 4.3.2. Evidence from RCTs cannot prove effectiveness because: 4.3.2.1. Curative processes are fundamentally individual, and so tests which generate statistical likelihoods of success are not valid in an individual case (see 4.3). 4.3.2.2. There is no scientific definition of effectiveness (see 3.2ff.). 4.3.2.3. A scientifically valid definition of effectiveness is complex, as it needs to take into account all the outcomes of treatment and over a significant time-scale. 4.3.2.4. The mismatch between the definitions of diseases and their actual appearance in individuals leads to a conflict between 'homogeneity' and 'generalisability' (see 3.1ff.). 4.3.3. Since RCTs gather evidence in the absence of a scientific theory, the evidence cannot be checked against predictions based on a consistent theoretical framework, but only against other evidence gathered in the same flawed conditions. Consequences of Evidence without Theory 5. Using an approach which is not based on a scientific framework, but which attempts to balance different sources of unreliable evidence in order to develop more reliable solutions, means that there can be no certainty as to whether the correct balance has been achieved. In addition, none of the three aspects has scientific validity in its own right, and any tendency towards dominance of one aspect over the others will render the approach valueless. This is a growing tendency among opponents of homeopathy who insist on giving undue (even exclusive) weight to RCTs over other sources of evidence.([xii],[xiii],[xiv]) As a general attitude this would lead to: 5.1. A tendency for practitioners to ignore and fail to report adverse reactions in clinical practice on the grounds that there is nothing in the trial literature. 5.2. A tendency for long-term effects to go unidentified, including increases in chronic illness (as in the analogous case of cigarettes and lung cancer). There are indications that this is occurring: The cost of the National Health Service nearly trebled from 1951 to 1975 (at 1950 prices); both the consultation rate in general practice and the hospital admission rate rose, and the waiting lists became longer and longer. In Denmark the experience was the same. ... Obviously this growth has many aspects, but it must be admitted that it is difficult to register the beneficial effect in the available health statistics. The average expected life-span has not changed much, and hospital waiting lists have not been eliminated.([xv]) 5.3. Additional NHS personnel and financial costs of managing the adverse reactions. 5.4. Additional cost of research into new treatments for new illnesses; 5.5. Lost work days, and consequent costs for employers and the economy. 5.6. Potential increases in disability pension costs; 5.7. Deaths, entraining emotional trauma and other costs. Homeopathy6. There are further issues which mean that it is particularly inappropriate to apply this evidence-oriented process to homeopathy. Definition of what is to be treated. 7. Homeopathy uses a scientifically valid definition of disease. 7.1. The understanding of what is to be treated is based on the actual signs and symptoms of the individual in their totality.([xvi]) 7.2. The understanding of what is to be treated takes into account the chronological relationships of conditions in the individual.([xvii]) 7.3. Homeopathy organises this information on the basis of general principles, distinguishing the relative importance of the signs and symptoms on the basis of: 7.3.1. Severity and pain, which indicate urgent need in all systems of medicine; 7.3.2. Peculiarities, which indicate the individual curative reaction and so the specific remedy needed;([xviii]) 7.3.3. Location;([xix]) 7.3.4. Chronology.([xx]) Testing of remedies. 8. Homeopathy recognises that as no two unique substances can have identical effects on the human organism, so each must be tested for its pattern of action.([xxi]) As a result: 8.1. Homeopathy was the first medical system to gather as complete evidence as possible of the action of each substance on the human body.([xxii]) 8.2. Homeopathy was the first medical system to test substances on healthy people prior to their use, in order to avoid the distortions inevitable in tests on sick people.([xxiii],[xxiv]) 8.3. Homeopathy was the first medical system to seek to identify those peculiarities of the effects of each substance which enable one to be distinguished from another.([xxv]) Application of remedies. 9. With full information about what is to be treated and about the available medicines, there are only three theoretical posibilities for relating one to the other: 9.1. If there is no relationship between the bodies of information, then there is no possibility of a science of medicine. 9.2. The bodies of information can have no consistent relationship as opposites, because some conditions have no opposite, but are either present or absent (for example, a cough, pain, delusions). Again there is no possibility of a science of medicine. 9.3. Relating the bodies of information on the basis of similarity is possible, and so makes a science of medicine theoretically possible. This theoretical position is evidenced in practice, as in the case of cinchona (and its derivative quinine) which has been used for hundreds of years in the treatment of malaria even though the symptoms of quinine poisoning (cinchonism) closely resemble those of malaria.([xxvi]) Homeopathy uses a scientific approach to treatment. 10. On this basis homeopathy uses a scientifically valid approach, and confirmation can be seen in that: 10.1. Homeopathy was developed using the scientific method, employing experiment and observation to test and articulate its theoretical framework. This can even be seen in the inaccurate and incomplete descriptions of opponents of homeopathy.([xxvii]) 10.2. Homeopathy was the first medical system to recognise the importance of micro-organisms in disease, some 60 years before Koch identified the cholera bacterium.([xxviii]) 10.3. Homeopathy was the first medical system to recognise that these micro-organsms could evolve, some 30 years before Darwin published On the Origin of Species.([xxix]) 10.4. Homeopaths promoted hospital hygiene, some 50 years before Florence Nightingale.([xxx]) 10.5. Homeopaths promoted public hygeine before the start of the nineteenth century,([xxxi],[xxxii]) and the medical historian Simon Szreter has identified this as the primary factor in disease reduction at the end of that century.([xxxiii]) 10.6. Homeopathy was the first medical system to identify a role for biophysics.([xxxiv]) 10.7. The principles of homeopathy are capable of being tested scientifically, as there is a consistent theory linking selection of a treatment and analysis of the results of treatment. Furthermore: 10.7.1. The general principles are derived from clinical experience (see 7.3ff.). 10.7.2. Individuality is incorporated into the theory (see 7.1 and 7.3.2). 10.7.3. It is possible to determine what is treatable at a given point in time (see 7.3.4). 10.7.4. The results of treatment, even in individual cases, can be measured against the general principles (known as Hering's 'Law of Cure'), offering a scientific definition of effectiveness.([xxxv]) 10.7.5. Different outcomes can be distinguished from each other, and an objective assessment of effectiveness obtained.([xxxvi]) 11. It is possible to produce evidence for the effectiveness of homeopathy, but the mechanisms which have been used offer conflicting results. Randomised Controlled Trials. 12. Homeopathic principles can provide a scientific basis for RCTs to test effectiveness because: 12.1. Homeopathy can consistently define the conditions being treated. 12.2. Homeopathy can consistently define expected outcomes. 12.3. There is no problem with individuality in homeopathic treatment, and so no conflict between homogeneity and generalisability. 13. However, if a homeopathic RCT does not conform to the integrated whole of homeopathic principles, it will produce inaccurate results.([xxxvii]) 13.1. There are at least eleven factors which can affect the results of the trial, and even reduce the therapeutic intervention to a placebo intervention.([xxxviii]) These include: 13.1.1. Inappropriate definitions of what is being treated. 13.1.2. Inappropriate definitions of outcome. 13.1.3. Inappropriate timescales. 13.2. In practice RCTs produce ambiguous results. Moreover, positive trials are accused of being "implausible",([xxxix]) a "stitch-up",([xl]) too small, or insufficiently rigorous, where rigour' refers to adherence to an evidence-oriented trial structure rather than to scientific adherence to homeopathic principles.([xli]) Meta-analyses. 14. Because meta-analyses are based on clinical trials, and because they tend to use the same approach to rigour, they offer no improvement in terms of evidence. 14.1. The Linde analysis (1997) was reworked (1999) as a result of criticism based on the demands of evidence-oriented rigour.([xlii]) 14.2. The Shang analysis (2005) also defined the rigour of the trials they selected without reference to homeopathic principles.([xliii]) 14.3. These analyses show that a significant degree of subjectivity is introduced into the research process using this method.([xliv]) 15. In practice meta-analyses also produce ambigiuous results, but the arguments usually focus on the selection criteria.([xlv],[xlvi],[xlvii],[xlviii]) Outcome studies. 16. Outcome studies of homeopathy present very different results from RCTs. 16.1. The Get Well UK study in Northern Ireland showed health improvements in 84% of patients with GP correlation for 65% of patients.([xlix]) 16.2. The Bristol Homeopathic Hospital study showed positive change in 70.7% of patients, with 50.7% recording their improvement as better (+2) or much better (+3).([l]) 17. Outcome studies also measure "effectiveness" in a different area of the EBM model. 17.1. They assess the effect of 'care of the individual'and of 'clinical expertise' (see 6ff.). 17.2. They do not constrain the treatment process, and so do not affect the scientific integrity of this process. 17.3. Their results can be compared with the general tendency in the population to recover (or not) from such conditions. 18. Typically outcome studies show that substantial numbers of patients derive benefit from homeopathic treatment, and often to a substantial degree. Clinical practice. 19. Both historical and present-day evidence of homeopathy in clinical practice reflects the results seen in outcome studies. 19.1. A typical example is a cholera epidemic in London in 1854, when patients at the London Homoeopathic Hospital had a survival rate of 84 per cent, compared to just 47 per cent for patients receiving more conventional treatment at the nearby Middlesex Hospital.([li]) A mortality rate of 16% (at the homeopathic hospital) is unachievable without medical intervention, whilst 53% (at the conventional hospital) is typical without treatment.([lii],[liii]) 19.2. A number of similar cases have been compared.([liv]) 19.3. Homeopathy has also recently been used as a prophyactic for leptospirosis in over 2 million people in Cuba, dramatically reducing infection and mortality rates.([lv]) Conclusion. 20. Conventional medicine relies on an model known as Evidence Based Medicine which balances bodies of evidence in order to minimise the risks of harm. Within this model no form of evidence can provide a definitive statement of effectiveness. Attempts to limit the approach used and allow one form of evidence to dominate will defeat the object of this model. The model is an implicit (and often explicit) recognition of the fact that medicine has no underlying scientific theory. 21. Homeopathy has an underlying scientific theory. This theory is consistent with observed facts, it has led to analyses decades in advance of other medical practice, and it has a strong body of evidence of successful practice. On this basis it is entirely inappropriate to use the EBM model to assess its practice, let alone a single element of that approach. Instead it should be tested by relating its clinical practice to the predictions of its theory, as would be the case in any other field of science. Homeopathy requires a Science Based Medicine model.
[i] K R Popper, Conjectures and Refutations, 2nd edn (London: Routledge and Kegan Paul, 1965), p. 46, quoted in Henrik R Wulff, Stig Andur Pedersen and Raben Rosenberg, Philosophy of Medicine: An introduction (Oxford: Blackwell Scientific Publications, 1986), p. 22. [ii] Henrik R. Wulff, Stig Andur Pedersen & Raben Rosenberg, Philosophy of Medicine: An introduction (Oxford: Blackwell Scientific Publications, 1986), p. 40. [iii] Henrik R. Wulff, Stig Andur Pedersen & Raben Rosenberg, Philosophy of Medicine: An introduction (Oxford: Blackwell Scientific Publications, 1986), p. 43. [iv] Henrik R. Wulff, Stig Andur Pedersen & Raben Rosenberg, Philosophy of medicine: an introduction (Oxford: Blackwell Scientific Publications, 1986), p. 77. [v] Robert Berkow MD (Editor in Chief), Merck Manual of Medical Information: Home edition, (New York: Simon and Schuster Inc., 2000) pp. 194-200. [vi] For example: idiopathic pulmonary fibrosis and idiopathic pulmonary hemosiderosis, in Robert Berkow MD (Editor in Chief), Merck Manual of Medical Information: Home edition, (New York: Simon and Schuster Inc., 2000) pp. 190 and 191. [vii] Simon Singh and Edzard Ernst, Trick or Treatment? Alternative medicine on trial (London: Bantam Press, 2008), p. 225. [viii] Simon Singh and Edzard Ernst, Trick or Treatment? Alternative medicine on trial (London: Bantam Press, 2008), p. 196. [ix] Simon Singh and Edzard Ernst, Trick or Treatment? Alternative medicine on trial (London: Bantam Press, 2008), p. 140. [x] David L Sackett, William M C Rosenberg, J A Muir Gray, R Brian Haynes, W Scott Richardson 'Evidence based medicine: what it is and what it isn't', BMJ 1996;312:71-72 (13 January), at <http://www.bmj.com/cgi/content/full/312/7023/71, accessed 6 December 2008. [xi] Simon Singh and Edzard Ernst, Trick or Treatment? Alternative medicine on trial (London: Bantam Press, 2008), p. 23. [xii] Michael Born et al., 'Full text: letter calling for homeopathy boycott', Times Online, 23 May 2007 at <http://www.timesonline.co.uk/tol/life_and_style/health/article1827553.ece>, accessed 1 April 2008. [xiii] Micael Baum et al., 'Doctors' letter: In full', BBC News Online, 23 May 2006 at <http://news.bbc.co.uk/1/hi/health/5008034.stm>, accessed 4 November 2009. [xiv] Simon Singh and Edzard Ernst, Trick or Treatment? Alternative medicine on trial (London: Bantam Press, 2008), throughout, but especially p. 24. This distortion of what is meant by EBM is discussed in William Alderson, Halloween Science (Stoke Ferry: Homeopathy: Medicine for the 21st Century, 2009), pp. 19-20, available at < http://www.homeopathyworkedforme.org/#/halloween-science/4533482584>. [xv] Henrik R. Wulff, Stig Andur Pedersen & Raben Rosenberg, Philosophy of Medicine: An introduction (Oxford: Blackwell Scientific Publications, 1986), p. 51. [xvi] Samuel Hahnemann (trans. William Boericke), Organon of Medicine, 6th edn, manuscript completed 1841, 1st English edn 1921 (Calcutta: Roy Publishing House, repr. edn 1972), § 7 p. 94 and numerous other places. [xvii] Samuel Hahnemann (trans. William Boericke), Organon of Medicine, 6th edn, manuscript completed 1841, 1st English edn 1921 (Calcutta: Roy Publishing House, repr. edn 1972), §§ 84-86 pp. 164-165. [xviii] Samuel Hahnemann (trans. William Boericke), Organon of Medicine, 6th edn, manuscript completed 1841, 1st English edn 1921 (Calcutta: Roy Publishing House, repr. edn 1972), § 104 pp. 176-177. [xix] Kent, James Tyler, Lectures on Homoeopathic Philosophy (New Delhi: B. Jain Publishers, repr. edn 1993), lectures 32-33. [xx] Kent, James Tyler, Lectures on Homoeopathic Philosophy (New Delhi: B. Jain Publishers, repr. edn 1993), lecture 26. [xxi] Samuel Hahnemann (trans. William Boericke), Organon of Medicine, 6th edn, manuscript completed 1841, 1st English edn 1921 (Calcutta: Roy Publishing House, repr. edn 1972), § 118 p. 185, and see §119 p. 185-186. [xxii] Samuel Hahnemann (trans. William Boericke), Organon of Medicine, 6th edn, manuscript completed 1841, 1st English edn 1921 (Calcutta: Roy Publishing House, repr. edn 1972), § 122 p. 187. [xxiii] See William Alderson, Halloween Science (Stoke Ferry: Homeopathy: Medicine for the 21st Century, 2009), p. 90, available at <http://www.homeopathyworkedforme.org/#/halloween-science/4533482584>. [xxiv] Jeremy Sherr, The Dynamics and Methodology of Homoeopathic Provings (Malvern: Dynamis Books, 1994), pp. 29-31. [xxv] Samuel Hahnemann (trans. William Boericke), Organon of Medicine, 6th edn, manuscript completed 1841, 1st English edn 1921 (Calcutta: Roy Publishing House, repr. edn 1972), § 120 p. 187. [xxvi] 'Qualaquin (quinine) - Cinchonism', Doublecheckmd website at <http://doublecheckmd.com/EffectsDetail.do?dname=quinine&sid=12268&eid=4405>, accessed 1 February 2009. [xxvii] See William Alderson, Halloween Science (Stoke Ferry: Homeopathy: Medicine for the 21st Century, 2009), pp. 41-42, available at <http://www.homeopathyworkedforme.org/#/halloween-science/4533482584>. [xxviii] Samuel Hahnemann, 'Appeal to Thnking Philanthropists Respecting the Mode of Propagation of the Asiatic Cholera', (Leipzig: the author, 1831) in Samuel Hahnemann (trans. R E Dudgeon MD), The Lesser Writings of Samuel Hahnemann, 1851 edn (New Delhi: B. Jain Publishers, repr. edn 2002), p. 758. [xxix] Samuel Hahnemann (trans. William Boericke), Organon of Medicine, 6th edn, manuscript completed 1841, 1st English edn 1921 (Calcutta: Roy Publishing House, repr. edn 1972), § 81 p. 160. [xxx] Samuel Hahnemann, 'Protection against infection in epidemic diseases', and 'Things that spoil the air' in The Friend of Health: Part I (Frankfurt am Main: [n. pub.], 1792) in Samuel Hahnemann (trans. R E Dudgeon MD), The Lesser Writings of Samuel Hahnemann, 1851 edn (New Delhi: B. Jain Publishers, repr. edn 2002), pp. 168 and 178. [xxxi] Samuel Hahnemann, The Friend of Health: Part II (Frankfurt am Main: [n. p.], 1795) in Samuel Hahnemann (trans. R E Dudgeon MD), The Lesser Writings of Samuel Hahnemann, 1851 edn (New Delhi: B. Jain Publishers, repr. edn 2002), pp. 203-212. [xxxii] Samuel Hahnemann, The Friend of Health: Part II (Frankfurt am Main: [n. p.], 1795) in Samuel Hahnemann (trans. R E Dudgeon MD), The Lesser Writings of Samuel Hahnemann, 1851 edn (New Delhi: B. Jain Publishers, repr. edn 2002), pp. 212-227. [xxxiii] Simon Szreter, 'The importance of social intervention in Britain's mortality decline c. 1850-1914' in Davey, Basiro, Alastair Gray and Clive Seale (Eds), Health and Disease: A reader (Buckingham and Philadelphia: Open University Press, 1993), p. 199. [xxxiv] Samuel Hahnemann (trans. William Boericke), Organon of Medicine, 6th edn, manuscript completed 1841, 1st English edn 1921 (Calcutta: Roy Publishing House, repr. edn 1972), § 11 fooote 7 pp. 96-98. [xxxv] See William Alderson, Halloween Science (Stoke Ferry: Homeopathy: Medicine for the 21st Century, 2009), p. 43, available at <http://www.homeopathyworkedforme.org/#/halloween-science/4533482584>; and see also Kent, James Tyler, Lectures on Homoeopathic Philosophy (New Delhi: B. Jain Publishers, repr. edn 1993), lecture 35. [xxxvi] Kent, James Tyler, Lectures on Homoeopathic Philosophy (New Delhi: B. Jain Publishers, repr. edn 1993), lecture 35. [xxxvii] See, for example, Paolo Bellavite and Andrea Signorini, The Emerging Science of Homeopathy: Complexity, biodynamics, and nanopharmacology (Berkley: North Atlantic Books, 2002), p. 45. They refer to R.H. Savage and P.F. Roe, 'A further double-blind trial to assess the benefit of Arnica montana in acute stroke illness', Brit. Hom. J., 67 (1978), p. 210 and A.M. Scofield, 'Experimental research in homeopathy: A critical review', 2 parts, Brit. Hom. J., 73 (1984), p. 161. [xxxviii] The full list is in William Alderson, Halloween Science (Stoke Ferry: Homeopathy: Medicine for the 21st Century, 2009), pp. 57-62, available at <http://www.homeopathyworkedforme.org/#/halloween-science/4533482584>. [xxxix] J. Kleijnen, P. Knipschild, and Riet G. Ter, 'Clinical trials of homoeopathy' BMJ, 302 (1991), 316-23. [xl] Ben Goldacre, Bad Science (London: Fourth Estate, 2008), p. 53. [xli] Vance W Berger PhD, 'Is the Jadad Score the Proper Evaluation of Trials?' (letter to the editor), J. Rheumatol. (2006) at <http://www.jrheum.com/subscribers/06/08/1710-c.html> and Vijay K Shukla, Annie Bai, Sarah Milne and George Wells, 'Systematic Review of Quality Assessment Instruments for Randomized Control Trials: Selection of SIGN50 Methodological Checklist', Cochrane Colloquium Abstracts (The Cochrane Collaboration) at < http://www.imbi.uni-freiburg.de/OJS/cca/index.php/cca/article/view/5053>, both accessed 3 March 2009. [xlii] Simon Singh and Edzard Ernst, Trick or Treatment? Alternative medicine on trial (London: Bantam Press, 2008), p. 134. [xliii] Aijing Shang, Karin Huwiler-Müntener, Linda Nartey, Peter Jüni, Stephan Dörig, Jonathan A.C. Sterne, Daniel Pewsner, Prof Matthias Egger, 'Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy', The Lancet, 366 (2005), 726-732. [xliv] See the commentary on this subject in William Alderson, Halloween Science (Stoke Ferry: Homeopathy: Medicine for the 21st Century, 2009), pp. 64-67, available at <http://www.homeopathyworkedforme.org/#/halloween-science/4533482584>. [xlv] Klaus Linde, Wayne B. Jonas, 'Meta-analysis of homoeopathy trials' (letter to the editor), Lancet, 9503 (2005) at <http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)67878-6/fulltext>, accessed 3 March 2009. [xlvi] Peter Fisher, Brian Berman, Jonathan Davidson, David Reilly, Trevor Thompson and 29 others, Letter to the editor, Lancet, 9503 (2005) at <http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)67879-8/fulltext>, accessed 3 March 2009. [xlvii] R. Lüdtke and A.L.B. Rutten, 'The conclusions on the effectiveness of homeopathy highly depend on the set of analyzed trials', J. Clin. Epidemiol., (2008) at <http://www.aekh.at/fileadmin/Bilder/Hom_opathie_int/LuedtkeRuttenJCE08.pdf>. [xlviii] A.L.B. Rutten and C.F. Stolper, 'The 2005 meta-analysis of homeopathy: the importance of post-publication data', Homeopathy, 2008 at <http://www.aekh.at/fileadmin/Bilder/Hom_opathie_int/RuttenStolperHomeopathyarticle.pdf>, both accessed 15 April 2009. [xlix] Get Well UK website at <http://www.getwelluk.com/>, accessed 27 April 2009; full report at <http://www.dhsspsni.gov.uk/final_report_from_smr_on_the_cam_pilot_project_-_may_2008.pdf>. [l] Spence DS, Thompson EA, Barron SJ, 'Homeopathic Treatment for Chronic Disease: A 6-Year, University-Hospital Outpatient Observational Study', Journal of Alternative and Complementary Medicine, 2005, 11:793-798. [li] Simon Singh and Edzard Ernst, Trick or Treatment? Alternative medicine on trial (London: Bantam Press, 2008), p. 107; see also the commentary in William Alderson, Halloween Science (Stoke Ferry: Homeopathy: Medicine for the 21st Century, 2009), pp. 55-57, available at <http://www.homeopathyworkedforme.org/#/halloween-science/4533482584>. [lii] See 'Vibrio cholerae and Asiatic Cholera (page 1)', Introduction, Cholera, para. 3 at <http://www.textbookofbacteriology.net/cholera.html>, accessed 19 March 2009. [liii] Robert Berkow MD (Ed. in Chief), The Merck Manual of Medical Information: Home edition (New York: Simon and Schuster Inc., 2000), p. 869. [liv] Thomas Lindsley Bradford, The Logic of Figures or Comparative Results of Homeopathic and Other Treatments 1st edn (Philadelphia: Boericke and Tafel, 1900), (Kessinger Publishing: [United States], repr. edn [n.d.]). [lv] Dr. Concepción Campa, Dr. Luis E. Varela, Dr. Esperanza Gilling, MCs. Rolando Fernández, Tec. Bárbara Ordaz, Dr. Gustavo Bracho, Dr. Luis García, Dr. Jorge Menéndez, Lic. Natalia Marzoa, Dr. Rubén Martínez, 'Homeoprophylaxis: Cuban Experiences on Leptospirosis ' at the International Meeting on Homeoprophylaxis, Homeopathic Immunization and Nosodes against Epidemics, 2008, in Havana at http://www.finlay.sld.cu/nosodes/en/ProgramaNOSODES2008Eng.pdf
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