Homeopathy/Draft

Homeopathy or homoeopathy is a 200+ year old system of alternative medicine based on the "principle of similars", which asserts that substances known to cause particular syndrome of symptoms can also help to cure diseases which display similar symptoms. Its principles are based on the theory that the symptoms of a disease reflect efforts of the human body to resist damage from infection, environmental toxins, or various stresses. Homeopaths historically called this inherent survival response to be the body's vital force - akin to what physiologists would call the body's "defense systems" (or qi in traditional Chinese medicine). Homeopathy is a fundamentally different model of health whose principles are not generally utilized or accepted by most medical approaches.

Homeopathic treatment involves remedies, which are extremely small doses of substances repeatedly diluted and vigorously shaken ("succussed") in water or ethanol, and ultimately dispensed in pills or liquid form. These substances are chosen for their ability (in large doses) to provoke the very symptoms that the remedy is intended to heal (and thereby for their presumed ability to stimulate natural healing). Such substances must be administered in extremely small doses; it is a homeopathic principle that the process of repeated dilution with succussion makes the remedy more potent. Dilution often continues to the point where none of the original substance remains in the remedy; homeopaths assert that the process of dilution and succussion fundamentally changes the nature of the medicinal solution and enable it to have profound healing effects. The body of evidence for the benefits of homeopathic treatment include clinical research, basic science research, epidemiological evidence, outcome studies, cost-effectiveness evaluations, and historical case reviews. Although most homeopaths themselves are astonished by the results of their medicines, the fact that some homeopathic medicines are so dilute that they may lack even one molecule of substance leads scientists to doubt its plausibility and generally reject the possibility that the remedy itself is responsible for any of the effects that may occur.

The term homeopathy derives from the Greek hómoios (similar) and páthos (suffering). Some principles of homeopathy have been used in various forms in medical systems for thousands of years in diverse cultures, but they were first methodically set out by a German physician, Samuel Hahnemann (1755–1843), who observed that a medicine sometimes evoked symptoms similar to those of the illness for which it was prescribed. Related maxims such as the "Law of similars" are common in general anthropology, traditional healing and the literature of homeopathy. When homeopathy was developed in the 19th century by Hahnemann and his followers, conventional medicine offered few safe and effective drugs; homeopathic treatments were at least not actively toxic.

Physicians are concerned that some patients seek homeopathic treatment as a first resort, even for conditions where there are effective conventional treatments. For example, asthma and other respiratory disorders with a seemingly mild initial presentation can be a life-threatening condition, and acute attacks, if not treated promptly and effectively, can lead to sudden death. According to conventional opinion, prescribing homeopathic remedies in these cases may delay the delivery of conventional treatment with potentially serious consequences. Medical organisations advise that there is no evidence that homeopathic remedies are effective in these circumstances, and recommend that they should only be used in conjunction with conventional treatment. A number of homeopaths consider vaccines to be actively dangerous and recommend they not be used, which public health specialists say presents a danger to the community. Some homeopaths advise against the use of drugs to prevent malaria, to which advice even the director of the Royal Homeopathic Hospital objects (see Section "Safety" below).

Most medical doctors and scientists doubt its therapeutic value beyond a placebo effect. Nevertheless, homeopathy is currently practiced by some medical doctors, as well as by other health professionals in virtually every country in the world. In Europe, homeopathic medicines are one of the most popular of the alternative and complementary treatments, with between 11% and 27% of general practitioners in each country using homeopathic medicine at least occasionally. In India, homeopathy has the status of a 'national system' of medicine, and approximately 100 million Indians use homeopathic medicines as their sole method of medical treatment.

Overview
It is commonplace to state with regard to homeopathy that extraordinary claims need extraordinary proof. Homeopaths respond that the overall evidence for homeopathy, including clinical research, animal research, basic sciences research, historical usage of homeopathic medicines in the successful treatment of people in various infectious disease epidemics, and widespread and international usage of homeopathic medicines today, indeed provide the required extraordinary evidence for the benefits of this system.

Homeopathy has a rich history; many famous people over the past 200 years have been users and advocates of it ; homeopathy has tended to attract people who are educated and wealthy. The growth of homeopathy in the 19th century had a significant influence in determining the way that conventional medicine organised and developed, and in how it came to formulate its present vision of evidence-based medicine, in contrast to practice based on individual clinical experience. Homeopaths are proud of this history that convinces them of the efficacy of their remedies. They add that their conviction is further based on their clinical experience and that it is bolstered by the outcomes of most of their clinical trials.

Homeopathic remedies are used by many people throughout the world. As many other complementary and alternative therapies, homeopathy generally scores highly in "patient satisfaction" surveys, and it has a reservoir of public support. In the U.K. for instance, one of the countries where homeopathy has relatively strong public support, a survey cited by the British Homeopathic Association found that 15% of the public put trust in homeopathy.

Many scientists and medical professionals also are interested in homeopathy. They are interested in why so many people believe in homeopathy, considering that they consider that it has no scientific plausibilty. They are interested too in why many studies have positive outcomes&mdash;do these reflect real efficacy, or can they be accounted for by flaws in study design or in statistical analysis, or "publication bias"&mdash;the tendency for small studies with chance positive outcomes to be published while studies with negative or inconclusive outcomes are not. They also are interested in whether positive results against expectation sometimes reflect manipulation of data or perhaps even fraud.

Historical origins
The early Greek physician Hippocrates of Cos (c. 450 BCE - 380 BCE), who is considered to be the "father of medicine", is also claimed by homeopaths as a pioneer in their own tradition—-notably because Hippocrates taught that "Natural forces within us are the true healers of disease," but also because he recorded what some physicians of that day did to initiate healing: he noted that some physicians cured people by using the same medicinal substances that caused the symptoms that the sick people were experiencing-—arguably an early expression of the "principle of similars." In the 15th century the alchemist, physician, and astrologer Paracelsus proposed the healing power of "signatures", by which he meant that the appearance of a substance in nature (its color and its shape) represented the types of diseases that it could cure. It was not until the early 19th century, Hahnemann created an experimental method, called "drug provings," whereby a substance is given to healthy human substances in continual dosage until symptoms are elicited. Initially, Hahnemann and other homeopaths gave their experimental subjects crude doses of medicinal substances, but over time, homeopaths found that they could also elicit symptoms in healthy subject when given potentized doses of medicines in repeated doses. "Drug provings" provide the experimental basis for determining what a substance causes in healthy people and thereby what it will cure in sick people.

In 1783, disillusioned with the medicine of his time and the many toxic effects of its treatments, Hahnemann, who knew nine languages, gave up his medical practice and devoted himself to translating medical books, including many of the leading textbooks of the day. Among them was the Treatise on Materia Medica (1789) by William Cullen, the leading physician of the 18th century. Cullen had written that cinchona bark (which contains quinine) was effective in treating malaria because of its bitter and astringent properties. Hahnemann questioned this theory because he knew that other substances were as bitter and astringent, but had no therapeutic value in this deadly disease.

Being an avid experimenter, Hahnemann took cinchona bark himself and saw that the symptoms that it caused were similar to the symptoms of the diseases for which it was prescribed. He then experimented with other substances and found that the symptoms that they caused were also similar to the symptoms of the diseases for which they were prescribed. These experiments led him to formulate the "principle of similars" - similia similibus curentur or "let likes cure likes". He used his experiments and the principle of similars to develop a new system of health care, as an alternative to the often toxic and ineffective drugs and treatments offered by conventional physicians of the time.

Hahnemann named his system of health care "homeopathy" (meaning "similar to disease"). He coined the term "allopathy" ("different than disease") to refer to the conventional medicine of the day, because its drugs were sometimes "similar," sometimes "opposite," but usually just "different" to the symptoms of the sick person.

For the first two decades of Hahnemann's practice of homeopathy, he used "crude" doses of various medicinal substances ("crude", in homeopathic use, means doses that still contain some of the original ingredient). He strove to find the lowest doses at which his remedies would still be effective, as he thought this the best way to avoid any adverse side-effects. To his surprise, it seemed that reducing the dose did not reduce the effectiveness of his treatments. Instead, he concluded that his remedies worked better the more he diluted them as long as the medicines were properly “potentized,” that is, they were serially diluted (either 1:10, 1:100, or 1:50,000) with vigorous shaking (succussion) in-between dilutions. Homeopathy thus became inextricably linked with this process of ultradilution—-repeated dilution of substances with succussion. Hahnemann did not offer a clear explanation as to how or why these potentized medicines might have therapeutic benefits; he distrusted all theoretical explanations and argued that all that mattered was whether a treatment was therapeutically effective. . He believed that diseases were caused by "spirit-like derangements of the spirit-like power that animates the human body" and that effective healing called for medicines that was also "spirit-like" and would stimulate this life force.

Homeopathy was introduced into the U.S.A. in 1825 by Hans Burch Gram, a Boston-born doctor who had studied homeopathy in Europe. In 1830 the first homeopathic schools opened. The first homeopathic medical college in the U.S.A. opened in 1835, in Allentown, Pennsylvania, and throughout the 19th century dozens of homeopathic institutions appeared in Europe and the U.S.A. Apart from his ventures into homeopathy, Hahnemann had been a prominent and respected public health reformer, and in the 1830s the Medical Society of the Country of New York had granted him honorary membership. However, a few years later the society rescinded this when they realized the "ideological and financial threat" that homeopathic medicine posed. In 1844, the first U.S. national medical association - the American Institute of Homoeopathy - was established.

By the end of the 19th century, 8% of American medical practitioners were homeopaths, and there were 20 homeopathic medical colleges (including Boston University, New York Medical College, Ohio State University,University of Iowa, University of Minnesota and University of Michigan) and more than 100 homeopathic hospitals in the U.S.A. One reason for the growing popularity of homeopathy was its relative success in treating people suffering from the infectious disease epidemics that raged at the time. Cholera, scarlet fever, typhoid fever, and yellow fever were rampant and killed many people, but death rates in homeopathic hospitals were often very much lower than in the conventional hospitals, whose cures – purging, blood-letting and mercury treatments, were often worse than the diseases, and did nothing to combat them.Death rates in conventional hospitals were typically two- to eight-fold higher than in homeopathic hospitals for patients with these infectious diseases.

In the early 20th century, the "Flexner Report," sponsored by the Carnegie Foundation with support from the American Medical Association, triggered major changes in American medical education. As a result, most homeopathic schools were closed down, while others became conventional medical schools (including Boston University, New York Medical College, and Ohio State University). In the 1960s, the popularity of homeopathy began to revive again in the U.S.A, and a 1999 survey reported that over 6 million Americans had used homeopathy in the previous 12 months.

Homeopathic "provings"
Homeopathic practitioners determine the specific therapeutic indications for their remedies from experiments in toxicology called provings, in which volunteers are given repeated doses of substances (usually in single-blind or double-blind trials), until symptoms of overdose are observed. The effects of each medicinal substance are recorded in textbooks, called Materia Medica and Repertory, or nowadays in expert system software. Homeopathic provings provide an experimental basis to determine what a substance causes in overdose and thereby what it is thought to cure. The symptom complexes that these substances cause are subsequently used to compare with a patient's physical and psychological symptoms in order to select, as the appropriate most similar remedy, the substance whose effects are closest to the patient's symptoms—called the "simillimum".

An example of a proving is that of Bambusa arundinacea (bamboo). In this proving, the 20 subjects did not know whether they were taking the bamboo or a placebo, and the investigator knew only the substance name, but not, at that time, its properties. The 6C and 30C potencies were used. The symptoms elicited by the treatments are detailed in a 237-page book, which details the hundreds of symptoms that bamboo was found to cause (and therefore, accord to homeopathic principles, potentized doses of this medicine will stimulate to heal people whose symptoms are similar to this syndrome of symptoms). In the first two phases of the proving, all of the subjects were given the remedy in various potencies. In the third phase, seven of them were given placebo. The study started in October 1994 and lasted until February 1995, during which time they recorded every symptom they experienced in a diary and noted whether it was a persistent, new, old, altered or unusual symptom. The recorded symptoms take up 84 pages in the book. The symptoms are then converted into repertory rubrics in the next 46 pages. The last 76 pages consist of the author's commentary about the proving symptoms, and 14 cases in which bamboo was the prescribed remedy.

Homeopaths prescribe this remedy (in potentized doses) when a sick person has a syndrome of symptoms that resemble the syndrome of symptoms that it causes in drug proving. The recorded symptoms need to be interpreted by an experienced homeopath to understand the conditions for which the remedy might be considered as possibly useful. In the case of bamboo, some homeopaths have determined that one of the themes of people who will benefit from this medicine is a "search for support." The proving cites that this remedy is also useful in treating post-natal depression accompanied by irritability and impatience, for example, when a mother makes statements like "I can't handle my child and I have no desire to get out of bed." In cases requiring physical support, it is indicated when there is a need for support in the back associated with pain, sciatica, stiffness and changes to the spine. Finally it is indicated with symptoms such as swelling of the breasts before menses accompanying depression.

In September 2006 the U.K.’s licensing body, the Medicine and Healthcare Products Regulatory Agency, altered their regulations to permit homeopathic remedies to be advertised using homeopathic provings to support their claims (justifying phrasing such as “For the relief of...”). This change elicited protests from scientists, who called it a departure from the principle that such claims should be justified by evidence of efficacy.

Homeopathic manufacture of remedies
In the U.S.A., the Homœopathic Pharmacopœia of the United States is a legally recognized handbook that describes how to manufacture homeopathic drugs. This reference text is recognized and approved by the Food and Drug Administration (FDA), the governmental agency that regulates drugs. Medicines listed in the HPUS defines them as homeopathic drugs which grants them a different standard of drug regulation due to their long-term history of safety than conventional drugs and medical devices. A summary describes the principles: FDA regulates homeopathic drugs in several significantly different ways from other drugs. The Manufacturers of homeopathic drugs are deferred from submitting new drug applications to FDA. Their products are exempt from good manufacturing practice requirements related to expiration dating and from finished product testing for identity and strength because the historic use of homeopathic medicines have not found a deterioration of effects over time and because finished product identification is not presently possible, though identification of the starting product using modern pharmacological processes is utilized by homeopathic drug manufacturers and is regulated by the FDA. Homeopathic drugs in solid oral dosage form must have an imprint that identifies the manufacturer and which indicates that the drug is homeopathic. In 1938, the federal Food, Drug, and Cosmetic Act, sponsored by New York Senator Royal Copeland, a homeopathic physician (and former homeopathic medical school dean), gave the FDA the power to regulate drugs and granted legal recognition to the "Homeopathic Pharmacopeia of the United States" as a compendium of drugs. In contrast, non-homeopathic drugs for which a New Drug Application is required must be accompanied by approved evidence of safety and efficacy; simple listing in a reference is not sufficient. Today, homeopaths use about 3,000 different remedies, from animal, plant, mineral, or synthetic sources.

By convention, the first letter of the Latin-derived name of such preparations is capitalized. When the source is well-defined, the traditional name rather than chemical, International Nonproprietary Name or biological nomenclature, is preferred, such as Natrum muriaticum rather than sodium chloride. Ultimately, any substance can become a homeopathic medicine if "drug provings" (tests to determine the symptoms produced by toxic doses) are first conducted to determine what it causes in overdose and therefore what it can cure in potentized doses. Remedies used in homeopathy are commonly made from plants, trees, fungi, and algae, as well as from a wide variety of mineral and animal sources. Even some unusual substances, called imponderables, can and are made into homeopathic medicines, including electricity, X-ray, and magnetic north and south poles.

Homeopathic remedies are available in several different forms (single medicine, homeopathic formula or complex medicines, and a limited number of external applications). Remedies for internal consumption come either in pill form or as liquid. Most do not require a doctor's prescription, but some may need one if the dosage is in a non-potentized or low potency dose and if the substance is potentially toxic (in Europe, a medicine must be diluted at least 1:10 three times to be deemed homeopathic). In the U.S.A., if a homeopathic remedy is claimed to treat a serious disease such as cancer, it can be sold only by prescription. Only products sold for “self-limiting conditions”—colds, coughs, fever, headaches, and other minor health problems that are expected to go away on their own—can be sold without a prescription (over-the-counter).

Preparation of homeopathic remedies
The most characteristic &mdash; and controversial &mdash; principle of homeopathy is that the efficacy of a remedy can be enhanced and its side-effects reduced by a process known as "dynamization" or "potentization". In this process, liquids are diluted (with water or ethanol) and shaken by ten hard strikes against an elastic body ("succussion"), to get the next, succeeding higher potency. For this, Hahnemann had a saddlemaker construct a wooden "striking board", covered in leather on one side and stuffed with horsehair. When insoluble solids such as oyster shell are used for remedies, they are diluted by grinding them with lactose ("trituration"). The original serial dilutions by Hahnemann used a 1 part in 100 (centesimal; "C" potencies), or 1 part in 50,000 (quintamillesimal; "LM" or "L" potencies). Dr. Constantine Hering of Philadelphia later introduced the Decimal potencies ("D" or "X" potencies). A large number of homeopathic medicines sold in health food stores and pharmacies are "low potencies," that is, doses that are 3X, 3C, 6X, 6C, 12X, and 12C, all of which, except the last dose, have material doses of the original substances in the medicine. The higher potencies (30, 200, 1,000 and higher) are more commonly prescribed by professional homeopaths, and typically homeopaths have found these doses to be powerful enough to only need a single dose to have a long-term effect (from several weeks to several months or longer). Research studies that determine the efficacy of homeopathic medicines are discussed elsewhere in this article.

The dilution factor at each stage is 1:100 ("C" potencies), 1:50,000 ("LM" potencies) or 1:10 ("D" or "X" potencies) ; Hahnemann advocated $$30C$$ dilutions for most purposes (i.e. dilution by a factor of 10030 = 1060). The number of molecules in a given weight of a substance can be calculated by Avogadro's number (see the section "Proposed scientific foundations for homeopathy" below), and it is extremely unlikely that even one molecule of the original substance would be present in a $$30C$$ dilution. Thus, homeopathic remedies of a high "potency"' contain just water, but according to homeopaths, the structure of the water has been altered (see memory of water).

"Classical homeopathy" or "Hahnemannian homeopathy" refers to the original principles of this medical system in which a single remedy is chosen according to the physical, emotional, and mental symptoms that the sick individual is experiencing rather than only the diagnosis of a disease. "Commercial" or "user-friendly" homeopathy refers to the use of a mixture of remedies in a single formula containing individual ingredients that are generally chosen by the manufacturer for treating specific ailments. Such homeopathic remedies are used by consumers all over the world for self-treatment of common self-limiting ailments and injuries.

Similia similibus curentur : the law of similars
Similia similibus curentur or "let likes cure likes", is the assertion that a disease/syndrome can be cured by potentized doses of remedies that produce the similar symptoms when experimentally given in toxic doses to healthy people. This assertion, known as "the law of similars", is a guiding principle in homeopathy. Homeopaths consider that two conventional concepts, vaccination, and hormesis, can be considered as analagous to homeopathy's law of similars and the use of small doses.

Scientists and medical doctors today do not think that the principle of similars is generally true or useful, and they explain the efficacy of vaccination without referring to it.

Hormesis is a widely researched multi-disciplined field of scientific endeavor that has confirmed significant power and influence of low-dose effects, whereby some chemicals at high concentrations have opposite biological effects to those at low concentrations. Hormesis has been hypothesized as an explanation for some homeopathic affects, although hormetic doses still are constrained by the Avogadro limit.

The homeopathic principle of similars has also been linked to vaccination. Although homeopathic remedies and vaccinations both use low doses of active ingedients, there are important differences. First, the doses used in homeopathic remedies are always very much lower than used in vaccines. Second, every vaccine produce a measurable immune response (e.g., immunoglobulin production), while only select homeopathic medicines have been tested for having measurable immune response.

Professional homeopaths: who are they?
There are no universal standards for homeopathic education, so licensing and regulation varies from country to country and in the U.S.A. from state to state. Also support by (conventional) medical professionals for alternative and complementary medicine is different in different parts of the world.

In the U.S.A. one survey found that 39% of the faculty of a medical school for primary care physicians considered use of homeopathic medicine legitimate, although only 8% had personal experience with such medicine. A survey of physicians representing a broad variety of specialties in a mid-sized southeastern US city found that 17% of the respondents considered homeopathy legitimate medical practice, but only 1.4% of the respondents had actually prescribed such medicine.

In Europe the relative popularity of therapies also differs between countries. Regulation of practitioners varies widely: in most countries only registered health professionals may practice, but in the United Kingdom practice is virtually unregulated. Of 248,000 registered practitioners of medicine in the U.K., about 400 are members of the Faculty of Homeopathy. Because homeopathy is still not a fully regulated profession in the U.K., anyone can declare themselves to be a homeopath and practice without any qualification ("common law" that allows freedom of choice in medical care in England has a long history). Germany and some Scandinavian countries have intermediate systems. In most member states of the European Union, including Belgium, France, Spain, Italy, and Greece, the practice of medicine, except by statutorily recognized health professionals, is illegal, which has the consequence that in those countries, all (or virtually all) professionals that use homeopathic treatments are MDs. The Netherlands adopted in 1999 a new law regulating professions in individual health care, which gives more freedom to practitioners of complementary and alternative medicine, including homeopathy.

Some countries have exclusively homeopathic medical schools (India, Pakistan, Mexico etc.), some have naturopathic medicine colleges in which students are taught homeopathy as part of their curriculum (Germany has its heilpraktika [health practices]; the U.S.A., Canada, and Australia have naturopathic medicine schools that include homeopathy), and some countries certify "professional homeopaths" who have attended homeopathic schools and who then pass independent examinations that grant "certification" as homeopaths. In the U.S.A., there is also a separate certification process available only to MDs and DOs (there are similar choices of certification available in the U.K. for medical doctors, who have done at least MBBS). Also in the U.S.A., naturopathic physicians have their own homeopathic certifying agency.

In Europe complementary medicine is practiced by many conventional physicians. Over a third of France's 54500 general practitioners use complementary methods: 5% exclusively, 21% often, and 73% occasionally. Pediatric homeopathy is quite popular in Germany, particularly among children from families with a higher socioeconomic status. Nearly half of the homeopathic treatments of children are by medical doctors or by Heilpraktiker (non-medical practitioners). . In German obstetrics departments the use of complementary and alternative medicine (mainly acupuncture and homeopathy) is widespread. In The Netherlands almost all general practitioners occasionally refer patients to alternative practitioners, while half of them practice alternative medicine themselves (mostly homeopathy)

In India, where there are more than 200,000 registered practitioners of homeopathy, homeopathy is formally recognised by the Government as one of the Indian "National Systems of Medicine", under the Department of AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy), while conventional, western medical education is controlled by the Medical Council of India. About 10% of the Indian population depends solely on homeopathy for their health care needs. In India it is illegal to practice as a homeopath without a license and professional qualifications.

Some homeopathic treatment is partly covered by some European public health services, including in France, The Netherlands, and Denmark. In France, 35% of the costs of homeopathic medicine prescribed by a medical doctor are reimbursed from health insurance. In the U.K., five homeopathic hospitals are funded by the National Health Service (NHS) and homeopathic remedies are sold over the counter, and there, homeopathy is one of the most popular alternative and complementary treatment modalities.

In 2007, the over-the-counter market in homeopathy was around £40million in the U.K. (Popularity and the market place British Homeopathic Association); the total over-the-counter market was £1.2 billion in 1994. Family doctors in the U.K. issued 796 million prescriptions in 2007, of which 49,300 were for homeopathic remedies, down from 83,000 in 2005 (Fall in homeopathy prescriptions hailed as sign of changed attitudes The Times July 28th 2008). In January 2008, it was reported that the NHS was progressively withdrawing funding for homeopathic treatments because of doubts about their efficacy.

In France and Denmark licenses are required to diagnose any illness or to dispense any product whose purpose is to treat illness. In many countries, however, there are no specific legal regulations concerning homeopathy. In Austria, the public health service generally requires proof of effectiveness to reimburse medical treatments, but makes an exception for homeopathy.

Almost 70% of all over-the-counter homeopathic remedies are sold in Western Europe. France is the largest market for homeopathic remedies in the world, worth over 300 million euros in 2003 (in a total over-the-counter drug market of over 770 billion euros), followed by Germany (200 million euros). The global self-medication market is estimated at 48.2 billion dollars (13.4% of the world pharmaceuticals market), of which sales of homeopathic remedies account for 0.3%.

A typical homeopathic visit
Homeopathic remedies can be prescribed by professional homeopaths, naturopaths, acupuncturists, chiropractors, and physicians with additional homeopathic training and certification, and how these decide what to prescribe will differ accordingly. Classical homeopaths place emphasis on the patient's unique symptoms and their psychological state, and they gather this information from an interview, typically lasting from 15 minutes to two hours (comparable to conventional physicians), with one or more follow-up consultations of 15 to 45 minutes. They place special emphasis on the way the patient experiences their disease—i.e. they give priority to the overall syndrome of symptoms and the unique and idiosyncratic symptoms which they consider different than the conventional medical approach of trying to identify the causes of the disease. The goal is to determine the factors that might predispose the patient to disease and find a treatment that will strengthen that particular patient's "overall constitution".

After the interview, the homeopath consults the references described in the table on the right. Some homeopaths make quick prescriptions based on "keynotes"—the highlights of the best known characteristics of a remedy, but the real challenge of homeopathic practice is to find the remedy that best matches the patient's syndrome of physical and psychological symptoms—the "similimum". A fundamental reason for conflict between conventional medicine and homeopathy is that homeopathy rejects the concept of treatments that target mechanisms of disease, and instead uses remedies that target syndromes of symptoms that they believe strengthen a person's overall constitution. Some homeopathic protocols might look like the following:


 * A physician qualified in both homeopathy and conventional medicine, after diagnosing a chronic condition that does not indicate the need for medical urgency, will usually first prescribe a homeopathic remedy which he feels may be more effective and is likely to have fewer side effects than conventional drugs.
 * Homeopaths recognize that trauma might require conventional medical attention but may complement the conventional treatment with homeopathy.
 * Homeopaths disagree with conventional medicine about the role of immunization and chemoprophylaxis for infectious diseases and prefer to prescribe homeopathic remedies that they believe will strengthen a person's immune and defense system.
 * For some disease conditions, such as asthma and acute bronchitis, homeopathic remedies are often prescribed not only to alleviate chronic symptoms, but also to treat acute attacks. Homeopathic remedies might also be used after an asthmatic episode with the intent to prevent recurrences.
 * An adequately trained homeopath is expected to recognize symptoms that indicate an acute and potentially fatal condition. The practitioner is expected to have emergency medical training and equipment appropriate to his or her level of training in the place of practice (e.g., dressings and basic airway management tools for an individual with training at the Emergency Medical Technician (EMT) of Basic or higher level, and preferably an automatic external defibrillator and advanced cardiac life support resources generally accepted as appropriate for an office. Potentially serious acute ailments may require medical supervision, but homeopaths sometimes prescribe remedies either for adjunctive use or as alternatives to conventional treatment.

The homeopathic treatment of acute injuries does not need the same depth or breadth of interview as treatment of chronic conditions. According to homeopaths, because the symptoms of a common cold or a headache or an allergy vary from person to person, each may need a different remedy. However, they believe that people who experience an injury generally have similar symptoms, so they think that some homeopathic remedies might be routinely useful in such cases.

Homeopaths who practice "classical homeopathy" prescribe just one remedy at a time—a remedy that best fits the overall syndrome of the patient. The same remedy might thus be prescribed for patients suffering from very different diseases; conversely, patients suffering from what would be diagnosed conventionally as the same disease may be prescribed different remedies. For example, hay fever would be treated with any of several remedies, usually based on the specific symptoms, but sometimes on the etiology of the allergy. Some common remedies are: Allium cepa (onion, which causes tears to flow and a clear burning nasal discharge that irritates the nostrils), Euphrasia (eyebright, which causes a clear and bland nasal discharge along with tears that burn and irritate the skin under the eye), Ambrosia (ragweed) and Solidago (goldenrod); plants whose pollen is aggravating to some hay fever sufferers. These remedies are commonly given during the acute symptoms of hay fever. At other times, a professional homeopath will often treat these patients with a constitutional remedy based on the patient’s genetic history, health history, and present overall physical and psychological state, with the intent to strengthen the person’s general health, thereby reducing the frequency or intensity of the symptoms of hay fever.

The claims for homeopathy
Homeopaths view illness as a systemic condition, a disturbance in the overall homeostasis of the total being. Accordingly, they consider that almost any sick person may benefit from proper homeopathic treatment. As the American Institute of Homeopathy puts it in their "Standards of Practice": "The physician must remember that he is treating a patient who has some disorder; he is not prescribing for a disease entity.".

Homeopathic practitioners claim that their remedies are useful for a wide range of ailments. These include minor ailments from cuts and bruises to coughs and colds. Patients also come to homeopaths with long-term problems that have not responded to conventional medicine, and homeopaths prescribe remedies to people with these conditions. Some of the common ailments for which patients seek homeopathic care are eczema, chronic fatigue syndrome, asthma, migraine, irritable bowel syndrome, allergic disorders, arthritis, fibromyalgia, hypertension, Crohn's disease, premenstrual syndrome, rhinitis, anxiety and depression. They also treat patients with the most serious diseases, including multiple sclerosis, chronic obstructive pulmonary disease, cancer. and AIDS

Homeopaths claim that there is objective evidence that some of their treatments are beneficial (see Tests of the efficacy of homeopathy), and they believe that the success of homeopathy for the last 200 years is itself an indication of its value.

Conflict with conventional medicine
The theory underlying homeopathy is considered improbable and unconvincing by most scientists working in academic institutions in Europe and the U.S.A., and in key respects, the treatment advice offered by homeopaths is in disagreement with conventional medicine.

The conventional view is that homeopathy, insofar as it has any effect at all, exploits the placebo effect - i.e. that the only benefits are those induced by the power of suggestion, by arousing hope, and by alleviating anxiety. Conventional medical opinion does not deny the efficacy of placebo treatments in many cases ...we all recognise the strong placebo effect in, probably, all aspects of medical treatment, whether they are conventional or not [Professor Tom Mead], and placebos have played a large part in conventional medicine since their first deliberate use by William Cullen in the 18th century. Cullen used regular drugs as placebos, but at much lower doses than were thought to be effective. He gave them "to comfort and please the patient" rather than with any hope of a specific effect. He used the word "placebo" in this sense in lectures given in 1772. . Many modern physicians, however, consider it unethical to deliberately mislead their patients ; rather than prescribing placebos themselves, some therefore prefer to refer patients to regulated practitioners of alternative medicine.

Some homeopaths, especially with medical training, will use conventional techniques to treat asthmatic and other respiratory medicine, but will use homeopathic methods for long-term care. One of the challenges here is that the standard of medical therapy for asthma is to prevent inflammation, which commonly involves inhaled corticosteroids that are not absorbed beyond the respiratory system.

Homeopaths also assert that corticosteroids are immunosuppressant drugs that only provide temporary relief of asthma symptoms and may lead to more serious chronic disease and to increased chances of death. Medical opinion is that this assertion is uninformed scare-mongering. They advise that corticosteroids prevent inflammation that can have serious consequences and symptom relief is a result of this anti-inflammatory action. Inhaled corticosteroids that stay on the breathing passages and do not spread through the body are medically preferred to systemic corticosteroid therapy and thus reduce immune suppressing effects of these drugs.

Most homeopaths believe that the fundamental causes of disease are internal and constitutional and that infectious disease is not just the result of infection but also of susceptibility. This viewpoint leads them to seek to avoid conventional treatments that suppress symptoms. Physicians accept that some disease is indeed a disturbance in normal function, whether due to external, genetic, or internal reasons. However, they consider that most disease can be attributed to a combination of external causes (such as viruses, bacteria, toxins, dietary deficiency, physical injury) and physiological dysfunction (including genetic defects and mutations such as those which trigger cancers), some of which are more than the healthy body can resist. Homeopaths consider them to be co-factors to disease, not causes of them. Conventional physicians often use drugs to suppress the symptoms of a disease (to alleviate the pain, injury, and distress that they cause), but they maintain that their main goal of medical treatment is to eliminate the causes of the disease with the help of drugs.

Whereas homeopaths emphasize that they provide remedies tailored to the individual patient's symptoms, conventional medicine focuses on treatments shown to be effective when given in a standard form to large populations of patients with a given disease. However, large clinical trials also seek to identify subgroups of patients (by age, gender, ethnicity, lifestyle, comorbidities etc.) that are "responders" or "non responders" to a new treatment, to provide a rational basis for individualization of treatments. Physicians have access to a very large repertoire of prescription drugs for this purpose (11,706 in the U.S. Food and Drug Administration Approved Drug Products with Therapeutic Equivalence Evaluations 26th Edition Electronic Orange Book (EOB)4 ), a repertoire that is constantly changing as less effective drugs are replaced by better drugs.

Medical organizations' attitudes towards homeopathy
The American Medical Association (AMA) was founded in 1847, three years after the American Institute of Homeopathy. From the 1860s to the early 20th century, the AMA's ethical code forbade its members to consult with fellow MDs who practiced homeopathy. Although the AMA did not enforce many of its ethical guidelines, the "consultation clause" was one of the few that it did. The current AMA policy statement says: "There is little evidence to confirm the safety or efficacy of most alternative therapies. Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious."

Safety and efficacy of homeopathy
In conventional medicine (see New Drug Application), the basic phases of evaluating a drug are determining if it causes dangerous effects in healthy volunteers, if it is adequately present in the body to achieve an effect, and if it is more effective than established treatments, against a disease.

In conventional medicine, randomized controlled trials rely on statistical analysis of large groups of patients all of whom are given the same treatment to determine whether that treatment is indeed effective. This conflicts with an approach that believes that treatments must be individually tailored to each patient. In reality, some homeopathic trials do use some standardization, but not always to an extent which would make the trials statistically robust.

Few people question the safety issues in choosing homeopathic medicines themselves, and the U.S. FDA determines what dose is basically safe for over-the-counter sales of homeopathic medicines. However, homeopaths discourage the general public from using the homeopathic high potency medicines (the 200th potency and higher potencies) unless the person is adequately trained in homeopathy. Homeopaths warn the public that repeated doses of high potency medicines can lead the person to experience a "drug proving," a situation in which the person experiences symptoms akin to an overdose of the substance (the symptoms are generally known to resolve themselves shortly after the person stops taking the medicine).

Proposed mechanism of action for homeopathic medicines
Homeopathy was developed at a time when many important concepts of modern chemistry and biology, such as molecules and germs, were understood poorly if at all. In Hahnemann's day, many chemists believed that matter was infinitely divisible, so that it was meaningful to talk about dilution to any degree.

Twenty years after Hahnemann's death it was established by Josef Loschmidt that a given volume of matter consists of a finite, albeit large, number of molecules. This implies that a finite volume of solution cannot be diluted infinitely, there comes a point that the solvent is pure and does not contain a single solute molecule. For example, a teaspoon of seawater (roughly 5 ml) contains about 160 mg of sodium chloride (NaCl), or about 2×1021 molecules of NaCl. A 12C dilution of seawater will have about one molecule of NaCl per liter. Thus homeopathic remedies diluted to more than about 12C are virtually certain to contain not even a single molecule of the initial substance. This is recognized by advocates of homeopathy, who assert that the essential healing power is not to be found in the chemical action of molecules, but perhaps in the arrangement of the water molecules, giving rise to the expression "the memory of water". The homeopathic literature proposes widely differing explanations for the purported existence of this water memory and has not yet converged on a single explanatory paradigm.

For instance, homeopaths point out that water is not simply a collection of molecules of H2O, but contain isotopologues, molecules with different isotopic compositions such as HDO, D2O and H218O. Mass spectroscopy can indeed detect different isotopologues, but their relative concentration is the same before and after homeopathic treatment&mdash;the concentration ratios can only be changed by nuclear reactions&mdash;so that the presence of isotopologues in water cannot explain its memory. Homeopaths also suggest that the appearance of the H2O molecule in two proton-spin forms (ortho and para) may provide a mechanism for the memory of water. These two spin forms appear in a ratio 3:1 and are very difficult to separate or to convert into each other. The 3:1 ratio is determined by fundamental principles of physics, and there is no known mechanism by which a homeopathic treatment could change this ratio. Moreover, even if it is assumed that homeopathic tinctures would somehow give rise to ortho:para ratios other than 3:1, there is no proposed explanation for how these (chemically undetectable) ratios could have different healing qualities.

Another suggestion is that double-distilled and deionized water contains trace amounts of contaminating ions. In particular, water, as a result of repeated vigorous shaking, might include dissolved atmospheric gases in the form of nanobubbles, molecular ions produced from water reacting with airborne contaminants, and silicates&mdash;tiny glass "chips". Nanobubbles and their implications for water structure have been studied using nuclear magnetic resonance, with the conclusion that the effects are temporary and "should not be extrapolated to the so-called memory of water, often alleged to explain the effectiveness of homeopathy."

Some homeopaths believe that there might be an effect of successive shaking on water structure leading to "clustering" of water molecules. This contradicts the dominant scientific view that motions in liquid water are on the picosecond (10&minus;12 second) time scale and that such clusters could not live longer than a few picoseconds.

People sometimes wonder if the water used to make homeopathic medicines already has other memory imprints from its history prior to use in medicine. However, the water used by homeopathic manufacturers undergoes double-distillation, a process that homeopaths contend eliminates or substantially reduces previous memory. This raises the question: how do homeopaths know that this reduction is sufficient? If the presence of homeopathic qualities is below detection threshold, then surely the absence of such qualities is also undetectable.

In brief, for homeopathy to receive serious scientific consideration, there needs to be plausible explanations for the following:
 * how the process of manufacturing a homeopathic remedy could yield a biologically active substance or solution, when the resulting remedy often is chemically and physically indistinguishable from pure water
 * why the principle of similars might apply in the case of homeopathic remedies
 * how a biological mechanism could have evolved to recognize the specific nature of homeopathic remedies

There also needs to be
 * clear and irrefutable evidence for the efficacy of homeopathic remedies, evidence that cannot be explained by placebo effects

These stringent demands are often summarised by the maxim "Extraordinary claims require extraordinary proof".

Meanwhile, homeopaths, working towards an elucidation of the effectiveness of their medicines, complain that they are up against a double standard in medicine and science. They point out that there is a long history of conventional medical treatments that are applied with positive effects, although  their mechanism of action is not known. Only relatively recently, for instance, has it been understood how aspirin works, but before that doctors used it regularly despite an inadequate understanding of its actual mechanism. In due time, the homeopathic community asserts, the scientific basis of their methods will be unveiled.

Clinical trials testing the efficacy of homeopathic remedies
The “balance of evidence” as to whether homeopathy has any effects other than placebo effects depends on who is balancing the evidence. Homeopaths strongly value the evidence of their own experience in treating patients, supported by the satisfaction reported by their patients in surveys; they believe that this is sufficient evidence of efficacy, but also state that most published clinical trials have shown some beneficial effects. A 1991 global meta-analysis of homeopathic clinical trials published in the BMJ (British Medical Journal) of 105 trials, 81 with positive outcomes, concluded that the placebo response could not explain the positive responses: “Based on this evidence we would be ready to accept that homoeopathy can be efficacious, if only the mechanism of action were more plausible.” and another meta-analysis published in the Lancet in 1997 drew similar conclusions. Several meta-analyses evaluating the homeopathic treatment of specific diseases have found positive results, including the treatment of childhood diarhea, some post-surgical conditions and respiratory allergies.

Other meta-analyses have suggested that the effect from a homeopathic remedy was no better than a placebo The Cochrane Collaboration is an organisation that publishes meta-analyses of trial results, and most of their analyses of homeopathic treatments indicate some treatment benefits but not adequate statistically significant benefit. The most supportive of their analyses is of the possible benefits of Oscillococcinum for influenza and influenza-like syndromes.

Cochrane Reviews did a meta-analysis of seven randomized controlled trials, three prevention trials (number of participants, $$N = 2265$$) and four treatment trials, $$(N = 1194)$$. This was a meta-analysis of seven randomized controlled trials, three prevention trials (number of participants, $$N = 2265$$) and four treatment trials, $$(N = 1194)$$. Overall, the authors found no evidence of any benefits in preventing influenza, but evidence of a small effect on the duration of symptoms. The outcome was sufficiently promising that further trials were recommended, but not strong enough for the remedy to be recommended for first-line therapy.

Why do most trials report positive outcomes for homeopathy, but some show no effect, and how is it that the positive evidence does not persuade most scientists and leaders of academic medicine? In the U.S.A., The National Center for Complementary and Alternative Medicine (NCCAM) administers public-funded research into alternative medicine, and some studies have reported positive outcomes, but NCCAM's acting deputy director, Jack Killen, said, in a Newsweek article, "There is, to my knowledge, no condition for which homeopathy has been proven to be an effective treatment." . In the U.K., the NHS recognizes that there have been about 200 randomised controlled trials evaluating homeopathy, some show efficacy of treatment and some don't. They conclude, "Despite the available research, it has proven difficult to produce clear clinical evidence that homeopathy works".

Homeopaths believe that such attitudes reflect bias against alternative medicine, and that because homeopathy does not lend itself to controlled trials, those with a negative outcome may be false negatives. Critics of homeopathy respond that the published trials of specific homeopathic remedies have been mostly small and flawed in design "“Examples of problems they noted include weaknesses in design and/or reporting, choice of measuring techniques, small numbers of participants, and difficulties in replicating results. A common theme in the reviews of homeopathy trials is that because of these problems and others, it is difficult or impossible to draw firm conclusions about whether homeopathy is effective for any single clinical condition.”" Larger, high-quality trials have tended to show little or no statistically significant effects, as was concluded by the authors of the second Lancet study cited above when they re-analyzed these trials: “There is increasing evidence that more rigorous trials tend to yield less optimistic results than trials with less precautions against bias.”  Homeopaths respond that the vast majority of the larger high-quality trials simply tested a single homeopathic medicine, without the requisite individualization of treatment common to homeopathic treatment.

But this does not explain why small trials should have more strongly positive outcomes than large trials. In fact this is a feature of trials of conventional medicine also – and it is believed that the explanation lies mainly in ‘’publication bias’’ – the tendency of trial outcomes to be published only if the outcome is clearly positive; many small trials with negative or inconclusive outcomes simply go unreported, because they are thought to be uninteresting.

In 1999, the government of Switzerland, for a trial period of 5 years, allowed health costs for treatment with homeopathy and four other CAM modalities to be reimbursed under the country’s compulsory health insurance scheme, and set up a programme to evaluate the cost-effectiveness of these treatments (the Complementary Medicine Evaluation Programme (Programm Evaluation Komplementärmedizin, PEK). Under this programme, a team of scientists and practitioners, including a homeopath, conducted an innovative meta-analysis that became the single most cited study of homeopathy, arousing considerable media attention and a storm of protest from homeopaths. The study, which was also published in the Lancet, adopted a novel approach; whereas traditional meta-analyses have tried to combine all studies of a given condition, this was a "global" meta-analysis of homeopathy testing the hypothesis that all reported effects of homeopathic remedies are placebo effects. If so, the authors reasoned, then the reports of positive effects reflect publication bias, and if this is the case then the magnitude of such effects should diminish with sample size and study quality, and for the largest and best studies there should be no effect.

They analyzed 110 placebo-controlled homoeopathy trials and 110 matched conventional-medicine trials. Overall, the conventional medicine trials showed some real effect of treatment, in that some effect was still present in the largest and best trials, but the trials of homeopathy remedies did not. The authors concluded that their analysis was consistent with homeopathy being no better than placebo treatment, and controversially suggested that no further research on homeopathy is necessary. The article was accompanied by an unsigned editorial entitled “The end of homeopathy” " and a signed editorial by Jan Vandenbroucke, professor of clinical epidemiology, at Leiden University, the Netherlands This does not mean that that people treated with homeopathy do feel better as a result - the clinical literature clearly shows this, but Vandenbroucke suggested that this could be because its practitioners treatments spend more time with people than doctors do.

The Lancet subsequently published a selection of critical correspondence, and received an angry open letter from the Swiss Association of Homoeopathic Physicians (SVHA). which declared:

''“The meta-analysis may be statistically correct. But its validity and practical significance can be seen at a glance: not one single qualified homoeopath would ever treat one single patient in clinical practice as presented in any of the 110 analysed trials! The study cannot give the slightest evidence against homoeopathy because it does not measure real individual (classical) homoeopathy. It confounds real homoeopathic practice with distorted study forms violating even basic homeopathic rules.”'' In the Shang et al. review, 21 of the homeopathic trials were judged of “high quality”; these studies, overall, showed a benefit of homeopathic treatment. In the final phase of analysis, the researchers included only the largest of these studies; the 8 largest homeopathic trials showed that homeopathic treatment was comparable with a placebo, while 6 similarly large conventional medical trials were not compatible with a placebo effect. Of the 8 largest and best homeopathic trials, only one used an individualized approach to treatment, the other seven used a single medicine prescribed to homeopathic treated subjects. Such non-individualized treatment is common in the larger clinical trials (one of the trials even tested a rarely used homeopathic medicine, Thyroidinum, in the treatment of weight-loss, in a previously untested treatment protocol).

Subsequent critics of the Shang et al. analysis have questioned how definitive it actually is, noting that it involved subjective judgements of study quality. Several studies defined as "high quality" by Linde et al. (1997) were not defined by high quality by Shang et al. most of which showed a positive effect of homeopathic treatment.The Shang et al. analysis also excluded a relatively large study of chronic polyarthritis (N=176) by Wiesenauer because no matching trial could be found. The authors of an article in the Journal of Clinical Epidemiology say "This result can be interpreted differently. Following Shang's perspective it can be explained by small study bias (which includes publication bias). In contrast, one may hypothesize that Shang's result is falsely negative." The authors noted that four of the 21 best trials selected by Shang et al. dealt with preventing or treating muscle soreness—these consistently found no benefits to homeopathy, so if it is accepted that homeopathy is not useful in this condition, the remaining 17 trials show an overall significant effect, mainly determined by two trials on influenza-like diseases. Thus they argue that it is still possible that homeopathy might be effective for some conditions and not for others.

Proponents of homeopathy also note that some of the conventional medical studies analysed by Shang et al. may have shown a treatment effect but that some of these have since been withdrawn because of side effects found subsequently. Critics of homeopathy agree—they say that in conventional medicine, treatments are abandoned when trials show them to be ineffective or unsafe, or when a better drug is found; by contrast, no homeopathic treatment has ever been withdrawn after a trial showed it to be ineffective. The Shang et al. study did not evaluate "adverse effects" of treatment; three of the eight drugs tested in the larger trials, trials which suggested that were effective, have since been withdrawn because of concerns about their safety.

Safety

 * The highest ideal of cure is the speedy, gentle, and enduring restoration of health by the most trustworthy and least harmful way (Samuel Hahnemann)

The U.S. Food and Drug Administration's (FDA) view of homeopathy is that there is no real concern about the safety of most homeopathic products because they contain little or no active ingredients. The FDA has deemed that the vast majority of homeopathic medicines are over-the-counter drugs (OTC), that is, drugs that do not need a doctor's prescription and that are safe enough for home care. In the U.S.A., homeopathic remedies must have at least one indication for usage for a disease or condition that is self-limiting and that does not require medical diagnosis or medical monitoring. The European Union allows homeopathic medicinal products, "....provided they are prepared according to the European Pharmacopoeia or the pharmacopoeias currently used officially in the Member States" if they are at least 3X, that is, they may not contain either more than one part per 10&thinsp;000 of the mother tincture or more than 1/100th of the smallest dose of an active substance. No specific therapeutic indication may be given on the label of the product. Some physicians, however, maintain that homeopathic treatment is relatively unsafe, because it might delay conventional medical treatment. Homeopaths respond to these concerns by stating that homeopathic medicines are actually safer and more effective than conventional medicines; they argue that it is conventional medicine that is the unsafe kind.

Probably every modern pharmacologist would agree with Hahnemann that the drugs prescribed by conventional physicians of the 19th century were at best ineffective and often dangerous. However, some homeopaths question whether even modern medical drugs are safe and effective, and recommend homeopathic remedies instead. For example, a 2006 survey by the U.K. charitable trust Sense About Science revealed that homeopaths were advising travelers against taking conventional anti-malarial drugs, instead recommending they take a homeopathic remedy. Even the director of the The Royal London Homeopathic Hospital, Peter Fisher, condemned this practice, saying "I'm very angry about it because people are going to get malaria - there is absolutely no reason to think that homeopathy works to prevent malaria and you won't find that in any textbook or journal of homeopathy so people will get malaria, people may even die of malaria if they follow this advice."

Another concern of conventional physicians is that some homeopaths discourage the use of vaccines. These homeopaths assert that vaccination for common diseases such as measles and chicken-pox is unnecessary, and some believe that vaccines can even be damaging to health, because of the mercury and aluminum in them, because the bacterium or virus in the vaccine may neither be dead nor weak enough, or because some childhood infectious diseases may strengthen immune responsiveness. Such advice is considered irresponsible by nearly all public health professionals, who assess the benefits of vaccination as vastly outweighing the risks. For example, measles is not a major killer in the western world, where most children are vaccinated at about two years old, and vaccination initiatives in Africa have cut the incidence in half there.