DISCLAIMER: I do not intend to offend anyone. The writing style here is largely informal and scented by the burning of the midnight oil. Please forgive any typos.
In March 2023, Vol. 10 of the new exciting journal Lancet Regional Health Southeast Asia (LRH-SEA) published my correspondence on why homeopathy should not be included in the new efforts towards forging a pluralistic health system in India. In this piece of <600 words and 18 references of which 11 were systematic reviews/meta-analyses, I made the following main arguments:
There is no-to-negligible evidence for the efficacy of various homeopathic treatments. Even the positive evidence is cautioned to be of poor quality.
There is some evidence that the use of homeopathy might be unsafe and can lead to non-fatal and fatal injuries to patients.
The commonly used defense by homeopathy supporters that randomized controlled trials (RCTs) and other study designs used for establishing evidence in medicine are not suitable for testing homeopathy is an unsubstantiated way of escaping valid criticism. If fields such as economics and political science can use modified forms of RCTs to establish evidence for efficacy, why can’t homeopathy?
Over the last 100 years, there has been NO concrete evidence for proposed mechanisms of action for homeopathy. No mechanistic (molecular, physiological, biochemical, or otherwise) evidence for how and why ‘like cures like’, ‘extreme dilution’ or ‘dematerialized spiritual force’ result in better health. In the same period, several allopathic practices have updated themselves based on growing and changing evidence.
Homeopathy is not original to India. It is a German colonial practice adopted by rich Indians under British rule. Hence, it should not be clubbed with other traditional medical practices of India. Promoting homeopathy is at odds with decolonizing medicine.
The Vol. 12 of the LRH-SEA will publish a response by Drs. Gadhave and Tillu to my article. I was not aware of this until Dr. Gadhave sent me the link. Their letter starts as follows -
“The letter "Yes to a pluralistic health system, but no to homoeopathy", must be challenged for its unfair approach towards homoeopathic medicine and its role in Universal Health Care (UHC).”
In their attempt to challenge my article, the authors seem to be particularly fixated on one out of the five points raised by me. The fifth one. The authors agree with me that homeopathy was introduced by an Austrian physician but insist that it should be taken as Indian because it helped an Indian Raja and was also used for treating cholera. How these two things make homeopathy traditional Indian medicine remains unanswered to me. However, if I understand the authors’ argument and apply it crudely to another scenario, then Yoga belongs to the traditional cultural healing practices of California sheerly due to the number of yoga studios in Los Angeles and San Diego, and other places in the state. While what can be considered foreign to or a part of one’s traditions is subjective, it seems obvious that practices that originated earlier within a geography would take precedence over the ones brought in by others later to the geography in the census of traditions. My argument is simply that in that sense, homeopathy cannot be considered traditional while Ayurveda or Unani can be.
The authors go on -
“How is it a colonial force? If we consider every western pharmaceutical development as a colonizer, we must also reconsider allopathic medicine. The arguments of the letter fail to propose that homoeopathic medicine promotes colonialism; on the contrary, homoeopathic medicine should be included in India's medical decolonization movement as it follows an open approach of ‘pluralistic health systems, right from the British era.”
Here, in an attempt to do some “gotcha” exposition, I believe that the authors completely missed my original point - the one that seems to have been understood quite well by thousands of people who read my article. In fact, my article has an explicit statement that goes -
“More important than its colonial origins is the lack of evidence for efficacy and safety of homeopathy for treating common ailments and severe diseases.”
But let me clarify it further. The argument is not that all practices introduced during the colonial era should be given up. Absolutely not. Practices that have been demonstrated to help societal development and maximize social benefit can be retained. Examples would be evidence-based elements of allopathic medicine, gender role reforms, caste reforms, etc. The argument to reject homeopathy is not based on its coloniality. It’s based on the other four points that I raised. The argument for not clubbing homeopathy with Ayurveda and others is based on homeopathy’s colonial origins. These are two separate arguments.
Next, the authors write something that seems abjectly odd -
“Mahatma Gandhi and Rabindranath Tagore praised homoeopathy. Gandhiji encouraged homoeopathic medicine and advocated government patronage.”
Before going into the details, let me mention that for such a loaded statement, the authors have not provided a single reference. My piece was not spontaneous. It was a culmination of my reading over the last couple of years. Reading that included going through the history to better understand the context beyond articles in medical journals. Hence, when I came across this statement, I was reminded of a few other things that I had read on the issue. I was reminded of a thread on StackExchange discussing this. This thread guides you to another important resource named Gandhiserve. This is an international network that has put together an archive of Gandhiji’s communications, writings, audios, videos, and chronological account of events. In the Gandhiserve archive, the word homeopathy comes up only a couple of times. I could find it once in 1940 and twice in 1941. In 1940, Gandhiji wrote to someone to let them know that he had arranged for their (i.e., someone else’s and not Gandhiji’s own) homeopathic treatment in Delhi (see serial no. 000031054). In 1941, his correspondence with Amrit Kaur is more revealing of his views (see serial no. 000029312):
“I have little faith in homeopathy and yet a homeopath a crank like myself is here and treating some patients.”
If this is found to be somewhat ambivalent, let me present more evidence of what Gandhiji truly thought of homeopathy. ‘Gandhi’s Body: Sex, Diet and the Politics of Nationalism’ by Joseph Alter cites two instances of Gandhji’s views. Screenshots below:
From pg. 63 from the chapter Nature Cure and Yoga.
From pg. 160 from the notes section.
Anyone with legitimate comprehension and unbiased intent would be able to gauge that Gandhiji did not support homeopathy. Furthermore, Ramchandra Guha - one of the greatest historians of Gandhi - has previously written on how Gandhiji’s views on allopathy changed positively after he saw the evidence. However, this change of opinion never happened for homeopathy. As per Guha, if anything, Gandhiji seemed upset with the indifferent approach of alternative medicine practitioners toward quackery in their field -
“I regret to have to record my opinion based on considerable experience that our hakims and vaids do not exhibit that spirit in any mentionable degree. They follow without question formulas. They carry on little investigation. The condition of indigenous medicine is truly deplorable. Not having kept abreast of modern research, their profession has fallen largely into disrepute.”
I have been unable to find any evidence for the notion that Gandhiji asked for governmental support for homeopathy. Nor there seems to be any direct reliable archival evidence of Tagore praising homeopathy. I am unsure of where the authors found credible information to put forward such a loaded claim. My best guess is that the authors seem to have fallen for the dubious third-party homeopathy websites on the internet putting random fake quotes. These are the same websites that also incited the StackExachange discussion. I am not going to link them here to avoid giving them any platform. Maybe inadvertently, but by claiming that Gandhiji encouraged homeopathic medicine, authors are propagating misinformation. If authors are unable to present reliable references, this statement should be retracted from the letter.
In the next paragraph, the authors write -
“Secondly, unproven and controversial theories like severe dilutions and dematerialized spiritual energy are the debate. The word "vital force" (dematerialized spiritual power), refers to the human body's ability to respond to external stimuli. We agree that these ideas seem different, but homoeopathy and ancient medicine should not be judged by contemporary medicine's epistemological and ontological standards.”
I appreciate all these ideas. But my argument is that these are just words and ideas. What about the evidence? Also, if homeopathy should not be held to contemporary medicine’s epistemological and ontological standards, what standards should it be held to? BTW, the “standards” that allopathic medicine is held to are not set by practitioners of allopathic medicine. They are mostly set by people pushing for evidence-based medicine where evidence is determined by experimental designs and statistical analyses that are invented and conducted mostly by epidemiologists and biostatisticians and not clinical allopaths. There are several instances of practices in allopathic medicine that have been torn down and left out because they did not pass the standards. Yet, allopaths don’t seem to have a problem with the standards.
“These systems are the product of experimental and traditional healing knowledge, as well as social and cultural philosophies that have grown with time.”
Instead of this verbosity, why don’t the authors cite three solid (high-quality and reliable) references to convince the readers that homeopathy is efficacious and safe?
“Every traditional medicinal system has these ideas. Ayurveda has tridoshas and Unani has four humours (blood, phlegm, yellow bile, and black bile.[4] Therefore, this shouldn't be a reason to leave homoeopathy out of the coverage of the UHC.”
One of the original claims in my article was that homeopathy has been piggybacking on Indian traditional medicine. The authors seem to have (unknowingly) supported my claim. More importantly, the method of argumentation is flawed here. Comparing a set of controversial beliefs (homeopathy) with another set of beliefs (Ayurveda) that hasn’t passed the litmus test itself is hardly useful to generate any credibility or trust in the eye of the reader. The fact that the authors could not cite a single useful reference that makes a clear case for homeopathy’s efficacy, safety, and tested mechanisms of action is quite telling.
Anyway, the authors go on -
“Thirdly, randomised controlled trials (RCTs) have not demonstrated the efficacy of homoeopathy medicines. The authors agrees to have different study designs for individualized treatments, as RCT evidence may not be the best. Modern medicine uses reductionist biomedical epistemology to generate proof, which may not be effective for homoeopathy, which views health and disease holistically.”
In my article, I have pointed out that RCTs are no longer limited to allopathic medicine but are heavily used across “… several other disciplines including psychology, economics, community health, implementation science, and public policy…”. Why is it that all these disciplines are able to establish their findings using RCTs but only homeopathy constantly fails to do so? Further, the authors’ conception of “modern medicine” seems to be out of touch with reality. In 2023, a large chunk of allopathic practitioners are aware and accepting of biopsychosocial approaches toward health. In fact, the World Health Organization (WHO) predominately composed of “modern medicine” practitioners and supporters, promotes a biopsychosocial view in its constitution.
“Homeopathy's worldview regards medicine as more than pharmaceutical products and techniques. It is impossible to comprehend or value the usefulness of these medical systems to their fullest extent without understanding the philosophical viewpoint provided by them.”
Maybe authors should have thrown a light on what that philosophy entails and how can its path be traced all the way to therapeutic potential in an evidence-based manner. Without that, it all is a word salad. BTW, the lack of references for all such statements continues.
In the next part, the authors have attempted to make it look as though homeopathy is a highly prevalent and important practice.
“Currently, the use of homoeopathic medicines falls second to the use of Ayurvedic medicines under the AYUSH umbrella, as reported by Kaur et al.[5]”
Let me break it down. Kaur et al. note -
“Within AYUSH, homeopathy is second only to Ayurveda in terms of demand.”
These are two very different claims given that demand here is measured by the number of government-run health and wellness centers. Nowhere in the article do Kaur et al. claim that homeopathic medicines are being consumed in second only proportion after Ayurveda. (Side note: public health infrastructure is primarily an indicator of supply in healthcare and not demand, so, Kaur et al. has it wrong too). More importantly, second-only in AYUSH translates to 4.4% of total health and wellness centers. The review also notes that 85.5% of such centers are allopathic. As a health systems researcher, let me add more context. Health and wellness centers form only a chunk of the healthcare infrastructure in India. There are sub-centers, community healthcare centers, subdistrict and district hospitals, civil hospitals, medical college teaching hospitals, private secondary and tertiary hospitals, multispecialty hospitals, etc. And of these, over 75-80% are allopathic.
“Although homoeopathy units are only 5%, they treat around 20% of patients when compared to the services offered by allopathic clinical units.”
This statistic is based on Figure 3 in Kaur et al (see below). What do you see at the top? It is a statistic based on 2016-17 outpatient data from govt. run health and wellness centers in Delhi. How representative should this be considered for a diverse country of 1.4 billion? The answer is absolutely not.
The authors could have cited data from the National Sample Survey (NSS) - the nationally-representative household surveys conducted every few years that the government and every other national and international organization relies on. The NSS data from 2017-18 reveals that a meager 1.97% of outpatient visits in India fall under homeopathy.
So, it is completely misleading to say that homeopathy is treating 20% of patients when it’s handling (because treating is a high bar to cross) less than 2% of outpatients. Side note, we haven’t counted inpatient hospitalizations that are mostly treated by allopathic practitioners.
The last part goes the following way -
“Homoeopathic medicines may help reduce the burden on allopathic outpatient departments. It treats chronic illnesses carefully and at a reasonable rate, benefitting the society. After all, patients’ treatment choices are of utmost importance in evidence-based medicine. Homeopathic medicine has a potential to serve as a strong pillar of AYUSH and contribute substantially to achieve universal healthcare in India. We need to be open to achieving UHC, which is the ultimate goal of healthcare.”
Again, all this is in the right spirit. But all these are just words. After reading this half-baked and full-bland letter, the questions that bugged me are the following: Where is the evidence for homeopathy? Can the strongest supporters also not present it? At least the evidence of the kind that follows “homeopathic standards”. Why is India so interested in homeopathy when Germany (where this quackery originated) and several other countries have already given up? How many more Indian patients need to suffer from adverse events and delay to real care before we stop pushing this quackery?
To be clear, my argument is not that I would never believe that homeopathy works. I will gladly change my view if the evidence starts bending toward the benefits of homeopathy. But until that day, I will boldly call homeopathy quackery because -