Retail pharmacies have had a sugar pill problem for some time – in the form of glorified placebos that are sold as medicine. Homeopathic “remedies” may look like conventional medicine when they’re stocked on pharmacy shelves. But unlike conventional medicine that has actual ingredients, homeopathic products don’t contain any “medicine” at all. Not surprisingly, there is convincing evidence to show that homeopathy is useless as a medical treatment, and fundamentally incompatible with a scientific understanding of medicine, biochemistry and even physics. So why is it sold in pharmacies? There is a fair case to be made that this practice is unethical, as pharmacy sales may mislead consumers into thinking that these products are safe and effective. Yet a recent survey showed two-thirds of Montreal pharmacies sell the placebo flu remedy Oscillococcinum. In the midst of flu season, why would pharmacies sell an inert substance to consumers?
Duck that’s really, really, (really) diluted
Part of the objections to homeopathy in pharmacies is based on the fact that it is nothing but a placebo. Homeopathy is often misunderstood as a natural remedy, akin to a type of herbalism. Homeopathy was invented out of whole cloth in 1796 by Samuel Hahnemann, a German physician. He described the practice as guided by two key principles, which he called “laws”:
- The “Law” of Similars – Hahnemann believed substances that produce specific symptoms in healthy people will cure those same symptoms in an ill person. Sometimes referred to as “like cures like”, the law of similars is simply a form of magical thinking. Homeopathic “remedies” can be made with natural ingredients like salt or onions, but also substances like shipwrecks, light bulbs, the Berlin Wall and even vacuum cleaner dust or moonlight. When infectious material is used, the remedy is called a “nosode” and homeopaths believe that these products can cure or prevent infections. Deciding which substances will cure which symptoms is determined by a process called a “proving” which is entirely without any scientific basis.
- The “Law” of Infinitesimals – Hahnemann believed that the effectiveness of a remedy increases the more that remedy was diluted. He advocated a series of sequential dilutions with shaking (succussion) after each dilution, believing that the water would “remember” its with the original substance. According to Hahnemann’s theories, when sufficient water has been added to dilute the original substance away so that zero molecules remain, the “remedy” was thought to be at its most powerful. Imagine putting one drop of a substance into a container of water. Only that container is 131 light-years in diameter. Now shake it. That’s equivalent to the “30C” dilution that is popular with homeopaths. You’d have to eat a tablet of sugar the size of the Earth to get a single molecule of the original substance.
Oscillococcinum is prepared by decapitating a barbary duck, taking 35 grams of its liver and 15 grams of its heart and fermenting it for 40 days:
The fermented duck broth then undergoes serial dilutions (1 part in 100) 200 times in a row, (i.e., 200C). The final dilution is dripped on tablets of lactose and sucrose. 200C is seriously potent in homeopathy-speak. It’s been noted that in order to obtain even a single molecule of the original fermented duck, a volume of tablets greater that the mass of the entire universe would need to be consumed. Here is a table showing just how dilute it is:
It is mathematically impossible that there is any of the original fermented goo in the final product. Yet you might not know any of that if you read the packaging.
There is no serious scientific debate about homeopathy. Consequently you’d expect pharmacy schools, filled with PhD’s with backgrounds in pharmacology, medicinal chemistry, and therapeutics, to have the requisite background and ethical principles to caution students, and the broader pharmacy profession, about the implausibility and ethical unacceptability for the pharmacy profession to offer homeopathy for sale. You’d probably expect the profession (which is self-regulated in most countries) would want to avoid the association with pseudo-science. You’d be wrong:
A survey of 150 Montreal pharmacies conducted last month by the McGill Office for Science and Society found that two-thirds of them stocked Oscillococcinum, despite the fact that the product “does not work [and] cannot work according to our scientific knowledge,” reads a publication on the office’s website. The product, which claims to shorten the duration of flu symptoms, was retailing for $37.99 for a box of 30 doses at a Montreal Jean-Coutu pharmacy Wednesday.
The Office for Science And Society at McGill University recently undertook a survey in Montreal to understand just how easy it is to find Oscilliococcinum in a pharmacy:
We focused exclusively on the five biggest pharmacy chains in Quebec: Jean-Coutu, Familiprix, Uniprix, Proxim, and Pharmaprix. For each chain, a sample of 30 pharmacies was chosen by a random number generator.
And the calls started, all in French, with the following script: “I would like to know if you carry a certain homeopathic remedy. It’s called Oscillococcinum, it’s a homeopathic remedy against the flu made by Boiron.” If they did not have it, I asked if this was something they normally carried. I spoke to either a floor clerk or a member of the pharmacy staff behind the counter, depending on who knew the answer. That was it. And I kept a tally.
Out of the 150 pharmacies on the island of Montreal that were called for this investigation, 66% of them reported carrying Oscillococcinum (30% did not, while 4% could not be reached, often because the listed pharmacy had closed). Some chains were more likely to sell the product, with Jean-Coutu and Pharmaprix being the most likely (80% of their stores had it) and Proxim being the least likely (50% of their stores carried it).
Who is looking out for consumers?
I’m not surprised at the findings. I have seen Oscilliococcinum in virtually every pharmacy I’ve visited. In the few times I’ve asked the pharmacist why they sell it, the response is invariably “We don’t get to decide what’s carried on the shelves”, which is a fair point, because most pharmacists work for large corporations now – as employees, and the autonomy they might have in an owner-operated pharmacy is long gone. Yet it’s also fair to note that selling homeopathy is contrary to pharmacy ethics, a point I’ve made before and one that’s echoed in this investigation:
An evidence-based profession is selling you sugar pills
The fact that two-thirds of Montreal-based pharmacies will sell us a pseudo-treatment for the flu that targets adults, children and infants alike is hard to square with the Quebec Order of Pharmacists’ mission statement. They describe said mission as “ensuring the protection of the public”, but how is the public protected when pharmacies are selling them placebo pills? The harm is partly financial: 30 doses of these worthless globules retail for CAD 36. It is also in the false sense of security parents will gain and the delay in proper treatment if needed. And, ultimately, it is in the legitimization of a pseudoscience the founding principle of which is that the more you add water to something (like alcohol), the more powerful it becomes.
This isn’t just an issue for Quebec – it’s a worldwide issue for the profession of pharmacy. Given the ethics of homeopathy, it’s disappointing to see some pharmacy associations change their codes of ethics to facilitate the sale of homeopathy, rather than simply removing them from pharmacy shelves. In contrast, other pharmacy associations are calling for their removal, as we’re seeing in Australia:
Community pharmacy banner and buying groups should draw a line in the sand and cease all activities that encourage the stocking, promotion, recommendation or marketing of homeopathy, the Pharmaceutical Society of Australia (PSA) said today. PSA National President Dr Chris Freeman published an open letter and wrote to major banner and buying groups, stating that many people were not aware that there was no reliable evidence for the use of homeopathic products.
“Public health is put at risk if people choose homeopathy over treatments that evidence shows are safe and effective,” he said.
PSA provided advice to pharmacists in its Choosing Wisely recommendations last month. One of the six recommendations is:
“Do not promote or provide homeopathic products as there is no reliable evidence of efficacy. Where patients choose to access homeopathic treatments, health professionals should discuss the lack of benefit with patients.”
“Where there are homeopathic products available from community pharmacies, patients may see this as a de-facto endorsement,” Dr Freeman said. The supply of homeopathic products is in contravention of the PSA Code of Ethics for Pharmacists. The Code of Ethics, recognised by the Pharmacy Board of Australia, states that pharmacists should only “supply or promote any medicine, complementary medicine, herbal remedy or other healthcare product where there is credible evidence of efficacy and the benefit of use outweighs the risk.” “The PSA Code of Ethics makes it clear that homeopathic products should not be stocked or sold in community pharmacies. Banner and buying groups should do everything in their power to remove these products from their shelves,” Dr Freeman said.
This continued tension between the “business of pharmacy” and the professional responsibilities of pharmacists, as health care professionals, has always been around. At one time, most pharmacies sold cigarettes. Now (at least in Canada) they don’t – it was a professional decision to stop the sale, implemented by the profession itself. But that pressure to get the customer in the door and sell them what they want (and not just what they need) continues. And despite the evidence, homeopathy is allowed for sale, and it’s marketed for medical conditions. Few pharmacies seem willing to turn down a potential sale. Yes, pharmacists are trusted health professionals. That trust has been earned. Will the profession maintain it?