Friday, 13 July 2018

Antibiotics are failing. Our Government and Conventional Medicine does not know what to do. This is the advice provided for government by the Alliance of Registered Homeopaths

Written evidence from the Alliance of Registered Homeopaths (ARH)

1. Declaration of interests
The Alliance of Registered Homeopaths (ARH) is the second largest voluntary registering and regulatory body for the homeopathy profession in the UK, and currently represents just under one thousand qualified homeopaths. ARH is set up as a Company Limited by Guarantee, and is a not for profit organisation. ARH has based its regulatory criteria on the UK National Occupational Standards for Homeopathy (NOS), which were developed and agreed across the profession. We are committed to supporting and promoting a high standard of safe, effective homeopathic practice, and to ensure that quality homeopathy is available to all who wish to use it.

2. An overview of antimicrobial resistance
In 2001 the World Health Organisation (WHO) published its global strategy for containment of antimicrobial resistance. (1) Acknowledging the urgent need for all countries to take effective action to reduce AMR, the WHO strategy included several important recommendations such as:

     * Encouraging more appropriate use of antimicrobials
     * Reducing antimicrobial use in food production animals
     * Reducing antimicrobial use by improving both public health and domestic hygiene routines
     * Developing knowledge and understanding of AMR
     * Developing new drugs to combat AMR

3. In 2012, the WHO published ‘The evolving threat of antimicrobial resistance; Options for action (2) is a book which re-emphasised the urgency of the situation, redefined the actions necessary to effectively manage AMR, and encouraged policy makers and the global community to commit to increasing their actions to combat AMR. A detailed account of the threat posed to public health by AMR is outlined in Volume II of the Chief Medical Officer’s Annual Report (2011), which was published in March 2013. (3) This report also makes a number of recommendations which broadly concur with the findings of the earlier WHO publication. The situation is clear; AMR has become a major threat to world health. Infectious diseases already place a social and economic burden on society, so an increase in AMR is likely to have a significant impact in three main areas:

     I. Loss of productivity due to absence from work as a result of minor illnesses (this cited as the cause for over one fifth of all lost work days in the UK during 20113).
     II. Increased need for hospitalisation as a result of unresolved infectious diseases (in the UK, it is estimated that the costs to the health service, labour market, and to individuals, amounts to £30 billion/year (3).
     III. Increased mortality resulting from infectious diseases, or routine interventions/surgical procedures, which respond to currently available antimicrobial drugs.

4. Research into other treatments
Although the development of new drugs is one of the recommendations listed to combat AMR, experience suggests that this may prove to be a self limiting approach. Microorganisms have the ability to modify over a relatively short period of time, leading to the development of new strains, which are resistant to antimicrobial drugs. An approach to AMR which focuses on improving general health and reducing the use of antimicrobial drugs, is more likely to produce long term benefits.

5. This observation is supported by the results from a recent retrospective cross-sectional analysis of national primary care prescribing data, undertaken by researchers from the University of Bristol in England during 2016 (4). In this study, a group of UK, German and Dutch researchers led by Bristol University, set out to examine if there was any difference between antibiotic prescription rates in conventional GP practices, and GP practices where doctors had an additional training in integrative approaches (ie, they had also been trained in a complementary/alternative (CAM) system of medicine). This study used NHS digital monthly prescribing data for 2016 and covered 7,274 surgeries. The data was then compared with results taken from nine surgeries where GPs had been trained in integrative medicine (IM). As well as looking at overall anti-biotic prescribing, the study also considered anti-biotic prescriptions made specifically for respiratory infections and urinary tract infections (UTI).

6. Analysis showed no significant difference between the two types of practice when it came to anti-biotic prescriptions for the treatment of UTIs. However, practices that employed GPs trained in IM has significantly lower anti-biotic prescribing rates overall, than those with GPs with a conventional training only. The treatment of respiratory infections also required less anti-biotic prescriptions in surgeries using an integrated approach.

7. It is acknowledged that the results of this study are limited by the lack of data in several areas, such as the number of consultations, individual GP characteristics, individual deprivation scores and continuum of care. Also, the number of practices which have GPs trained in IM is small because accessibility of IM/CAM within the NHS in general practice in England is very limited. Currently, IM/CAM provision is currently almost exclusively private in the UK.

8. Nevertheless, the authors of this study have concluded that the difference seen in antibiotic prescribing rates at practices with GPs trained in IM warranted further study. Significantly, the lower antibiotic prescription rates of practices with GPs trained in IM are in line with current national guidance aimed at reducing antibiotic usage and antimicrobial resistance.

9. The fight against antimicrobial resistance should include utilizing additional treatment strategies to manage infections commonly encountered in primary care. One such intervention is homeopathy, which has been successfully used to treat a wide range of medical conditions, since the early 1800’s. Some historical, and more recent, examples follow below:

10. Homeopathy and epidemics
Extensive medical records exist, recording the effectiveness of homeopathy in the treatment of epidemics. For example, in the pre antibiotic era, homeopathy was successfully used to treat the Spanish flu outbreak of 1918, a fact which has been well documented, especially in the US. The medical records of hospitals across the country consistently show a mortality rate of above 28% in sufferers treated allopathically, as opposed to a mortality rate of just over 1% of those treated with homeopathy. A more detailed account of homeopathy's efficacy in treating the Spanish flu outbreak in the US, is documented in a report to the Journal of the American Institute of Homeopathy, entitled 'Homeopathy in Influenza – A Chorus of Fifty in Harmony. (5)

11. In 2008, a groundbreaking research study was conducted in Cuba, where homeopathy was used to prevent an outbreak of leptospirosis in 2.4 million people during the hurricane season. The results of this remarkable experiment were first presented at a conference in Havana in December 2008. The Cuban based Finlay Institute, responsible for the production of allopathic vaccines, is also involved in the research and development of homeopathic products. They were responsible for the manufacture of a homeopathic Leptospira nosode, which was rapidly made available to populations in the three areas most affected by the hurricanes. The result was that following the intervention, a dramatic decrease in mortality was observed, with confirmed cases of Leptospirosis at lower levels than normally expected. (6) Furthermore, there were no fatalities in hospitalized cases. This compared to several thousand confirmed cases of Leptospirosis in previous years, including some fatalities, even in populations where the allopathic vaccine had been used. Another feature of this study was its cost efficiency. The Leptospirosis nosode programme had been delivered at a total cost of around US$200,000, whereas a 'normal' vaccination programme, which would only be delivered to the most 'at risk' population, would be expected to cost in the region of US$3,000,000. The implications of these findings to third world countries, struggling to provide effective health interventions at a price they can afford, are massive.

12. The Finlay Institute has continued to use a homeopathic prophylaxis against Leptospirosis since 2008, and the results have shown a significant reduction in the occurrence of this disease. The subsequent studies demonstrate the potential effectiveness of homeopathic prophylaxis in reducing the spread of an infectious disease which would normally be widespread, and would probably require antimicrobial drugs to be used as part of a treatment routine.

13. Homeopathy and infections
Respiratory disorders, such as pneumonia, have been identified as a leading cause of infectious disease related mortality, especially in our increasingly ageing population. Upper respiratory tract infections (URTIs) occur frequently in children, and in one study assessing morbidity in pre school children due to URTI (7), the authors observed that over 58% of the study cohort developed a common cold, and over a twelve month period, over 47% had more than two colds. There appears to be a link between a compromised immune system leading to recurrent infections, and the over prescription of antimicrobial drugs. For several decades, antibiotics have been used to treat common conditions such as upper respiratory tract disorders, even before they develop symptoms associated with bacteriological involvement, and now it is recognized that this intervention may lead to complications in addition to recurrent infections, such as disruption of pro bacteria in the colon, which can result in abdominal pain and diarrhoea. One outcomes based trial, originally intended as a cost evaluation of the effectiveness of homeopathy, demonstrates that homeopathy can provide a valuable treatment option for some respiratory disorders.

14. A cost evaluation of the treatment of respiratory disorders, was undertaken in the Campo di Marte Hospital, Tuscany, Italy, from 1998 – 2003. (8) The cost of conventional drug treatment given to a group of patients suffering from asthma and recurring respiratory disorders, was monitored for one year prior the introduction of homeopathic treatment, then compared to the conventional drug costs incurred over a two year period, following the introduction of homeopathic treatment. The analysis shows a reduction in drug costs specific to respiratory disorders of over 46%, and a reduction of general drug costs of over 42% in the patient group given homeopathy. Overall patient wellbeing also improved significantly, a fact which undoubtedly contributed to the reduction in drug requirements. For the patient group suffering from asthma specifically, conventional drug costs were reduced by 71% during the first year of homeopathic treatment, compared to the group receiving only conventional medication, whose drug requirements resulted in a 12% increase in overall costs. According to a news release from Asthma UK, dated 21 October 2009, the treatment of asthma in the UK costs an estimated £1 billion per year. The Italian study shows a cost saving on conventional drugs ranging from between 42% to 71% over a two year period. This makes the long term implications for delivering effective, cost efficient treatment of asthma with homeopathy, highly significant.

15. Evidence which shows the effectiveness of homeopathy
A number of scientists consider the randomised, double blind, placebo controlled trial (RCT) to represent a gold standard for determining the efficacy of a therapeutic intervention. However, RCT's have several inherent fundamental flaws: They are designed to support/enhance a particular outcome. The results they produce can, either intentionally or unintentionally, be interpreted to reflect the required outcomes. RCT protocols are founded on a number of broad generalisations and assumptions, making it difficult to take into account the reactions of each individual participant. RCT's were originally developed as an appraisal tool, and were intended to support and augment evidence acquired through other, more observation based means. Because homeopathy is a system of medicine in which individualisation is key to a successful prescription, gathering evidence via RCT's presents a significant challenge. However, a number of RCT's looking for quantitative evidence to support the efficacy of homeopathy, have been undertaken. For example, in 1997, a meta analysis of data extracted from 89 clinical trials was published in The Lancet, (9) and concluded that the results showed the beneficial action of homeopathy could not be attributed to the placebo affect alone. Two subsequent reviews, analysing trials from the same data set, corroborated this conclusion, (10, 11) though less strikingly than the original systematic review. This highlights a problem associated with meta analyses in general, which is that the quality of the reviews under consideration determines the usefulness of the information extracted via systematic analysis. Another problem may arise when the researcher selects the reviews to be analysed, via criteria likely to influence the outcome. Undoubtedly there is a valuable place for the RCT within scientific research, providing its limitations are fully acknowledged when interpreting the resulting data.

16. Most RCTs in homeopathy are small scale when compared to RCTs in conventional medicine, however they consistently indicate a positive outcome. For example, a study undertaken between 2002-2004 in Trondheim, Norway, (12) investigated whether individualized homeopathic treatment could be effective in preventing URTIs in children. One hundred and sixty nine children under the age of ten, who all had a history of URTIs, were selected, and randomly assigned to either receive individualized homeopathic treatment, or conventional care, over a twelve week period. This was a pragmatic trial, designed to measure the effectiveness of homeopathic treatment under everyday ‘real life’ circumstances. The children who received homeopathic treatment experienced fewer days suffering from URTIs (an average of eight days, compared to thirteen in the control group), and had significantly fewer symptoms, suggesting that homeopathy can be effective in both the prevention and treatment of URTIs in children.

17. Other RCTs have shown homeopathy to be effective in treating childhood infections such as glue ear, where antibiotics would normally otherwise be used. In 1999, a small scale study (13) concluded that the group of children treated with homeopathy required less antibiotics and less visits to the specialist, than the group receiving standard care. A different trial, which was comparative and non-randomized, showed that children suffering from acute otitis media14 experienced more rapid pain relief, and a reduction in recurrence of infection, following homeopathic treatment, when compared to the group of children treated conventionally. Undoubtedly, there is a need to undertake more RCTs in homeopathy in order to further develop our knowledge of the potential of homeopathy in reducing AMR. Further research is also required in the fields of outcomes-based evidence, (which can either be clinically sourced, or patient generated in the form of a 'measure yourself medical outcome profile' (MYMOP)), and empirical evidence, which is data acquired through direct observation, usually under controlled circumstances, where results are reported according to previously agreed protocols. There may be some overlap with outcomes-based evidence.

18. The overuse of antibiotics in production animals
In April 2011, the Director General of the WHO, Dr Margaret Chan, issued a stark warning about the imminent dangers presented by antibiotic resistance. As part of a panel discussion entitled ‘Antibiotic resistance. No action today, no cure tomorrow’, Dr Chan presented some of the facts currently being considered in this investigation. In the European Union, Norway and Iceland, an estimated twenty five thousand people die each year from common resistant bacterial infections. This figure is taken from about half of the fifty three member states within the WHO European Region, and the death toll from all of Europe in unknown, but without question, antibiotic resistance is increasing at an alarming rate. All this carries financial costs as well as human costs, with the EU alone paying out an estimated €1.5 billion on dealing with the consequences of antibiotic resistant organisms.

19. Dr Chan was also critical of the overuse of antibiotics in production animals, warning that resistant bacteria can easily spread via the food chain. It appears that outside of the EU, low doses of antibiotics are routinely used to aid growth promotion, a practice which carries health implications for all of us. Globally, it is estimated that about 80% of antibiotic use, is in production animals, including fish, meat, dairy and egg production. Tetracycline has been added to a paint applied to the hulls of ships, in order to reduce accumulations of barnacles and algae. This is certainly an area where alternatives to antibiotics need to be considered.

20. Homeopathy has been used to treat both domestic and farm animals for many decades, and although most of the literature supporting its effectiveness is empirical, a number of RCTs involving veterinary homeopathy have been conducted. In 2012, the first full study of RCTs in veterinary homeopathy was published (15). Out of one hundred and fifty published trials, just thirty-eight met the researchers rigorous criteria of representing a ‘substantive report of a clinical treatment or prophylaxis trial in veterinary homeopathic medicine randomised and controlled and published in a peer-reviewed journal’, and only three trials focused on individualised homeopathy (the remainder using a non-individualised approach, such as homeopathic prophylaxis). A full and systematic review of all the selected studies is currently being undertaken, and the results will further develop our knowledge and understanding of the effectiveness of homeopathy in enhancing the general health of production animals.

21. In the UK, an increasing number of farmers are becoming aware of the role homeopathy has to play in improving general levels of health and wellbeing in their production animals.
Just over nine years ago, a small group of homeopaths and homeopathic vets, established a course designed to help farmers learn how to use homeopathy safely and effectively. This teaching course developed into Homeopathy at Wellie Level (HAWL), and has since taught over five hundred farmers about the use homeopathy as an additional tool within their normal health management strategy. Farmers who have completed a HAWL course have consistently observed an improvement in the overall health of their animals, and have found themselves better able to take immediate and appropriate action in a range of emergency situations.

22. In conclusion
This submission has been an attempt to demonstrate the breadth and range of homeopathy as an effective treatment option for a number of conditions where antibiotics might otherwise be used. It focuses mainly on section two of this investigation’s terms of reference; ‘What should be the key actions and priorities Government’s next AMR strategy?’ AMR is a problem which will prove challenging to resolve, but it is to be hoped that increased awareness of the health crisis we currently face, will encourage policy makers and healthcare providers, to invest in developing our knowledge and understanding of how homeopathy, and other CAM interventions, can be used instead of anti-biotics, to effectively treat infectious diseases.

23. In the Netherlands, the Dutch Research Consortium (16) was established in 2015 to explore CAM’s potential role in the future treatment of common infectious diseases. The objective of this consortium is to investigate and further develop effective CAM treatments for infectious diseases affecting both humans and animals. Perhaps the time is now right for the UK to consider establishing its own consortium, with similar objectives.

Karin Mont, on behalf of the Alliance of Registered Homeopaths
28 June 2018


Bibliography
1/ WHO Global Strategy for Containment of Antimicrobial Resistance – WHO/CDS/CSR/DRS/2001.2

2/ The evolving threat of antimicrobial resistance; Options for action - WHO Patient Safety Programme, 2012

3/ Annual Report of the Chief Medical Officer; Volume II, 2011 – Infections and the rise of antimicrobial resistance (DoH, March 2013)

4/ van der Werf ET, Duncan LJ, von Flotow P, Baars EW (BMJ Open, March 2018) - Do NHS GP surgeries employing GPs additionally trained in integrative or complementary medicine have lower antibiotic prescribing rates? Retrospective cross-sectional analysis of national primary care prescribing data in England in 2016

5/ Dewey, WA. Homeopathy in Influenza – A Chorus of Fifty in Harmony. Journal of the American Institute of Homeopathy, 1921

6/ Bracho, G, et al - Large-scale application of highly-diluted bacteria for Leptospirosis epidemic control –- Homeopathy (2010) 99, 156e166 (Faculty of Homeopathy)

7/ Kvaerner KJ, Nafstad P, Jaakkola JJ. - Upper respiratory morbidity in preschool children: a cross-sectional study - ArchOtolaryngol Head Neck Surg 2000; 126: 1201–1206.

8/ Rossi E, Crudeli L, Endrizzi C, Garibaldi D - Cost-benefit evaluation of homeopathic versus conventional therapy in respiratory diseases. 2009

9/ Linde K, Clausius N, Ramirez G, et al. - Are the clinical effects of homoeopathy placebo effects? A meta- analysis of placebo-controlled trials. Lancet, 1997; 350: 834–843

10/ Linde K, Scholz M, Ramirez G, et al. - Impact of study quality on outcome in placebo controlled trials of homeopathy. Journal of Clinical Epidemiology, 1999; 52: 631–636.

11/ Ernst E. - A systematic review of systematic reviews of homeopathy. British Journal of Clinical Pharmacology, 2002; 54: 577–582

12/ Steinsbekk, A. Fønnebø, V. Lewith, G. Bentzen, N. - Homeopathic care for the prevention of upper respiratory tract infections in children: A pragmatic, randomised, controlled trial comparing
individualised homeopathic care and waiting-list controls – Elsevier Publications - Complementary Therapies in Medicine (2005) 13, 231—238

13/ Harrison H, Fixsen A, Vickers A. - A randomized comparison of homoeopathic and standard care for the treatment of glue ear in children. Complement Ther Med 1999;7(3):132—5

14/ Friese KH, Kruse S, Ludtke R, Moeller H. The homoeopathic treatment of otitis media in children—– comparisons with conventional therapy. Int J Clin Pharmacol Ther1997;35(7):296—301

15/ Mathie RT, Hacke D, Clausen J. Randomised controlled trials of veterinary homeopathy: Characterising the peer-reviewed research literature for systematic review. Homeopathy 2012; 101: 196–203. [doi: 10.1016/j.homp.2012.05.009]

16/ Kok, E.T et al (2015) - Resistance to Antibiotics and Antifungal Medicinal Products: Can Complementary and Alternative Medicine Help Solve the Problem in Common Infection Diseases? The Introduction of a Dutch Research Consortium. Evidence-Based Complementary and Alternative Medicine 2015, Article ID 521584