The Dangerous Allure of Alternative Therapies for Pets with Cancer

Posted on December 28, 2014 by skeptvet

Most pet owners understand that science-based medicine is the best hope for maintaining and restoring health in their animal companions. The tremendous successes of preventative and therapeutic healthcare in the last couple of centuries is difficult to deny (though proponents of alternative medicine certainly try).

While there are plenty of obvious and dramatic successes for specific interventions, like vaccination and antibiotics, the real power of science-based medicine is in the use of systematic methods for learning about how nature works, and how disease comes about. A true understanding of how our bodies work and what goes wrong in illness is more likely to lead to effective disease prevention and treatment than an elaborate set of myths and metaphors with little connection to the reality of nature.

Unfortunately, it is all too easy to find such myth-based systems, applying treatments in complex and ritualized ways without doing the hard and important work of scientific investigations to evaluate the truth behind their systems or the real effects of their interventions. I’ve addressed the bizarre pseudoscientific theories of homeopathy and the pre-scientific mythos of so-called Traditional Chinese Veterinary Medicine here before.

Such approaches may seem at best quaint and anachronistic, at worst deluded, but for the most part even people who understand the value and importance of science and science-based medicine tend to view them as harmless. However, false beliefs about nature that are used to construct systems of medical treatment and aggressively marketed can be harmful, both directly and indirectly. Even a system like homeopathy, which ultimately sells only magic water as medicine, can cause harm when it is applied to serious illness and used to discourage or even supplant appropriate medical care.

A recent issue of the Integrative Veterinary Care Journal (IVC) devoted to alternative therapies for cancer illustrates the danger of such misguided approaches. Two articles, in particular, discussing naturopathic and homeopathic cancer treatment, reveal some of the core beliefs of these practitioners who, despite their talk of “complementing” conventional medicine, really have a view of health and disease incompatible with and deeply opposed to that of science:

  1. Health and disease are as much spiritual issues as they are questions about physical health.
  2. Conventional medicine is fundamentally mistaken in its understanding and less effective in its treatments than alternative therapies, and it is always harmful even when it seems to be helping.
  3. Alternative therapies can effect cures where conventional treatment cannot, and no scientific research is needed to prove this claim

It is easy to see how such beliefs and claims could be attractive to someone facing the frightening diagnosis of cancer in their beloved animal companion. It is also, hopefully, equally obvious that when such claims are untrue, they can do harm by leading vulnerable and desperate pet owners to make poor choices in the care of their pets. Despite the appeal of the marketing language used to promote such practices, if they are based on faulty understanding and their effectiveness is unproven or non-existent, then choosing these approaches when our pets are ill is not likely to benefit, and at least as likely to harm, the pets we want so much to help.

The first article describes a “naturopathic” approach to cancer treatment.

Fougere, B. Naturopathic oncology. IVC. Winter 2104/2015. 20-23.

Naturopathy is a rather vaguely defined approach to health that incorporates virtually every alternative therapy, from acupuncture to herbs and dietary supplements, from chiropractic to homeopathy and “energy medicine.” It even includes many perfectly conventional practices such as nutrition and exercise, which it disingenuously claims to be “alternative” therapies. Naturopathy is characterized mostly by a reverence for the concept of “natural,” despite the misleading and largely illusory nature of this term. Naturopaths decide, somewhat arbitrarily, which therapies are “natural” and which aren’t and then claim to prevent and treat disease by using natural therapies to support the body’s own defenses and healing abilities. A lovely concept if there were much evidence to suggest it was true, but for the most part there is not.

In this article, Dr. Fougere makes it clear that she believes naturopathy to be safer and more effective than conventional medicine, and she clearly illustrates her belief that the scientific understanding of disease is mistaken and irrelevant to naturopathic treatment.

The greatest joy of being involved in naturopathic oncology is that our toolbox is so much larger than the one other veterinarians draw upon. It is empowering to know that there is always something more than can be done to help our patients, and even more phenomenal to be able to improve their health well beyond expectations, and create “spontaneous remissions”—something that the veterinary paradigm says is impossible…

The notion that there is never a situation in which further treatment is not in the best interests of a patient is a significant cause of great suffering, in human and veterinary medicine. While we all want to have hope, and while unexpected positive outcomes can sometimes occur, it is naïve to believe that there are never situations in which continued treatment does more harm than good. Of course, Dr. Fougere would respond that this only applies to conventional treatment, since alternative therapies can magically have only benefits and no risks.

We emphasize therapies that are non-invasive and natural and that do not make our patients less well.

Such a claim has never been proven true when examined in the objective light of science. It flies in the face of the clear evidence that one does not get something for nothing in nature. When working with a system as complex and interconnected as a living organism, it is impossible to alter one aspect as we wish without unintentionally affecting other aspects, sometimes with undesired results. The only therapies with no side-effects are therapies with no effects.

But such facts don’t disturb Dr. Fougere, who makes it clear she has little use for the understanding of health and disease produced by science, regardless of how successfully it has improved all our lives.

The diagnosis of cancer is important, but the definitive diagnosis is not central to our approach…We need to address all aspects of health and well-being, including physical factors…environmental factors, spiritual aspects, and even genetic factors.

She claims her treatments go beyond the physical health of her patients and affect their spiritual health as well. Such claims are easy to make as they cannot be proven or disproven, only accepted or rejected on faith. This also makes them of little value, since accepting any one such claim means we must rationally accept them all, stripping us of any ability to tell true from false.

Such approaches to understanding the world are natural to human beings, and they have been employed since before written history. They also did almost nothing to improve our health and longevity in thousands of years, whereas a science-based approach has had clear and unprecedented benefits. There is a cost to such beliefs, as appealing as they may be, because they lead us to acting on claims that can never be meaningfully evaluated as true or false.

Dr. Fougere’s rejection of the scientific view of cancer goes beyond simply rejecting the value of specific diagnoses. She substitutes a common, and false, alternative theory of disease.

From a naturopathic perspective, cancer arises from an imbalance or accumulation of toxicity…

Such a view of disease as caused by vague “toxins” is a reincarnation of the evil humours and it exaggerates, distorts, and ignores real scientific understanding of environmental risk factors for disease. Such toxins are claimed to be everywhere, from our food, air, and water to the very medical therapies supposed to protect and heal us, such as vaccines and medicines. The lack of specificity and evidence makes such claims about disease being caused by toxins no different than claims about disease being caused by evil spirits and demonic possession. Once again, actually finding the toxins, proving they cause disease, and testing if and how one’s treatments restore health are all irrelevant. This is faith-based medicine at its finest.

Most of the specific therapies Dr. Fougere recommends have little to no evidence to show they benefit cancer patients. They often have mutually incompatible theories behind their supposed effects, which are conveniently ignores, and they are often illustrations of the anti-scientific world view underlying the whole practice of naturopathy. A few examples:

We use [acupuncture] routinely to enhance energy and well-being. [whatever these might be and however acupuncture might enhance them, all without any risk, of course]

Ideally, herbs are prescribed according to the patient’s vitality, energetics, symptoms, concurrent treatments, prognosis, and diagnosis. [the order in which these factors are listed is interesting, with anything objective or scientifically established last and anything subjective and immeasurable given greater importance.]

Detoxification is an herbal medicine principle in cancer treatment, because cancer is thought to be the end result of accumulated toxins in the body.

Herbs with antioxidant effects can reduce the side effects of chemotherapy and radiation….[There is, naturally, no mention of the fact that antioxidants can also reduce the effectiveness of chemotherapy (e.g. 1, 2) and even increase cancer risk. The myth that such things can only be beneficial and must be safe because they are “natural” is a dangerous one.]

Another article in the same issue makes similar, and even more absurd, claims:

Stieg, S. Homeopathy for cancer: A gentle approach to a cure. IVC. Winter 2104/2015. 52-55.

Given the overwhelming evidence that homeopathy is only a placebo, the very suggestion that it could be used to treat, even cure, cancer is so at odds with reality it is difficult to see how it is not malpractice. There is really no way such a therapy can benefit the patient, even though the therapeutic ritual might comfort an owner. And belief in such a patently false view of health and disease, which leads one away from the proper use of science-based diagnostic and therapeutic methods, is only going to lead to harm. Yet Dr. Stieg blithely suggests this nonsense is safer and more effective than conventional medicine.

Homeopathy…offers a gentle approach to cancer, treating not just the lesion or condition but the patient as a whole. General well-being is first restored while the cancerous condition is being abated or resolved, and is followed by a return of good health….It is a good alternative to an allopathic approach.

Armed with this delusion that homeopathy is actually an effective alternative to real cancer treatment, Dr. Stieg gives further examples of her complete dismissal of the entire basis of modern, scientific medicine.

While allopathic nomenclature may be helpful in understanding a clinical situation, general disease labels are not needed to find an accurate prescription in homeopathy since they do not describe what is unique to an individual patient.

In other words, homeopaths don’t care what your actual diagnosis or disease is. They choose their therapies, as we have seen, based on arbitrary factors on questionable relevance, like what kind of dreams you’ve been having, what time of day you feel worst, and so on. Knowing you have a particular cancer does not, apparently, help them decide how to treat you, but these sorts of extraneous personal details do.

The hubris displayed, in claiming clear superiority in goals, safety, and effectiveness over real medicine despite the extensive evidence to the contrary only adds to the clear message here: anyone trusting their animal companion to this sort of treatment is being dangerously misled.

Homeopathic treatment aims to cure the patient and have the cancer completely resolve, without causing harmful side effects or requiring repeated medication…The case studies accompanying this article demonstrate how the homeopathic treatment of cancer successfully returned the patients to health and provided an increased quality of life without surgery, chemotherapy, or harmful side effects.

Apart from the generally unreliable nature of anecdotes, one imagines it should be fairly easy to find examples of patients with cancers that resolved complete under homeopathic treatment since homeopaths don’t find “allopathic” diagnosis relevant or necessary and so may well not bothering confirming it before proceeding with treatment. I once had a client whose young, asymptomatic dog was diagnosed annually with some dire illness, often cancer, which I could never identify. Each time, this illness which could only be seen by the homeopath was also magically cured, all without a single outward symptom of illness. Miraculous indeed!

Conclusion
It sometimes difficult not to find such articles amusing in their clear lack of connection to reality. Yet they are actually more tragic than funny, because unfortunately they fool people into believing the practices discussed have real value. The majority of the specific therapies are untested, and the general approach flies in the face of established science.

This is not to say there cannot be any benefit from any of the specific therapies. Some of the things naturopaths recommend, such as a healthy diet and exercise, are certainly beneficial. However, there is also nothing “alternative” about these practices, and they are regularly recommended by science-based clinicians as well. Other therapies, such as herbal remedies, may well have benefits, but these are almost always unproven. What is crucial is that those which do have benefits will also have risks, and these are as unknown as any potential benefits without proper scientific study. And many of the therapies recommended, such as homeopathy and “energy” therapies, are patently useless.

The key problem is that using therapies with unproven or no benefits and unknown risks guided by pseudoscientific notions of how health and disease work, especially in place of therapies based on a sound scientific understanding of disease and for which the benefits and risks are well-established, exposes patients to unnecessary harm. Such an approach had better be capable of performing miracles because only a miracle, a special suspension of the natural laws that govern the physical world, could make such an approach more likely to help than to harm the patient. Unfortunately, humans relied on such approaches for most of our history, with terrible results. Science has more than proven that while it is flawed and imperfect, as all human endeavors are, it is a far better choice for us and for our pets.

 

 

 

 

Posted in General | 5 Comments

Science or Magic? A Illustration of Homeopathic Provings

Posted on December 21, 2014 by skeptvet

Introduction
One of the ways that homeopathy manages to look like a science, rather than essentially the practice of magic, is through the use of detailed and systematic methods that resembles those of real science. One example of this is the “proving,” or what is sometimes called a “pathogenetic trial.”

This experiment resembles clinical trials used in science-based medicine in some superficial ways, and it is often misrepresented as a form of research study. However, the fundamental purpose of true scientific research, including clinical trials, is to control for the misleading effects of various sources of error, most notably biases and other errors arising from subjective human observations. Provings, however, are entirely subjective and so have no control for such errors.

The core principle of homeopathy, that “like cures like” rests on the notion that if a homeopathic remedy causes a specific pattern of symptoms in a healthy person, that pattern of symptoms can be reliably associated with that remedy and used as a guide to when to employ the remedy in treating disease. If a patient has a pattern of symptoms that match those listed in homeopathic references for a particular remedy, that remedy might be the best one for that patient, regardless of what scientific medicine might consider his or her actual diagnosis.

This sound deceptively reasonable, until we look into how it works in detail. I have covered the concept of like-cures-like before, as have many other authors (e.g. Science-Based Medicine, Skeptic’s Dictionary). Basically, homeopaths accept a version of the ancient and widespread, and completely false, theory of sympathetic magic. This is the belief that things which have some sort of superficial resemblance must have a fundamental connection such that one can be used to manipulate the other. The voodoo doll is a classic example. In this case, homeopaths claim that substances which cause certain symptoms in healthy people should be used to cure the causes of those symptoms in the ill. This is a notion that has stubbornly resisted all attempts to prove it is actually true.

In any case, even if this notion were true, there are some pretty seriously problems with how the symptom pattern for a given remedy are defined and identified through provings. Basically, presumably healthy people (no systematic effort to ensure they are healthy is generally made) take a remedy and keep a diary of every experience, physical or mental, they have for a period of time afterwards. After the trial, homeopaths look at these diaries and decide what patterns of symptoms are meaningful, and this becomes the defining characteristic pattern of that remedy.

The subjective nature and potential for bias in this approach has long been recognized. One of the most incisive criticisms of hoemoapthic provings was written by Oliver Wendell Holmes in his Homeopathy and Its Kindred Delusions in 1842, while Hahnemann was still alive. Nothing of consequence has changed in the intervening 173 years.

The effects of drugs upon healthy persons have been studied by Hahnemann and his associates. Their results were made known in his Materia Medica, a work in three large volumes in the French translation, published about eight years ago. The mode of experimentation appears to have been, to take the substance on trial, either in common or minute doses, and then to set down every little sensation, every little movement of mind or body, which occurred within many succeeding hours or days, as being produced solely by the substance employed. When I have enumerated some of the symptoms attributed to the power of the drugs taken, you will be able to judge how much value is to be ascribed to the assertions of such observers.

The following list was taken literally from the Materia Medica of Hahnemann, by my friend M. Vernois, for whose accuracy I am willing to be responsible. He has given seven pages of these symptoms, not selected, but taken at hazard from the French translation of the work. I shall be very brief in my citations.

“After stooping some time, sense of painful weight about the head upon resuming the erect posture.”

“An itching, tickling sensation at the outer edge of the palm of the left hand, which obliges the person to scratch.” The medicine was acetate of lime, and as the action of the globule taken is said to last twenty-eight days, you may judge how many such symptoms as the last might be supposed to happen.

Among the symptoms attributed to muriatic acid are these: a catarrh, sighing, pimples; “after having written a long time with the back a little bent over, violent pain in the back and shoulder-blades, as if from a strain,”—”dreams which are not remembered—disposition to mental dejection—wakefulness before and after midnight.”

I might extend this catalogue almost indefinitely. I have not cited these specimens with any view to exciting a sense of the ridiculous, which many others of those mentioned would not fail to do, but to show that the common accidents of sensation, the little bodily inconveniences to which all of us are subject, are seriously and systematically ascribed to whatever medicine may have been exhibited, even in the minute doses I have mentioned, whole days or weeks previously.

Provings are still conducted in this way, with no real effort to control for bias of any kind. And the kinds of symptoms attributed to the remedies tested are as arbitrary and irrational as even. I recently ran across a beautiful example in a proving conducted by a senior homeopathy student about five years ago.

Homeopathic proving of Procyon lotor (Raccoon fur). Sonya McLeod and Kathleen Taylor, 2009.

That’s right. These homeopaths decided to test the potential medicinal properties of raccoon fur. Well, since they used mostly a 30c preparation, this means they mixed the fur (from a dead raccoon found “in the wild”) with a solvent (water or alcohol) and successively diluted it until there was no chance of any molecules of raccoon fur remaining. So actually they were testing the effects of water that had once had some raccoon fur in it. But the issue of ultradilute substances is a different subject.

At this point, it is also important to mention that what homeopaths consider relevant symptoms is quite different from what science-based medicine considers relevant. Homeopathy is ultimately a practice for healing spiritual ills, of which bodily symptoms are only one manifestation. So mental, emotional, even spiritual “symptoms” are included in the characterization of remedies and the evaluation of patients. Homeopaths also view as salient features like the time of day symptoms are experienced or the side of the body in which they manifest.

While this may sound thorough and “holistic,” it is quite misleading. Since no human is capable of considering the influence of everything in the universe on a patient’s condition, all practitioners make decisions about what is or is not relevant. Science used systematic methods with controls for bias and error to do this. Homeopaths just pick what to pay attention to and what to ignore with no objective attempt to determine which factors really are relevant to maintaining or restoring health.

If I have a dog who is vomiting, what they have eaten is very likely to be relevant to why they are vomiting and what can be done to help them. This has been established by extensive research into how the gastrointestinal system works and how various substances affect its function. The fact that my patient may dream of rabbits, may have been born under a particular constellation, or may live in a house with hardwood floors rather than linoleum are probably less likely to be relevant or useful facts. Without a systematic and objective process of establishing whether these factors are actually connected to disease or the success of treatment, we end up arbitrarily considering anything and everything, which is not a rational or efficient way to practice.

In the raccoon fur proving, 8 individuals were chosen to take the remedy, at a variety of doses and dilutions. None of the methods used in true clinical trials to control for the influence of differences between individuals or groups of subjects were employed. No effort was made to establish the pre-existing physical or mental condition of the subjects or to control for differences between the individual subjects or between the subjects and the population who might one day be treated with this remedy.

The homeopaths did include one individual who received a “placebo” (how this is defined in homeopathic trials is always problematic, since the actual test remedies contain no active ingredients). However, the authors write, “we decided to include symptoms experienced by the prover who took placebo as well.”

This is clearly inconsistent with the approach of scientific research, which uses placebos to control for the influence of belief and expectation on the reports of subjects in a trial. The authors of this proving justify including the individual receiving the placebo with reference to an essay which makes it clear, yet again, that homeopathy is a variety of religion or magic, not science. According to this author, placebo controls are unnecessary since it is not the remedy itself that influences subjects but the idea, intention, or “immaterial essence” of the remedy.

A proving begins, in a literal sense, with the intention to prove a thing, with it being imagined, identified, obtained, and possibly potentised. Should the name of the thing be kept under wraps, double blinded, picked at random out of a hat, the proving date sprung upon the proving group, nonetheless the event field of the proving is the moment in time that intention arose.

…The concept of participation mystique comes to mind in order to afford a description of this phenomenon. In the case of the School, provings have become a recognised corner stone of homeopathic training. This plus familiarity, shared endeavour and healing ideals combine to engender group consciousness and participation mystique. That those who did not ‘take’ the thing, that those who did not even know that the proving would take place within the group, had been affected demonstrates the dynamic nature of the phenomenon.

It is only matter that is bound to space and time. The immaterial essence of the thing, actuated by the intention of the proving group constellates the action field. Forgive me labouring the point: the thing that we are dealing with is essence, spirit, call it what you will, and is not bound within the constraints of space and time. Those who key into it are part of it irrespective of distance or time; they know it telepathically.

The action field of a proving is not necessarily set up by taking orally or sniffing, nor is it necessarily either substance or potency. It may be derived from and by these means or not. Directed meditation and attentive listening is sufficient to initiate and sustain a proving. We have invoked group provings by one member ‘holding’ the concept/image of a thing…Rajan Sankaran experimented with music provings, while at the School we have experimented with ‘thought’ provings. In none of these was pharmacy involved. There was no use of potency, no ‘memory’ of water, no nuclear or crystalline patterning, because there was no substance.

One can see pretty clearly why the claim that provings are in any way at all equivalent to scientific clinical trials is nonsense. The similarity is more that between astrology and astrophysics, or between meteorology and divination.

The symptoms reported in the raccoon proving, which presumably will be used to decide when to employ this remedy in treating actual patients, reads, in some ways, like a horoscope. Vague or ambivalent descriptions are given which could apply to anyone at one time or another, or patterns of completely opposite symptoms are recorded and both interpreted as resulting from the remedy. For example:

…there are periods of effort alternating with inactivity…there were days where they were very active and restless, alternating with times when they had no energy to do much of anything.

Many of the provers also experienced menstrual symptoms…Two of the provers had their periods come as early as 9 days early. One supervisor had intermittent bleeding that came and went. For two provers it either caused or cured heavy period flow.

Many of the provers experienced more ideas and flow of thoughts after taking the remedy.

Sometimes this rush of thoughts increased at night, preventing sleep. Other provers found it very difficult to think and to concentrate, like their minds had become foggy, becoming absentminded and confused.

For some provers, their normal anxiety was ameliorated during the proving. One supervisor experienced a pronounced anxiety on waking at 5am.

The subjective symptoms, including emotions and dreams, show such obvious bias associated with pre-conceptions about the nature and cultural symbolic attributes of raccoons, it is difficult to imagine anyone could be unable to identify this obvious bias.

A few of the provers felt dirty or ugly…There was also a lot about survival.

People needing this remedy will fight for their survival…There was a lot in the dreams about victimization and subordination, abuse, being attacked, and then fighting back or protecting oneself or others.

Many provers…had an increased need to take care of and nurture their children. Many also had dreams of family members. This theme of nurturing and family also came out in the dreams of many of the provers. This is a them common to all mammal remedies, including raccoons who can stay with their young for up to a year.

We also found it interesting that two of the provers had itching and dryness of the nipples. This symptom fits in with the theme of nurturing.

Fear of snakes is also common to all mammal remedies. This symptom showed up in a few separate dreams of one of the provers.

Some provers became sensitive to colour and to bright light. One prover had the desire to wear black, as she found bright colours too stimulating. We can guess this symptom may be related to the raccoon’s increased sensitivity to light since their eyes are suited to night vision.

There were lots of dreams about committing crimes, stealing, criminals, and police. One of the provers had her proving journal stolen during the proving. The raccoon’s reputation as a sneaky bandit and thief comes through very strongly in this proving.

Lots of dreams about food and eating. Many of the provers had increased appetite, perhaps mimicking the raccoon’s voracious appetite in the fall, in preparation for sleeping away the winter.

[Raccoons are] also excellent climbers. In the proving, many of the provers had dreams of trees, and of climbing those trees.

The symptoms attributed to the remedy included things which could not be seen in any rational way as related to the preparation tested except through magic. These included:

Provers and their supervisors often had difficulty getting hold of each other during the proving. At the extraction meeting, the master prover’s internet stopped working,

A few days before the extraction meeting, the master prover’s parking lot was flooded. [categorized with symptoms related by “Flow & Lack of Flow: Water and Dryness”]

Conclusion
As is often the case, the ideas put forward by homeopaths can, at first, seem rational and even superficially similar to scientific practices. However, any investigation into the details of their claims and methods makes it clear that this is a relic of spiritualism and faith healing with no fundamental similarity, or even compatibility, with contemporary science. The methods rely entirely on subjective personal experience and make not even the most minimal effort to acknowledge or account for the biases this introduces.

Posted in Homeopathy | 5 Comments

A Visit to Hogwarts: The BAVH Introductory Course in Homeopathy

Posted on December 16, 2014 by skeptvet

One of the things I like best about homeopathy is that when I want to illustrate how fanciful and ridiculous the theories and beliefs of homeopaths are, there is no need to exaggerate or embellish their claims in any way. All that is needed to demonstrate homeopathy is nonsense and that homeopaths are ultimately faith healers who have rejected the very foundations of conventional science-based medicine is to allow them to describe their beliefs and practices in their own words. A fairly simple comparison of what they claim to reality makes the point quite clearly.

I recently took a brief online introductory course in homeopathy offered by the British Academy of Veterinary Homeopathy (BAVH). This was a free offering intended to lure veterinarians into their full introductory training course, which will set you back £1,300 (about $2100). The course made many of the usual claims about both homeopathy and conventional medicine and illustrated the deep inconsistencies in what homeopaths say and what they really practice.

Throughout the course, the instructors repeatedly emphasize that they accept science and evidence-based medicine and do not reject established healthcare. They then repeatedly emphasize, exaggerate, or manufacture flaws in science and science-based medicine and claim that homeopathy is fundamentally different, and superior, in both theory and practice.

For example, the stated aim of the course is “To enable and encourage veterinary healthcare professionals to integrate the discipline into their clinical practice and to facilitate this within the framework of an evidence based approach.”  However, the instructors repeatedly claim that homeopathy can replace conventional therapies and that homeopathy is fundamentally different, safer and more effective than conventional medicine. Here are a few examples.

Homeopathy can work where conventional treatment has failed.

These natural remedies do not have traditional side effects.

Homeopathy can, in many cases, avoid the need of using antibiotics.

[Homeopathy provides] the opportunity to cure an animal whereas with a conventional approach all you can do at best is to hope to control it with continuous medication or in the absolute worst situations to carry out euthanasia.

[Homeopathy] is an actual philosophy of health and disease, a different understanding of what health and disease actually is… than in current medicine.

This material seems more appropriate for Hogwarts than for a veterinary continuing education course. Let’s have a look at the content in a bit more detail.


An Introduction to Potion Making

The central tenets of homeopathic theory, which originated with the father of homeopathy, Samuel Hahnemann in the 18th century, are reviewed in this course. Generally, no effort is made to provide evidence that these are true, they are simply assumed or implied to be true.

  1. Law of Similars

I have covered this subject before, as have many other authors (e.g. Science-Based Medicine, Skeptic’s Dictionary). Basically, the homeopaths accept a version of the ancient and widespread, and completely false, theory of sympathetic magic. This is the belief that things which have some sort of superficial resemblance must have a fundamental connection such that one can be used to manipulate the other. The voodoo doll is a classic example. In this case, homeopaths claim that substances which cause certain symptoms in healthy people should be used to cure the causes of those symptoms in the ill. This is a notion that has stubbornly resisted all attempts to prove it is actually true.

2. Dilution and Succussion

The instructors acknowledge that one of the biggest stumbling blocks to acceptance of their claims is the fact that many homeopathic remedies are diluted far beyond the point at which any of the original substance could possibly be present. The instructor for this course appears to be trying to have his cake and eat it too. He claims that dilution is not necessary for homeopathic remedies, but then admits that “most of the remedies we use involve dilution way beyond Avogadro’s number.” He admits that homeopathic remedies are usually ultradilute but suggests that Avogadro’s number is no longer relevant for some mysterious reason because we now have quantum physics, which has supplanted Newtonian physics. He offers, however, no evidence for exactly how quantum physics invalidates basic chemistry, merely mumbling about “nanoparticles” and “hydrogen bonds” in a way that is supposed to imply some deep meaning but simply illustrates that he really doesn’t know and is just waving away the problem on faith alone.

If quantum physics had replaced Newtonian physics, I would expect we would be using quantum principles to magically transport airplanes instantaneously anywhere we wanted, rather than shooting them laboriously through the sky using old-fashioned Newtonian physics. Yet we are not.

Finally, the instructor claims it is not the dilution which makes a homeopathic remedy but the succussion. Unfortunately this is just a fancy word for “shaking,” and why shaking should transform water into a specific medicine with properties derived from a substance no longer present is not explained (nor, I would argue, explicable). In any case, he undercuts this attempt to dodge the problem of dilution when he says, “dilution does add to the effectiveness of a remedy.”

Another instructor, in the “evidence-based” section of the course, uses almost exactly the same strategy. She begins by suggesting conventional scientific understanding of chemistry as an interaction between molecules is outdated and not applicable to homeopathy. The scientific view, “requires active substance in this old-fashioned kind of lock-and-key type mechanism.” This instructor also claims homeopathy does not require using ultradilutions, but then acknowledges that “homeopaths mostly do use high dilutions.”

She goes on to claim it is widely accepted that ultramolecular solutions do have activity despite this not being possible under the conventional understanding, and then makes a lot of vague references to various scientific-sounding phenomena like “thermoluminescense,” “NMR studies,” “epitaxy,” “nanobubbles,” “stabilized water clustering,” etc.  Again, there is no attempt at explaining what, if anything, this has to do with the magic of pure water have all sorts of potent and varied therapeutic effects.

This is a classic hallmark of quackery, using a lot of vague, “sciency” language without any actual understanding of the concepts referred to or any real theoretical or data-based connection between them and the claims they are implied to be supporting. All of this is part of the typical pattern of homeopaths acting as if their theories are established, accepted science despite the reality that they are accepted by almost no one except other homeopaths.

3. Individualization of Treatment

Homeopaths like to claim that they tailor their therapies to each individual’s personal needs, while conventional medicine treats patients as so many identical units. I’ve written before about this supposed individualization, and why it is complete nonsense.

Basically, the claim to individualize treatment ignores the whole issue of relevance. Since no human doctor is capable of considering the effect of everything in the universe simultaneously throughout all time on the condition of the patient before them at the moment, all of us must decide which factors are relevant and which aren’t. In scientific medicine, we use the accumulated results of scientific research to understand the relationship between biological processes and all the things that can influence them to bring about disease or to preserve and restore health. It is impossible to perfectly account for all possible factors, but as scientific knowledge grows, we get better and better at understanding what matters and what doesn’t in the care of each patient.

A good example of this is the gradually improving understanding of the white blood cell cancer known generally as lymphoma. Rather than being a single cancer, it is a collection of related but different diseases, and the differences that matter vary from those that can be lumped into broad categories and are common to many patients, down to those that are unique to each individual. We are constantly improving our understanding of these differences, and how they influence treatment, and we are embarking on an era in which we will eventually be able to tailor cancer therapies very precisely to the needs of each individual, through detailed analysis of the genome of each person and each cancer. This is not yet a reality, but it is a plausible future we can reach by hard work and patience.

Homeopaths, on the other hand, choose which factors are relevant to the individual in a subjective, haphazard way that is essentially arbitrary. For example, one instructor in this course indicates that one way to decide whether the homeopathic remedy arsenica album is appropriate for a given patient is the time of day their symptoms seem to worsen. Specifically, “all the symptoms…whatever they may be, are much worse around or just after midnight.” Whether you have vomiting or coughing, a fever or back pain, and regardless of what scientific medicine would determine to be the cause of your disease, this remedy is for you if you think, or your doctor thinks, the symptoms are worse during this magical hour of the day. If you think your symptoms are worse at another time, you might well choose a different remedy. This criterion is based on the uncontrolled, personal anecdotal experience of some homeopath and then blindly followed by subsequent homeopaths without any rational or scientific attempt to find a sensible explanation for why this might be true.

Many other similar criteria, including the emotional experiences of patients, the color or smell of body fluids, the character of pain, and others are assumed to be relevant to the treatment based solely on subjective experiences without any rational or plausible, much less scientifically demonstrated, relationship between these factors and the cause of illness or the success or failure of treatment. This is witchcraft, not science or medicine!

Homeopaths also like to complain that clinical trials don’t provide good evidence for how to treat patients because they rely on the experiences of a group of people, and every individual is different. Yet how do they decide which symptoms indicate the need for which particular remedy? Why through a type of test they call a “proving.” This basically involves giving a remedy to a group of healthy people and having them write down everything they experience, physical, emotional, spiritual, and so on, while taking the remedy. Homeopaths then look through these subjective diaries and subjectively decide which patterns are meaningful, and they then assign specific symptoms to the remedy. In the future, other homeopaths then look at these symptoms to help decide which remedy to use. This is simply basing the choice of treatment for a given patient on the experiences of a group of other people, just as is done in clinical trials. The only difference is that in provings no attempt is made to objectively measure anything, and all the data are subjective and subject to innumerable sources of uncontrolled bias.

 

Evidence-based Magic

Of course, as I’ve discussed previously, the use of language like “scientifically proven” and “evidence-based” has great marketing value for alternative therapies. This is because people, regardless of their philosophical perspective, recognize that science has given us far more reliable knowledge about the world than any other approach, and it has brought about a tremendous and unprecedented improvement in human health and well-being. However, homeopaths use such language in a completely dishonest and disingenuous way.

As already pointed out, the instructors in this course claim to be committed to scientific evidence, yet they belabor, exaggerate, or manufacture all the flaws of scientific research and suggest that their subjective and anecdotal methods are superior. In an entire lecture of this course devoted to discussing “The Evidence Base for Homeopathy” the instructor never once suggests that any tenet of homeopathy or any basis for homeopathic practice might be proven wrong by scientific research. Science is not used by such individuals as a method to develop knowledge and test beliefs but as a marketing tool to promote their faith.

This is clear from the beginning, as the instructor describes how she began studying and using homeopathy at a time when there was no research evidence at all to support it in veterinary medicine. She chose to study it anyway, however, because she already knew it worked based on her personal experience.

The instructor then lists the number of research studies she claims exist to support veterinary homeopathy, without discussing them at all. The strategy is clearly to say that studies exist and allow the listener to suppose they show homeopathy is effective. Having reviewed the evidence base for homeopathy myself in great detail (1,2), I have learned that in fact the sheer number of studies is meaningless since the overwhelming bulk of the evidence is too biased and poorly conducted to mean anything, and the best quality evidence consistently shows homeopathy is nothing more than a placebo.

The instructor then indicates that she does not, in fact, believe scientific clinical trials are necessary or relevant to homeopathy anyway, despite having just suggested they proved homeopathy works. She lists numerous real and imagined weaknesses of clinical trials, without ever addressing their strengths or the tremendous positive impact they have had on healthcare. She then says that homeopathy is buttressed by exactly the subjective evaluation of individual cases that science has proven to be so deeply unreliable:

Case based reasoning is solving a new problem by remembering a previous similar situation and reusing the information and knowledge from that situation…200 years of homeopathic documented case reports and pathogenetic trials form the basis of every prescription choice…alongside cured case analysis…If we look at the case report, perhaps it may be the gold standard [rather than randomized clinical trials].

The approach here seems to be to say that homeopathy is validated by science, but that science isn’t all that reliable, and anyway homeopathy doesn’t need to be validated by science because we already know it works. Needless to say, this is not a logic that is in any way compatible with evidence-based medicine.

The instructor does discuss a recent systematic review of veterinary homeopathic clinical trials, which I have evaluated previously. The conclusion of the review’s authors was that additional research is needed to validate homeopathy. My conclusion is that if the best evidence committed advocates of homeopathy can come up with after 150 years consists of two clinical trials, one of which is weak and the other shows no effect, then there is no reason to think more research will be of any use.

In any case, I found it interesting that the instructor repeatedly mentioned the problem of bias when questioning the value of clinical trials on pharmaceuticals and other conventional therapies, but she neglected to mention the fact that both authors of this systematic reviews are “employed by a homeopathy charity to clarify and extend an evidence base in homeopathy.” Neither does she acknowledge that almost all of the research evidence cited in favor of homeopathy is funded and conducted by advocates for the practice, and most of it is published in journals devoted to homeopathy or other alternative therapies. The problem of investigator and publishing bias cuts in both directions, but homeopaths conveniently ignore this when discussing studies that agree with their own bias.

 

Integrating Magical & Muggle Medicine

The final lecture in this course was a general discussion of so-called “integrative medicine” and why veterinarians should mix science-based medicine and unproven or nonsensical alternatives like homeopathy.  I’ve discussed before the misleading nature of this term (3, 4). Mark Crislip has probably most effectively characterized the integration of scientific and alternative medicine:

If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.

This lecture repeats many of the unsupported claims about the superior safety and effectiveness of alternative therapies. It conveniently ignores the fact that several of the various therapies recommended and used together are based on completely incompatible models of health and disease. The instructor claims that using this hodgepodge of approaches will:

Allow “less reliance on suppressive conventional treatment” with “no suppression of signs or symptoms for a later and much more vicious reappearance later, which is something we see with suppressive conventional therapies”

Integrative medicine “can work where conventional treatment has failed” and lead to “fewer drug side-effects, better clinical outcomes, [and] quality of life for patients and owners.”

She even goes so far as to hint at the truth homeopaths so often struggle to conceal–that homeopathy is ultimately a form of faith healing.

Hahnemann viewed the health of the body as dependant on spiritual health, and he saw disease as fundamentally not a physical abnormality but an abnormality of spirit. Curing disease, then, was a spiritual matter:

During health a spiritual power (autocracy, vital force) animates the organism and keeps it in harmonious order. Without this animating, spirit-like power, the organism is dead.

In disease the vital force is primarily morbidly deranged and expresses its sufferings (the internal change) by abnormal sensations and functions of the organism.

The affection of the diseased vital force and the disease symptoms thereby produced constitute an inseparable whole—they are one and the same. It is only by the spiritual influences of morbific noxae that our spirit-like vital force can become ill; and in like manner, only by the spirit-like (dynamic) operation of medicines that it can be again restored to health.

The instructor of this course references this spiritual orientation when she contrasts scientific medicine with homeopathy, revealing her view that they are fundamentally incompatible. The use of the word “dynamic” is intended to hide the fact that the real force referred to here, which Hahnemann also used the word dynamic to reference, is spiritual and supernatural:

Conventional thinking is based in the material world, with most current treatments and research being centered around genes and the biochemical pathways that are altered in the expression of disease.

Homeopathic thinking is based in the dynamic world with treatments based on symptom expression of the whole individual with symptoms and material changes being a consequence of dynamic disturbance and not a cause of disease.

This lecture also most dramatically paints a picture of harmful and ineffective conventional medicine contrasted with gentle and miraculous alternative medicine. Next to a picture of a dog looking sad, she describes how in conventional medicine “a failure to understand and explain the disease process often leaves the client with a pocket full of drugs, a dog that looks no better,  and a feeling of deep dissatisfaction.” Clearly, science-based medicine is really Sad Dog Medicine.

In conventional medicine “a failure to understand and explain the disease process often leaves the client with a pocket full of drugs, a dog that looks no better, and a feeling of deep dissatisfaction.”

In conventional medicine “a failure to understand and explain the disease process often leaves the client with a pocket full of drugs, a dog that looks no better, and a feeling of deep dissatisfaction.”

Along with a photo of the same dog looking happy, the instructor explains how integrative medicine can improve client compliance and lead to fewer drug side-effects, better clinical outcomes, better quality of life for patients and owners.” Clearly, integrative medicine is Happy Dog Medicine!

 

Integrative medicine can improve client compliance and lead to fewer drug side-effects, better clinical outcomes, better quality of life for patients and owners.”

Integrative medicine can improve client compliance and lead to fewer drug side-effects, better clinical outcomes, better quality of life for patients and owners.”

 

The Ethics of Fairy Dust

There is nothing especially surprising or original in this course. All of the usual clichés, fairy tales, and misinformation associated with homeopathy are present. What is disturbing is that this course is offered as continuing education for practicing veterinarians. Veterinarians are legally required to update and advance their knowledge base to maintain their license to practice. This is intended to protect the public from outdated ideas and ineffective care. However, the purpose of such a requirement is defeated entirely when veterinarians can maintain their license by learning outdated ideas and ineffective care.

What is more, such courses can mislead veterinarians into believing homeopathy has some legitimate scientific basis and is something other than an 18th century pseudoscientific form of faith healing that functions only as a placebo. And the placement of the BAVH and its course alongside mainstream, reputable veterinary medical organizations and their science-based continuing education materials implies an equivalence that is entirely false. It is unethical to practice homeopathy on veterinary patients and to make false claims about it to animal owners and other veterinarians. Some veterinary and governmental organizations have recognized this and taken a principled stand in defense of the public and our patients. If only more would join them.

The British Veterinary Association–

The BVA cannot endorse the use of homeopathic medicines, or indeed any medicine making therapeutic claims, which have no proven efficacy.

The Australian Veterinary Association–

That the Board agreed that the veterinary therapies of homeopathy and homotoxicology are considered ineffective therapies in accordance with the AVA promotion of ineffective therapies Board resolution.

The AVMA Council on Research–

There is no clinical evidence to support the use of homeopathic remedies for treatment or prevention of diseases in domestic animals.

The Australian National Health and Medical Research Council–

NHMRC concludes that the assessment of the evidence from research in humans does not show that homeopathy is effective for treating the range of health conditions considered.

The United Kingdom House of Commons Science and Technology Committee–

In our view, the systematic reviews and meta-analyses conclusively demonstrate that homeopathic products perform no better than placebos. We could find no support from independent experts for the idea that there is good evidence for the efficacy of homeopathy.

 

 

 

Posted in Homeopathy | 8 Comments

Vaccination Protects Children from Allergies Later in Life

Posted on December 14, 2014 by skeptvet

One of the innumerable complaints made about vaccination is that it “stresses the immune system,” and that this can lead to immune-system diseases, including allergies. Dr. Crislip at Science-based Medicine has already dealt with the notion of immune system overload, pointing out that our immune system is exposed to as many antigens in about a month of daily life as it is in the entire recommended childhood vaccination regime. Yet vaccine opponents continue to blame all sorts of health problems on damage to the immune system from vaccinations, including allergic diseases. A recent study in children challenges that claim.

Herbarth, O. World Allergy Organization International Scientific Conference (WISC) and Congress of the Brazilian Association of Allergy and Immunology. Abstract 1014. Presented December 7, 2014.

The study looked at about 2,200 children. In every group studies, including those considered at increased risk for allergies due to having parents with allergic disease, vaccinated children had LOWER rates of allergies than unvaccinated children.

As always, a single study is never the last word on any subject. And a small study in human children doesn’t rule out the possibility of some link between vaccination and allergies in dogs and cats. But in addressing concerns about potential adverse effects of vaccination, it is important we be guided by evidence, not mere theory or fear. There is now at least some evidence that vaccination not only doesn’t increase allergy risk but that it may be protective against allergies. Those who believe otherwise should bear the burden of providing evidence for their claims.

Posted in Vaccines | 8 Comments

The Fence-Learn to Love Nuance, Complexity, and Ambivalence

Posted on December 13, 2014 by skeptvet

From the only humanist, atheist, skeptic rock star out there, Tim Minchin!

 

Posted in Humor | 2 Comments

Antibody Titer Testing as a Guide for Vaccination in Dogs and Cats

Posted on December 11, 2014 by skeptvet

I have been involved in a number of discussions lately regarding the concept of testing antibody titers in lieu of vaccinating, and I thought it might be useful to summarize some of the issues involved in this complex topic. I will briefly explain the basic biology of immunization and then talk about the issues surrounding the usefulness of vaccine antibody titers.

How Vaccination Works
The immune system has many mechanisms for identifying and destroying infectious organisms, such as bacteria and viruses, in order to prevent or control disease. The details are bewilderingly complicated, and entire courses, even entire careers in science, are focused on trying to understand how this process works. There are a number of web sites that offer simple overviews of how vaccination stimulates the immune system to protect against infectious organisms (e.g. National Institutes of Health, Centers for Disease Control, National Network for Immunization Information).

Briefly, when a virus or bacterium invades the body, specialized cells that are part of the immune system begin to attack it. Some of these fight off the organism directly, but others communicate with the rest of the immune system to stimulate a host of different responses throughout the body. Part of this global reaction is a memory response. After an initial infection and illness, the immune system learns to recognize the organism so if it sees it again in the future, it can mount a faster and more effective response. Sometimes, this memory provides complete and lifelong immunity. However, sometimes, this immunity is incomplete or only temporary. The difference depends on a lot of factors involving the type of infectious organism and the individual’s immune system.

Vaccines teach the immune system to recognize an infectious organism without producing the actual illness. Usually, vaccines use a killed or weakened version of the infectious organism so the immune system can learn to recognize it without an actual infection and illness. In the future, then, the immune system of a vaccinated individual will be able to generate a faster, stronger protective response to the real organism, therefore avoiding an infection. Again, the effectiveness of vaccination and the duration of this immunity to infection vary and depend on many factors.

There are two basic components to the immune system’s memory of a disease-causing organism. One, called humoral immunity, involves producing proteins called antibodies. These are proteins that recognize a particular organism and help the body to fight it. Antibodies are produced for almost every organism we encounter, naturally or through vaccination, so we all make antibodies to thousands of organisms all the time. We can also get some antibodies from our mothers as babies, through nursing.

The other aspect of the memory response is called cell-mediated immunity. This involves special cells in the immune system which learn to recognize and attack invading microorganisms.

So when we talk about measuring antibody titers, we mean that we are measuring the amount of antibodies in the bloodstream which are produced in response to infection or vaccination for a single microorganism. If we have had an infection or vaccine in the past, we will often have antibodies against that particular organism. These may last for weeks, months, or years. It is important to realize, however, that having antibodies does not always mean we are immune to an infectious organism. If we have too few antibodies, we may be susceptible. And in the case of some organisms, having antibodies is not enough to fully protect us, so we may be susceptible no matter how many we produce. And since we produce antibodies during an infection, having them may not mean we have been vaccinated or had past exposure to an infectious disease, they may simply mean we are currently infected with that disease!

The challenge, then, in using antibody levels to make decisions about vaccination is that the significance of the measurement depends on the details of the biology of the particular organism. When we talk about antibodies and vaccination, we have to talk about one specific disease at a time, because the rules that apply to one disease won’t necessarily apply to another.

Core Vaccines & Antibody Titers
As I mentioned above, for some diseases antibody titers don’t represent immunity or susceptibility very well. Antibodies to common cat disease, for example, such as Feline Herpes Virus (FHV) or Feline Leukemia Virus (FeLV), don’t correlate well with protection against infection. A cat with a high antibody titer against FHV may very well still be susceptible to infection and may benefit from vaccination. And a cat with a high titer for FeLV is probably already permanently infected rather than immune. Antibody titers for rabies and Feline Panleukopenia, however, do correlate with immunity against these diseases.

For dogs, the most important core vaccines are for Canine Distemper Virus (CDV), Canine Parvovirus (CPV), and Rabies. In the case of these diseases, a high antibody titer does usually mean the dog is immune, which would mean additional vaccination for those diseases is not needed at the time the titer is measured. However, the rate at which individuals lose immunity to specific diseases varies quite a bit, so there is no way to predict based on a single titer when that individual will become susceptible again or need additional vaccination.

What most people don’t realize is that while a high titer for some disease, such as CDV, CPV, and Rabies, means a dog is probably immune, a low titer does NOT mean the dog is susceptible and needs to be vaccinated. That is because the other component of the immune system’s memory response, cell-mediated immunity, can protect against infection sometimes even when measured titer levels are low.

So a positive or high titer may mean no vaccine is needed right now, but a low titer does not mean a dog should be vaccinated. In the case of a low titer, we have no way of knowing if that dog is susceptible to these diseases or not.

Specific Titer Tests
You may wonder how we know whether or not a certain level of antibodies measured in the blood mean that individual is protected against that disease. The answer is that the only way to know is through challenge testing. This means that we have to measure antibody levels in a number of individuals with a variety of different titers, then try to infect them with the specific disease we are studying and see which ones get sick and which don’t. This is how cutoff levels for antibody titers have been determined for CDV, CPV, Rabies, and other canine and feline vaccine-preventable disease.

This kind of challenge testing may only be accurate for a specific titer testing method. So if two different laboratories use two different types of titer test, the titer level that is protective will be different, and both would need to do challenge testing to figure out what titer level is protective for the specific test method they each use

Obviously, there are ethical issues associated with this kind of research, and so very little of it is done any more. Most titer tests available have not been validated by challenge testing but have simply been compared to tests which have. This may mean that the values used to determine if an individual is immune to a particular disease are accurate, but it is also possible that they are not. So there is usually some uncertainty about what a “protective” titer really means.

As an example, one popular in-house antibody test sold to veterinarians is called Vaccicheck. This test provides a simple measure of roughly how much antibody an individual dog has against CDV, CPV, and also Canine Infectious Hepatitis. Again, no challenge studies have been done to validate the specific cutoff this test uses, but the test has been compared to what are considered “gold-standard” titer tests. For the canine Vaccicheck test, here are the results of one such study:

B.A. Butler; P.C. Crawford . Accuracy of a Point-of-Care Immunoassay to Determine Protective Antibody Titers For Canine Parvovirus and Canine Distemper Virus. ACVIM Forum, 2013.

Immunoassay sensitivity was 97% for CDV and 99% for CPV. Specificity was 75% for CPV and 79% for CDV. Many of the false positive reactions were in samples with antibody titers near the reference laboratory PAT cutoff. Overall diagnostic accuracy was 90% for CDV and 94% for CPV.

Sensitivity, specificity, and both positive and negative predictive value are somewhat complex statistical topics. Basically, this study showed that when the Vaccicheck test indicated a negative result (low titer level), this was very accurate. Of course, this result doesn’t help us make vaccination decisions because it doesn’t tell us whether or not the individual is vulnerable to infection since cell-mediated immunity may still be providing protection.

The accuracy of a positive result (high titer level) was also pretty good, but not nearly as good as that of a negative level. This means that some dogs will have a positive test, suggesting they are protected, when they really don’t have a high level of antibodies and may or may not actually be immune.

So overall, this test will usually tell us when a dog has a high CDV or CPV titer and does not need to be vaccinated, though it will get some of these wrong. It will more reliably tell us when a dog has a low titer level, but that doesn’t help much us decide if that dog needs to be vaccinated or not. Generally, other in-house titer tests have similar pros and cons. You can see that it can be difficult to make vaccination decisions based on this kind of test.

Legal Issues
The legal requirements for vaccination vary by county and even municipality, so it is difficult to make accurate generalizations. Most jurisdictions only require proof of vaccination against rabies, since that is the disease of greatest concern with respect to human health. Most jurisdictions also do not allow titer testing in lieu of vaccination for rabies, though some may. And when titers are used, the only test that is usually accepted is the FAVM from the Kansas State University veterinary laboratory. So while titers are representative of immunity for rabies in dogs and cats, and thus can indicate when vaccination is not needed, they are not often useful practically because they don’t fulfil the legal vaccination requirements.

Titers may or may not be accepted by other parties that require vaccination for other diseases, such as boarding kennels, training facilities, and dog show organizers. Which tests, if any, are accepted is up to the individual organization. So titers may not always be useful in avoiding vaccination if we are vaccinating specifically to meet a legal or institutional requirement.

Vaccine Safety
I have written many times about the subject of vaccine safety. While I believe in avoiding unnecessary vaccination, and while my own recommendations to clients often lead to less frequent vaccination than commonly practiced or suggested in some guidelines, I believe that the fear of vaccines that leads many people to desire to reduce vaccination is unjustified. Vaccines are very, very safe, and many of the specific concerns, such as mercury in vaccines, and autoimmune disease from vaccination, are unproven, exaggerated, or just plain untrue. So while I believe the evidence indicates we can safely vaccinate most dogs and cats far less often than has traditionally been recommended, I do not believe we should use titers or other methods to reduce vaccination out of fear.

Children in the United States and Europe are experiencing a growing risk of preventable infectious disease, and the real harm that comes from such infections, specifically because of a decrease in compliance with sound, evidence-based vaccination recommendations. Mumps, measles, and whooping cough, for example, are injuring and killing children who could have been protected, due mostly to fears among parents which are based on misconceptions or lies. I believe we must be very careful not to follow this same path in veterinary medicine.

So while I see utility for antibody titer testing in some situations, it is distressing that some companies selling these tests seem to be marketing them using fear and the testimonials of individuals who are known opponents of science-based medicine and promoters of irrational anti-vaccine positions and unscientific alternative therapies. Dr. Shawn Messonier, Dr. Karen Becker, Catherine O’Driscoll, and Dogs Naturally Magazine, are some of the entirely unreliable sources to which the Vaccicheck company refers pet owners in promoting their product. We will do far more harm than good for our pets if we base our vaccination decisions on pseudoscience or irrational fear, which is what these individuals often promote, rather than sound science.

Additional Information

  1. Here is a very clear, informative article on the use of antibody titers in guiding vaccination practices:

Ford, RB. Antibody titers versus vaccination. Today’s Veterinary Practice. May/June, 2013.

2. Here is the American Animal Hospital Association (AAHA) Canine Vaccination Guidelines, which talks specifically and in detail about particular vaccines and comprehensively reviews the available evidence on efficacy, safety, and duration of immunity. The guidelines specifically address titers and generally recommend some uses of them:

Despite the confusion and controversy surrounding antibody testing, these serologic tests are useful for monitoring immunity to CDV, CPV-2, CAV-1, and RV…. The tests are also medically useful to ensure that a dog responds to a specific core virus vaccine and/or to determine if immunity is present in a previously vaccinated dog. Those tests are also used to demonstrate protective immunity as well as DOI.

3. The American Veterinary Medical Association (AVMA) Report on Cat and Dog Vaccines also addresses the subject of titers, but the conclusion is somewhat different from the AAHA guidelines:

…it is currently impossible to determine the immune status of an animal relative to all the infectious diseases of concern without conducting challenge testing. Further, serologic results do not appear to be a sensitive indicator of immune response for some diseases or vaccines in cats and dogs. It was concluded that there are variations within and among laboratories, as well as a lack of validated sensitivity, specificity, and confidence intervals, leading to the conclusion that serologic testing is generally unreliable….

…higher serologic titers are generally associated with greater resistance, but…it is possible for an animal with no titer for a specific organism to have solid resistance to challenge. Conversely, an animal with a titer that is generally regarded as protective for a specific organism may also become ill as the result of challenge, possibly because of overwhelming exposure or immune suppression…

…practitioners are cautioned to consider carefully whether the test proposed has been appropriately validated, thereby providing a predictive value for whether the animal needs to be revaccinated, and includes confidence intervals to help the practitioner determine the risks and benefits of relying on the test results. Practitioners should also determine whether a selected laboratory has a quality control program sufficient to make the test results reliable.

4. The American Association of Feline Practitioners (AAFP) has also issued guidelines for vaccination of cats. These guidelines only comment briefly on the use of antibody titers (also called serology):

It is important to be aware that a variety of methods…are utilized to determine titers.…Titer results in individual cats determined at the same point in time, therefore, may vary depending on the methodology used. When electing to submit serum for antibody titers, it needs to be appreciated that a ‘positive’ antibody titer result obtained on one day is not necessarily predictive of a ‘positive’ titer at any point in the future.

In general, cats having a ‘positive’ antibody titer against FPV are immune. In fact, the protective immunity that develops following FPV vaccination is expected to be sustained for several years. By contrast, serum antibody titers for FHV-1 and FCV may not necessarily correlate well with protective immunity and should not be used to predict protection in the future. Antibody titers to FeLV and FIV do not correlate with immunity and should not be used to determine the need for vaccination. Although feline rabies titers can be determined (by a certificated laboratory) in individual animals, a rabies titer is only an indication of serological response to vaccination. Rabies titers are not recognized as an index of immunity.

In addition, the absence of significant levels of antibody (a ‘negative’ titer) is not necessarily an indication of susceptibility… In some diseases (eg, FHV-1), cell-mediated immunity is important and a cat may be immune even though no antibodies are detectable.

Because antibody titers may not reliably correlate with, or predict, the degree of protection or susceptibility for an individual cat, the Advisory Panel recommends employing defined revaccination intervals rather than measuring antibody titers to assure protection.

Bottom Line
Vaccine titers can tell us an individual is immune and does not need to be vaccinated for some specific diseases. For other diseases, a positive titer does not reflect immunity. And a negative titer cannot reliably tell us if an individual is susceptible and need additional vaccination. Therefore, the usefulness of titers in determining if an individual needs to be vaccinated is quite limited. This usefulness is further dependent on the specific kind of titer test used and how it has been validated.

Titers can lead to a reduction in unnecessary vaccination in some cases, if an individual has a titer that can be identified as representative of immunity. However, titers can also lead to an increase in unnecessary vaccinations if animals with negative titers are routinely vaccinated even though they may already be immune.

Titers cannot generally be substituted for legal vaccination requirements, particularly for vaccination against rabies

The vaccines we use are extremely safe, so we have to remind ourselves and our clients that when in doubt it is probably far safer to vaccinate than not to vaccinate, unless there is some know history of adverse vaccine reaction, autoimmune disease, etc. The resurgence of vaccine-preventable disease in children following the decline in vaccination rates is well-demonstrated, and we don’t want to go down that road.

Using scientific evidence concerning the duration of protective immunity following vaccination in a population, and the existing guidelines based on this evidence, is probably a more appropriate strategy for determining how often to vaccinate individuals than is the routine use of antibody titers. Current guidelines for specific vaccines are based on a comprehensive review of existing evidence, and they can be updated as new evidence emerges. While titers may have use in some specific situations, they are not a simple, universal substitute for rational, science-based vaccination guidelines, and they do not offer as reliable an “individualization” of vaccination recommendations as some promoters suggest.

Posted in Vaccines | 46 Comments

Probiotics in Horses

Posted on December 9, 2014 by skeptvet

I’ve written frequently about probiotics, microorganisms given as supplements to hopefully benefit health.  Often claimed as an “alternative” therapy, probiotics are really no different from any therapy in science-based medicine. The theory behind their use is certainly consistent with established scientific knowledge. Microorganisms are undoubtedly important in health and disease for humans and most other animals. And there is significant in vitro and lab animal research to suggest some value to the use of probiotics. Finally, there is some limited clinical evidence for the safety and efficacy of some probiotics for some health issues in human and veterinary patients.

However, there are also problems with probiotics as a medical therapy.  The natural microbial ecosystem of every individual is different, and the flora of different species is often quite dissimilar. We know very little about the type and role of most of the hundreds of species of microorganisms that live in and on most animals. Whether a particular probiotic organism helps, harms, or does nothing at all in a given patient depends on many factors, most of which we are still quite ignorant about. So our ability to utilize the potential of probiotic therapy is rudimentary for now, and it will only improve as we do the laborious work of building our knowledge and understanding.

Probiotic therapy is also hampered by the lack of regulatory oversight, especially here in the U.S. Several research studies have shown that the majority of probiotic products on the market are mislabeled and often contain nothing resembling what is on the label. A ridiculous proportion of these products contain no living organisms at all, and so are in no real sense even probiotics. The dramatic claims often made for such products are almost never justified given the limited evidence and abysmal quality control for most probiotic products.

This month’s issue of the Journal of Veterinary Internal Medicine has an excellent article on the subject of probiotics in veterinary medicine. Though this article focuses on probiotics for horses, a species I do not treat in practice, in touches on many important issues concerning probiotics that are also relevant to probiotics for dogs, cats, and other veterinary species.

Schoster, A. Weese, J.S. and Guardabassi. L. Probiotic Use in Horses – What is the Evidence for Their Clinical Efficacy? J Vet Intern Med 2014;28:1640–1652

The authors give a nice overview about the kinds of organisms that are most appropriate for use as probiotics. The usual criteria include the ability to survive passage through the acid environment of the stomach and commercial processing, adhere to cells in the GI tract, and have a measurable, beneficial effect on the patient. The available evidence they cite suggests that a probiotic organism need not necessarily come from the species in which it is to be used, though there is some debate about this.

The authors also mention a criterion often overlooked, especially by those who claim probiotics are inherently safe because they are “natural.” Microorganisms can share genetic material, and one type of gene sharing that can create significant harm is the transfer of antiobiotc resistance genes. If a probiotic organism has resistance to antibiotics and conveys this to another organism in the gut that can cause disease, this will make treatment of that disease more difficult if it develops. In Europe, regulators require probiotic product be tested for such antibiotic resistance, but this is not the case in the U.S.

The authors also cover the primary mechanisms of action proposed for probiotics: immune system modulation, production of antimicrobial substances, out-competing potentially harmful microorganisms in the gut ecosystem, and inhibition or inactivation of toxins produced by other organisms. The diversity of effects, and the differences between organisms, illustrate the complexity of such biological therapies, and why simple, general rules about “good” and “bad” organisms aren’t very reliable.

The authors discuss the issues of poor quality control and inadequate regulatory oversight, which I have already mentioned.

The article also covers the always-important question of safety. Few adverse effects have been reported in people or animals taking probiotics, but it is unclear what the real risks are at this point. For one thing, many probiotic products, as I have already mentioned, are mislabeled. If they don’t contain any appreciable quantity of live organisms, they of course aren’t likely to have any harmful effects, but they aren’t likely to have any positive effects either. For this reason, the absence of reports of harm may reflect the absence of any effect at all for many probiotic products. At least some negative effects have been reported, in humans and in other animals, so while these products are probably pretty low risk, there are likely some circumstances and individuals in which they can cause harm, and more research is needed o understand the risks.

Lastly, the article covers the clinical studies of probiotics in horses to date. Only eight studies are cited, with a mix of positive and negative results. Some studies showed beneficial effects, but many showed either no difference from placebo or effects on some outcome measures and not others. And at least one reported a negative effect. The overall evidence suggests some possible value to probiotic therapy, but at this time the risks and benefits are largely unknown. The authors conclusions are these:

Although probiotics have shown promise in the treatment of selected diseases in humans, the evidence that they can be used to control diseases in horses so far is weak.

Based on lack of regulation regarding quality control of commercial products, use of over-the-counter products is questionable, particularly in the absence of scientific information on safety and clinical efficacy.

Despite all of these limitations, probiotics generally are regarded as safe, cost effective and easy to administer. Therefore, additional research is warranted to test possible applications in equine veterinary practice.

Very similar conclusions likely apply to the use of probiotics in small animals. They are probably low risk and are relatively easy to use and inexpensive. In most cases, there is little evidence that they have significant benefits, but their use for some conditions, such as diarrhea, is reasonable given the limited but suggestive evidence available so far.

Unfortunately, most products are probably unreliable in quality, so those used should be ones from reputable companies that have demonstrated reasonable labeling accuracy (for example, Iams’ Prostora and Purina’s Fortiflora).

More research is certainly needed, and I am hopeful that as it is done more and better evidence will be available to support specific uses of particular probiotic organisms for particular problems. At this time, however, excessively broad or confident claims are, as always, unjustified, and we need to be clear with our clients that there is a lot of uncertainty and guesswork in our use of probiotics.

 

 

 

Posted in Herbs and Supplements | 5 Comments

The SkeptVet & the Media

Posted on December 7, 2014 by skeptvet

As I’ve often pointed out, the majority of the information on complementary and alternative therapies for pets available on the internet comes from companies or advocates selling these products and services. One of the reasons I write this blog is to make sure that the skeptical and evidence-based perspective on these practices is available for people to consider and to balance against the marketing and hype. And because this perspective is inherently less appealing to most people than optimistic anecdotes and testimonials, and since it draws a fair bit of hostile response, there are few individuals available to provide this point of view.

Because of this, I am often approached by journalists who are looking for someone willing to provide a skeptical “balance” to articles in the media about alternative veterinary therapies. The articles themselves, unfortunately, are often quite credulous or play to the heartwarming anecdote rather than the scientific evidence. But I still feel it important that pet owners are aware of the scientific and skeptical perspective so that they have the opportunity to consider the evidence before making healthcare choices for their pets.

Therefore, I usually agree to be interviewed for these articles even if I often end up being portrayed negatively or being the “token skeptic” in a piece generally very positive to a therapy I am critical of. On the other hand, sometimes I find I am asked to provide a negative perspective on a therapy I actually have a positive view of, since people sometimes mistake skepticism for a globally negative attitude towards new or unfamiliar ideas, rather than simply as an attitude of requiring substantive evidence before drawing conclusions about a claim.

I have kept track of many of the articles for which I have been interviewed since one of my interests is the portrayal of science and alternative medicine in the media. I have posted this list here, since the articles may be of interest to some readers. However, I must emphasize that just because an article is listed here or I have been quoted, I do not necessarily agree with the claims or perspective of that article. Even my own quotes, I have found, can sometimes be arranged so as to create a misleading impression of my views on the subject being discussed. Therefore, I do not necessarily endorse the claims or arguments presented in these articles, even if they are supported by selective citation of my comments. Certainly, there are many points I do agree with in some of these, but I only take credit or blame for my own words in their full context.

Vet says pet pot could fix one of most common owner complaints
By Robin Roberts
Daily Brew, 2015

If Your Veterinarian Offers Acupuncture, Find a Different Vet: Sticking needles in your dog won’t make it feel better.
By Brian Palmer
 Slate, 2014

Acupuncture for Your Dog
By Mary Helen Miller
WUTC radio story, 2014

Pet Lovers Beware: When The Drugs Don’t Work
By Peter Aldhous
Medium, 2014

Evidence, communication key to evaluating veterinarian
By Brennen McKenzie
SF Gate.com, 2014

Spay & Neuter Quandary: Weighing the new options.
By Martha Connors
Bark Magazine, 2014

Homeopathy Debate Heats up as AVMA Policy Review Nears
By Heather Biele
DVM360 Magazine, 2014

Judging Merits of Homeopathy not an AVMA Objective
By Jennifer Fiala
VIN News Service, 2014

Raw Diets for Pets: Weighing the Pros & Cons
By Sandra Murphy
Natural Awakenings, 2013

Pet Psychics: Pet Mind Readers?
By Rutaksha Rawat
Creature Companion, 2013

Nutrition Plus A wide variety of supplements are popular among pet owners.
By Kerri Chladnicek
Veterinary Practice News, 2013

Stem Cell Therapy for Dogs: Unleashing Hope, Angst
By Tom Kisken
Ventura County Star, 2013

How much rawhide is too much for dogs?
By Brennen McKenzie
SF Gate.com, 2012

The Promise of  Probiotics
By Elizabeth Devitt
Pet Age, 2012

Let the Evidence Show
By Mark Thill
Veterinary Advantage, 2012

Pet pointers: Meow-choo, Meow-choo! Sneezing in Cats, Diet and Kidney Disease
By Brennen McKenzie
San Jose Mercury News, 2011

How to Help Elderly Dogs with Degenerative Conditions
By Brennen McKenzie
San Jose Mercury News, 2011

Don’t Pamper Pets with Halloween Candy
By Brennen McKenzie
San Jose Mercury News, 2010

 

 

 

 

Posted in Presentations, Lectures, Publications & Interviews | 1 Comment

Evidence Update: Evaluating the Benefits & Risks of Neutering in Dogs and Cats

Posted on December 7, 2014 by skeptvet

In 2010, I published a narrative review of the literature evaluating the risks and benefits of neutering in dogs and cats. Much additional research has been completed and published since then, and I have just complete an update of my review. The new evidence has resulted in a number of changes to my conclusions and recommendations, so while I will leave the link to my previous review active, this update supersedes the older version.

Evaluating the Benefits & Risks of Neutering Dogs and Cats: 2014 Update

 

Posted in Science-Based Veterinary Medicine | 8 Comments

Dr. Andrew Jones, the Angry Saint of Alternative Veterinary Medicine

Posted on December 1, 2014 by skeptvet

I’ve written a couple of times about Dr. Andrew Jones, a vet from Canada who makes his living selling alternative therapies and “veterinary secrets” online. Dr. Jones was once a practicing veterinarian, not just an online huckster and snake oil salesman. However, despite repeated warnings and fines from the regulatory authorities, he refused to stop making unfounded and illegal claims, drumming up business by claiming the rest of the veterinary profession were incompetent and greedy and suppressing “The Truth” about alternative therapies. Rather than abide by reasonable standards of respectful, professional behavior, he choose to surrender his license to practice medicine.

The ruling against him by the regulatory board sums up how Dr. Jones operated, and how he continues to conduct himself:

This Panel was dismayed, disheartened and discouraged by the extent to which the Respondent, Dr Andrew Jones, expresses a disparaging attitude towards his colleagues and his profession throughout his writings.

The Panel considered Dr Jones’ marketing material a serious example of his unprofessional behaviour in that his marketing material has an all pervading, persistent theme of denigrating other members of his profession in order to draw attention to himself. In his self-laudatory statements, Dr Jones’ constant harangues serve to throw the veterinary profession into disrepute.

Giving up his license undoubtedly freed him to fully indulge his primary marketing strategy, sowing fear and mistrust of science-based medicine in order to sell questionable alternatives and quackery. What is more, it allows him to portray himself as an altruistic “outsider” speaking truth to power and caring only for the welfare of animals and their human companions. He manages to put quite a self-serving spin on his legal troubles, casting himself as a martyr oppressed by malign forces out to crush alternative medicine.

Clearly the College of Veterinarians wants me to stop publishing on the Internet, especially alternative dog and cat health information…The profession loses as the College of Veterinarians has directed disproportionate resources towards prosecuting me, and further muzzled any current practicing Veterinarians who are inclined to speak out. Who wins? A small group of conservative Veterinarians who want to keep practicing Veterinary medicine conventionally, with no room for dissenting opinions.

Ultimately, someone has to make a stand, and I am frankly tired of The College of Veterinarians being the big Bully on the playground that no one is willing to stand up to.

As silly and disingenuous as this image is, it certainly resonates with his supporters, who are vehement, even hysterical in their response to any criticism of Dr. Jones. In a follow-up to my post about Dr. Jones, I shared some of the bizarre and childish comments from his defenders, including these gems:

This idiot must not have much to do, or the jam to say who he is. That makes him a weak minded, useless piece of dog poop!

What a spineless excuse for a human being.

a highly volatile dictatorial site run by a wannabe megalomaniac. A truly disturbed person with a anger management issue venting via their little site to their own personal herd of sycophants. I would dismiss them like a fly on your arm. Just troubled souls with no purpose.

Just another stooge for corporate interests such as big pharma

You are a lying scumbag…… eat dog shit and die !!!! you evil money monger !!!!

Certainly, Dr. Jones sets the tone on his site with his own persistent slurs on the veterinary profession. Posts like “Why I am ashamed to be a vet: a shocking expose of the profession” and “Bad Vets,” and his book, “Veterinary Secrets: How conventional veterinary medicine may be harming your pet and what you can do about it” illustrate his attack-dog marketing style, and the enormous ego it takes to decide that nearly the entire veterinary profession is ignorant or venal and only you and a select few know The Truth.

And for someone whose business model is founded on denigrating other veterinarians, Dr. Jones seems to have a fairly thin skin. His response to my first post about him ignored all the issues and simply whined about my supposed anonymity. And though that little kerfuffle was three years ago, apparently Dr. Jones still harbors some resentment.

He recently wrote a post entitled Scientific Evidence for Homeopathy. This is ludicrously misnamed since he actually avoids scientific evidence almost entirely. I have reviewed the research on homeopathy in detail, documenting the case against it, responding in careful detail to the poor evidence presented to defend it. Dr. Jones ignores all of this, instead choosing to mention one medical institution that has bought into homeopathy, cite one research study (which has been critically reviewed and shown not to be reliable), and finally fall back on the refuge of quacks through the ages—personal anecdotes.

I noticed this post when it came out, mostly because Dr. Jones used a screenshot of a post from this blog to illustrate the science-based view of homeopathy. In the piece, Dr. Jones disparagingly refers to the majority of scientists and the medical profession, including myself, who acknowledge the failure of homeopathy in scientific tests as “so called torch bearers of ‘evidence based whatever’” and suggests that rather than warn the public that homeopathy is quackery we “sip on some soothing chamomile tea.”

Despite the reference to my blog, I didn’t see any reason to respond to the post since nothing of substance was said, and I’ve answered these sort of vacuous clichés many times. However, a reader subsequently pointed out a little detail I’d missed which I thought nicely illustrated the reality behind Dr. Jones’ carefully crafted image. Though he casts himself as altruistic and noble, standing up against the bullies, cynics, and hateful stooges of industry, occasionally little windows open up in this saintly façade. In this case, Dr. Jones couldn’t help but express his real feelings when he captured and named the screenshot of my blog:

http://www.theinternetpetvet.com/wp-content/……asshole.png

Though it’s been three years since I wrote about Dr. Jones, and despite his own “persistent theme of denigrating other members of his profession in order to draw attention to himself…in his self-laudatory statements,” Dr. Jones apparently still harbors some pretty personal anger about the criticisms of him I have made, and he expresses this in as silly and unprofessional a manner as the supporters I quoted above.

Dr Jones likes to characterize those who criticize his nonsense or his method of promoting it as angry, threatened, or somehow acting on malign personal motives. In the past, Dr. Jones characterized my criticism as expressing “a strong dislike” of him. This is merely a projection of his own narcissism. I have no personal feelings about Dr. Jones, and his claims and actions do not directly affect me in any way, neither personally nor professionally. I believe he is either deluded or dishonest in many of his claims, such as the claim that homeopathy has any therapeutic value. And I believe pet owners and our animal companions would be better off if he were not spreading misinformation on the internet. But he has the right to spread it, just as I have the right to identify it as the nonsense it is.

If Dr. Jones chooses to claim publically that science-based veterinary medicine is useless or harmful and that other veterinarians are misguided or venal, and he does so in order to sell his own products, he ought to expect some criticism. If he really believes in what he is peddling, he would be far more successful in defusing this criticism by backing up his claims with real evidence, rather than making silly, snide comments about “evidence-based whatever” and sneaking grade-school insults into his posts.

 

 

Posted in General | 27 Comments