The Benefits of Alternative and Complementary Therapies in Veterinary Medicine

This article previously appeared in CAm4animals blog. Reprinted Courtesy https://www.cam4animals.co.uk/

“Humanity’s true moral test, its fundamental test…consists of its attitude towards those who are at its mercy: animals.”

― Milan Kundera, author

This is a full-length article, so please pop the kettle on, make a brew, sit down and enjoy!

The current situation

The fundamental right to the freedom of choice in the healthcare of our animals is currently being eroded by governing bodies in several countries including the UK by the Royal College of Veterinary Surgeons (RCVS), which published a controversial statement on Complementary and Alternative Medicine (CAM) in 2017. This most recent position statement effectively bans alternative treatment unless conventional treatment is given before or alongside, thus rendering it complementary.

This article will demonstrate that alternative veterinary modalities used exclusively may, in certain circumstances, be in the best interests of the animal. They may also be useful as an integrated part of the animal’s overall veterinary healthcare package. Unfortunately, the RCVS’s view on CAM casts a wide shadow on treatment protocols and can limit vets from referring animals on for CAM treatments. Many CAM modalities can be offered as successful first line treatment, giving a valuable alternative to the purely pharmaceutical drug approach, which may bring with it the risk of unwanted side effects and antibiotic resistance.

To this end, the RCVS 2017 statement will be discussed and critically analysed, followed by the response of CAM4animals, a consumer group representing a wide range of animal owners, farmers, and CAM vets and practitioners. The article will conclude by suggesting a possible way forward to benefit all concerned, particularly our animals. It is important to state that all vets, including those who use CAM and holistic approaches, are governed by their professional codes of conduct and the welfare of the animal must be paramount in whatever treatment is selected. In no way does this article seek to dismiss conventional treatments as a first line option or in emergency situations.

The ongoing discussion around the RCVS statement

On November 2nd 2017 the RCVS issued a new position statement on CAM, including homeopathy.  It states:

“Homeopathy exists without a recognised body of evidence for its use. Furthermore, it is not based on sound scientific principles. In order to protect animal welfare, we regard such treatments as being complementary rather than alternative to treatments for which there is a recognised evidence base or which are based in sound scientific principles.  It is vital to protect the welfare of animals committed to the care of the veterinary profession and the public’s confidence in the profession that any treatments not underpinned by a recognised evidence base or sound scientific principles do not delay or replace those that do.”

Anyone who is familiar with homeopathic research would take issue with this statement, starting with the first line: “Homeopathy exists without a recognised body of evidence for its use.” This is unquestionably incorrect. Research studies continue to be published in peer reviewed journals, demonstrating the effective use of homeopathic remedies in animals. A prime example of animal research can be found in the following study where homeopathy was used to replace antibiotics in a case of E. coli in piglets with highly successful results (Camerlink et al., 2010).

The Italian Homeopathic data base of veterinary research studies (Marino, F.V.) features a collection of studies on pets and/or livestock animals treated with homeopathic medicines.  The source is mostly PubMed (The US National Library of Medicine) and many have positive findings, with several demanding more research.  There are also extensive studies listed here: Americans for Homeopathy Choice (2019). These sites are simply a sample of specific veterinary research: there are many more. It is difficult to imagine how the RCVS can dismiss such evidence, or at least fail to research it further. In addition, there are many high-quality research trials on humans via these data bases: (CORE-Hom) and (Bell, I. 2018).

Similarly, I question “Furthermore, it is not based on sound scientific principles.” Homeopathy has its own, very strict set of principles which I outlined in an earlier article ‘Clarification of the Basic Homeopathic Principles’ (Hpathy.com: 2017). In short, homeopathy is not based on the same principles as conventional medicine in that it treats the whole individual rather than singular symptoms and is hard to test using the randomised controlled trials (RCT’s) by which conventional medicine is typically gauged. However, there is on-going revolutionary research giving insight into how homeopathy might work as evidenced by the New Horizons in Water Science Conference at The Royal Society of Medicine in 2018.  Eminent scientists (with no homeopathic bias) including Nobel Laureates, were assembled from around the world.  They met to discuss the latest in their findings and revealed that current research is bridging the gap between mainstream science and the cutting-edge science surrounding the homeopathic mechanism of action and Ultra High Dilutions.

The RCVS considers that there is a lack of scientific rationale for homeopathy, thus it needs to be complementary rather than alternative. The words “lack of evidence base” in reference to homeopathy are touted frequently despite the fact many trials have been undertaken, as detailed above. In addition, it is difficult to quantify the vast number of cases treated which are evidenced empirically.  What has to be taken into account, are the paradigmatic differences in the two systems of medicine.  Systematic reviews, meta -analysis, RCT’s and controlled studies rarely do justice to homeopathic treatment because homeopathy treats the patient and not the disease.

It is imperative to understand that some things do not always make scientific sense in the first instance. However, knowing that they do exist, such as the phenomenon that is gravity, means it can be acceptable for them to be outside the realm of what science can currently explain. Another example is the action of aspirin, which was widely used, and its effectiveness lauded many years before its action was understood. (Walach, 2001). In addition, it is worth considering that both Louis Pasteur and Galileo were initially ridiculed and discredited, yet their theories were eventually embraced and changed science as we once knew it.

The RCVS statement goes on to say: “It is vital to protect the welfare of animals committed to the care of the veterinary profession.” Absolutely. This is why those of us involved in holistic medicine integrate it into our practices; we are not limited to one approach. We have the benefit of education and experience in many different therapies. This optimises rather than threatens animal welfare. The response to the global antibiotic resistance crisis is a good example. The College of Medicine and Integrated Health (2018) stated that “GPs who are trained in complementary medicine including homeopathy, prescribe less antibiotics than GPs without integrative medicine training.” This statement is applicable to those vets who also have the advantage of extensive training in both systems of medicine. This should be embraced and applauded by critics. Indeed, banning the use of homeopathy as a first line treatment under RCVS’s new guidelines is counterintuitive given the dangers surrounding antibiotic use, particularly where further research is being encouraged into homeopathy and herbs: (IAHV: 2017) and (NIHM: 2018).

My advice would be: if homeopathy or other CAM modalities work, is safe and prescribed by qualified vets or doctors, then use it. Veterinary medicine also has to deal with resistant superorganisms, adverse drug reactions, and the problems caused by polypharmacy. Alternative methods of treatment should be widely researched and, where proven to be effective, incorporated into treatment regimes. Likewise, it goes without saying that a purely conventional approach should be subjected to the same scrutiny in terms of research and results.

The RCVS’ rationale and The Faculty of Homeopathy’s response

Under the Animal Welfare Act 2006, animal owners and keepers are responsible for taking reasonable steps to ensure that their animals’ welfare needs are met. One of those basic welfare needs is protection from pain, suffering, injury and disease.  The RCVS states: “We consider that this welfare need is best served by the use of treatments underpinned by sound scientific principles, and would recommend that both vets and animal owners have this uppermost in their minds when considering treatment.”  The Faculty of Homeopathy’s statement in response to the RCVS can be read in full here.  https://facultyofhomeopathy.org/faculty-response-rcvs-statement-complementary-alternative-therapies/

Their response reflects the concerns of their members and pet owners who embrace holistic health modalities. They point out that the RCVS states it expects veterinary surgeons to offer “treatments underpinned by a recognised evidence base.”

The Faculty states: “The evidence base for many conventional medicines used in veterinary practice as well as human medicine is inconclusive. If the RCVS were to apply the same evidential criteria used for homeopathy to all treatments, there would be far fewer clinical options available to the profession.”

There is growing interest in homeopathy from animal owners as they see conventional medicines regularly failing or producing adverse side-effects. This is especially true in livestock farming where there is a drive to reduce the dependence on antibiotics in the light of concerns about antimicrobial resistance, AMR. At such a time, it is contradictory that the RCVS fails to engage with vets who are best placed to offer advice on the appropriate use of homeopathy.

It is clear that by adopting their position in relation to homeopathy and other complementary therapies, the RCVS is limiting the clinical freedom the veterinary profession has always enjoyed. Moreover, in allowing a vocal minority to influence a policy stance, the RCVS has set a dangerous precedent where similar groups could not only influence and further restrict clinical freedom in the future, but also stifle innovation, research and the development of new treatments. This presents a far greater threat to animal welfare than homeopathy could ever do.

The RCVS statement has taken away its members’ freedom to choose what is the best course of treatment for an ill animal. The RCVS has also applied a blanket ban to the use of all alternative therapies even where there are successful trials. This blinkered approach is not just applicable to the RCVS.  For instance, acupuncture for humans has become the latest casualty.  NICE has failed to include it as a recommended treatment for urinary incontinence (British Acupuncture Council, 2019) even though they were alerted to a high-quality study demonstrating its effectiveness.

The response to the RCVS from CAM4animals

CAM4animals was formed because of a widespread concern that the RCVS Statement is a ban on all alternative modalities reducing both the clinical freedom of vets and customer choice in veterinary healthcare. Initially, CAM4animals launched a Care2 petition to allow members of the public to show their support for holistic vets and this achieved well over 21,500 signatures within a year. Following on from this, an Animal Owners Charter was devised in order to further support holistic health choices and ensure informed choice (and consent) for all proposed treatment plans for their animals. Much of the Charter should be common practice since it is included in the RCVS Code of Conduct. Nevertheless, there are animal owners who have not experienced this, hence the need for the Charter.

CAM4animals audit reveals shaky foundations for RCVS position statement

CAM4animals acknowledges that CAM, including homeopathy, should be rigorously examined, as should all forms of veterinary medicine. However, it became evident that CAM in general, and homeopathy in particular, were not given adequate consideration in the discussion and development of the RCVS statement. After much lobbying, CAM4animals received the documents used by the RCVS on which they based their statement. CAM4animals conducted an in-depth audit of the RCVS documents and found that they were factually weak, scientifically flawed and narrow in scope. In summary they found the following:

A lack of key stakeholder consultation;

An overall lack of proper and unbiased scientific consideration;

A reliance on three flawed reports on homeopathy;

A demonstrable focus on, and bias towards, negative views of homeopathy with no counter-balancing views from specialists in any other CAM fields;

A significant over-reliance on opinion, social media commentary, including Tweets by known sceptics, and numerous media articles on the RCVS Councillor leading the campaign to ban alternative veterinary medicine;

No clear definition of ‘CAM’ leaving confusion as to what is accepted as alternative treatment and what must be complementary – not surprising since they have not considered ANY evidence for CAM modalities;

No consideration of the animal welfare implications of a de facto ban on alternative modalities, including homeopathy, as first line treatment;

No reference to client choice and clinical freedom; and

A failure to acknowledge the impact of the Statement on organic farming.

In addition, CAM4animals is concerned that RCVS Council members have been seemingly influenced by non-veterinary organisations which promote science scepticism regarding CAM in general and homeopathy in particular. The result is that RCVS’s own members are now placed in the vulnerable position of being formally disciplined and having to provide evidence to support the use of treatments they are legally and professionally qualified to practice and which have supporting evidence from their professional bodies. Evidence the RCVS appears to have chosen to disregard.

The RCVS denies that there has been any change to their position and yet repeatedly states that only treatments backed by sound, scientific evidence can be given. Although their statement is clearly biased towards making this relevant to CAM and homeopathy in particular, it is logical that this evidence requirement should apply to all treatments. Yet we know that many treatments offered by conventional vets have not been backed up with specific research on their application to a broad spectrum of species, but vets are able to choose to use such treatments without fear of censure from the RCVS. The RCVS has placed the onus on the vet to provide the evidence to support his/her use of an alternative treatment. The RCVS do not see their role as researchers which may go some way to explain why they did not examine homeopathy and other CAM adequately when considering their latest position statement. The implications of publishing the statement without engaging with all relevant stakeholders and gathering all the evidence in support of these treatments is consequently jeopardising animal welfare and compromising the position of their holistic veterinary colleagues. What is particularly significant and disturbing is the fact that the RCVS report was based on flawed studies. These are outlined below and shown in more depth here.

Science & Technology Committee EC2 Report, 2010

This is a non-scientific report compiled by a committee of 14 MPs, only four of whom considered it and only three ratified it with the remaining one abstaining concerned by the “balance of witnesses”. One of the four is an associate of Sense About Science which actively campaigns against CAM. An independent critique by Earl Baldwin of Bewdley concluded that the report was “an unreliable source of evidence about homeopathy.” His view is of particular significance given his familiarity with S&T Committee procedures and his involvement in the 1999-2000 S&T Committee on CAM. As a result, the 2010 report caused sufficient concern for 70 MPs to sign an Early Day motion. It was subsequently dismissed by the Department of Health.

The Lancet Report, Shang et al., 2005

This report was incorporated into evidence for the S&TC EC2 Report above. Its findings are clearly unreliable and outdated. It has been superseded by at least 41 published placebo-controlled randomised trials, which would have been suitable for inclusion but were ignored.  Read more on this here:  https://www.hri-research.org/resources/homeopathy-the-debate/the-lancet-paper-by-shang-et-al/

NHMRC, The Australian Report, 2013

This report shows evidence of deliberate bias and misreporting. As a result, it is currently under investigation by the Commonwealth Ombudsman for “scientific misconduct”.  I recommend further reading here.

EASAC Statement on Homeopathy, 2017

This is based on the flawed EC2 Report and the biased NHMRC Report above. It includes second-hand scientific analysis and excludes quality evidence from a wider body of homeopathic research supporting its efficacy. Read more here:

https://www.hri-research.org/2017/09/easac-statement-on-homeopathy/

Given all the post publication stakeholder responses to the statement and CAM4animals findings -particularly the flawed reports and the influence of non-veterinary organisations which promote science scepticism – everyone should be gravely concerned about how these documents were used as the ‘evidence’ on which the RCVS Council decided to change a well-balanced and long held policy statement. In addition, I feel there is a vast amount of confusion around homeopathy as evidenced by the chaotic analysis of a study which concluded that homeopathy only appears to work because of ‘perceptual errors’: (RCVS: 2017) which stated (my emphasis):

“Therefore, animals with conditions that could be treated by an approved veterinary medicine are going without effective treatments in favour of ineffective homeopathic products. Furthermore, not all homeopathic products are neutral in their effect and are sometimes administered in highly concentrated forms that can potentially harm patients. Although homeopaths report that their remedies are effective when used in their practice, efficacy beyond placebo is not apparent in well-controlled clinical trials that eliminate biases and other non-specific effects.”

I am seriously not sure how homeopathy can be referred to as “placebo” and “ineffective” and then, in complete contrast, “all homeopathic products are not neutral in their effect and sometimes administered in highly concentrated forms that can potentially harm patients” in the same paragraph. This nonsensical account of homeopathy goes to show the ignorance with which it is frequently faced. There is a knock-on and compounding effect with one poorly written paper being incorporated into the next and so on. Furthermore, there is a frequent lack of understanding by critics of this very complex therapy which requires much in-depth study and practice.

The Austrian model – one to take on board

In contrast, the Vets Österreichische tierärztekammer (Austrian Veterinary Chamber) released their position statement in January 2019 stressing the importance of integrative medicine and CAM. The modalities they embrace are homeopathy, chiropractic, osteopathy, phytotherapy, acupuncture (and TCM) and osteopathy. They do NOT rule them out as alternative therapies and insist on respectful, unbiased communication and education within the profession regarding all forms of CAM. It is suggested by CAM4animals that this would be a good example to follow. I believe this method of working should be adopted globally.

Detractors: social media and sceptic organisations

This article would be incomplete without briefly discussing the effect that certain social media figures and sceptic organisations are having on CAM therapies in the veterinary field. You may have heard of the Good Thinking Society and The Nightingale Collaboration which actively campaign against alternative practices such as chiropractic and homeopathy. Vet Danny Chambers promoted their views and went on to start a petition in 2016 to ban vets from using homeopathy: “A call to ban veterinary surgeons from prescribing homeopathy as a treatment for animals.

This had a mere 3,335 supporters. In contrast, the petition adopted by CAM4animals has almost 22,000 supporters, including animal owners, farmers, vets and CAM practitioners. From 2016 – 2017, The Good Thinking Society promoted Mr Chambers’ view on homeopathy and his position onto the RCVS Council. He worked with the now President of the RCVS to release the statement on CAM in November 2017. This situation, with reference to CAM detractors and their negative effect on veterinary practice as a whole, will be covered in more depth in my next blog in this series for CAM4animals.

The British Association of Homeopathic Veterinary Surgeons (BAHVS) in response to Mr Chambers’ petition issued a statement.

“The whole premise of this campaign is based on the blatant misrepresentation that homeopathic medicines are ‘only water’. This is plainly not true. A global initiative of over 100 researchers from a multiplicity of disciplines

(GIRI- Groupe International de Recherche sur l’Infenitésimal: http://giri-society.org/ )   has been studying solutions described as ‘ultra-dilutionse’ for 30 years. They have observed unequivocal evidence of their bioactivity. PubMed alone contains more than 100 papers. Recently, researchers have proven the existence of nanoparticles in such solutions.” Since this response was made, considerable developments have been made in relation to such cutting-edge science, see here: (Salter, C: Dec 2018).

Once again, the very fact the petition by Danny Chambers exists, shows how little research these uninformed and sceptical disparagers have done. Chambers stated after the RCVS published its statement, ‘‘I recognise that the majority of veterinary homeopaths are acting with the best of intentions, but unfortunately being well-intentioned but deluded is no substitute for being right, especially when the consequences could lead to unnecessary suffering and even death.’ (Chambers, D, cited by Fearon, R: BMJ.)

When you consider iatrogenic disease (adverse effects of drugs), this statement is not only erroneous in the light of the evidence above, but also short sighted and almost laughable; the irony does not escape me.  As with all vets, no homeopathic/holistic vet would intentionally harm an animal. They would simply choose the best method of treatment out of the many options available to them, giving them a greater choice than those limited to one approach – an approach which may come with a host of potential problems and adverse effects.

As was pointed out by the Veterinary Record, “A spokesman for the BAHVS said the (RCVS) council had been ‘seduced’ into a ‘precedent setting restriction on the clinical freedoms the profession has always enjoyed.”  The RCVS was now in a position where it could be accused of “putting profits before probity” and “corporations before conscience”, said the spokesman (No evidence for homeopathy, says RCVS, 2017 (Fearon, R. BMJ,: no date)

It is important to note that these claims of suffering and poor practice by anti-CAM campaigners are widely bandied about, but in fact no cases of poor practice by CAM practitioners have actually been brought to the RCVS. All vets are bound by Codes of Professional Conduct. If cases of poor veterinary practice – whether through conventional treatments, lack of treatment, maltreatment or even, in the highly unlikely event, by CAM treatments – are identified, then vets or their clients should bring these to the attention of the RCVS and let them be addressed by their disciplinary procedure.

DEFRA Statement

Subsequent to the RCVS statement, the Department for Environment, Food and Rural Affairs (DEFRA) stated that vets using homeopathy are not putting animals at risk. They were responding to a parliamentary question tabled on 28 March 2018 by David Tredinnick MP, who had taken up the cause of vets unhappy at the RCVS position statement. In his written answer the Secretary of State, George Eustice MP, was unequivocal: “The Department does not have any evidence that shows that homeopathic vets are a risk to animal welfare by using homeopathy as an alternative treatment to conventional medicine options.”

Peter Gregory, veterinary dean of the Faculty of Homeopathy, said: “This drives a coach and horses through the Royal College’s reasoning for adopting its anti-homeopathy stance. The argument that homeopathy endangers animal health is spurious, unsubstantiated and wrong.” He continued: “Growing numbers of pet owners and farmers are seeking a more holistic approach to animal health and have found homeopathy can help to achieve this. In light of the Secretary of State’s statement, I call on the Royal College to look again at its position on the use of complementary medicines in veterinary practice.” . Thus, the division of opinion is still evident, and all are looking for justice to be done, for the sake of the animals and those treating them.

The way forward

The following are suggested as a way forward by CAM4animals:

If CAM modalities were fully integrated into veterinary practice and training, and therefore fully accessible to clients, the UK veterinary profession would meet client and patient needs on all levels: health, welfare and well-being. This would fulfill the RCVS’s core objectives and benefit animal welfare.

CAM4animals suggests RCVS contacts the Homeopathic Research Institute and all relevant professional bodies governing all Complementary and Alternative Veterinary Medicines and modalities to enable a fully considered consultation with all relevant stakeholders.

Since there are inherent difficulties with fitting individualised medicine such as homeopathy, acupuncture and chiropractic treatment into traditional trials methodology, CAM4animals would like recognition of the fact that there are other ways of developing an evidence base for veterinary treatments, including what are known as Real World Trials, which fit RCVS’s definition of evidence based veterinary medicine and demonstrate the effectiveness of such treatments.

CAM4animals would urge RCVS Council members to take up offers to visit holistic vets and consult with farmers and pet owners.

By implementing the above, I feel all the RCVS objectives would be achieved.  We would be putting the animal first by enabling a wider range of treatments to be available at the discretion of a qualified vet.

Conclusion

CAM4animals considers that integrating expertly chosen holistic modalities as first line treatments where appropriate (frequently obviating the need for potentially harmful drugs) into veterinary practice would enhance overall animal care. I share this view. Where alternative homeopathic and other holistic treatments have been seen to be effective, it is, in my opinion, unjust and unreasonable that conventional medicine should always take precedence. The statement from the RCVS, to make conventional medicine the first line of treatment, has been critically analysed here and contested. However, it is appropriate to re-iterate this article does not seek to dismiss conventional treatments as first line or emergency treatment options.

In summing up, I suggest that there should be an overall recognition of the benefits of alternative medicine and that it should be integrated into general veterinary care to be used as first line treatment where appropriate. In addition to homeopathy, this includes chiropractic treatment, osteopathy, acupuncture, herbs, massage and other therapies which have been proven to be effective both empirically and in controlled trials. As shown here, all these therapies are currently seen as complementary under the new RCVS statement and cannot be used in the first instance.

I would strongly suggest that observation and judgment must always take precedence over statistical analysis alone, and that the benchmark for so called standards is changed to include those which have already been proven to be effective. Clinical evidence in the form of numerous studies, RCTs, Real World Trials and those documented empirically, has been referenced within this article. These demonstrate that the homeopathic approach improves the health of animals and successfully treats a wide range of clinical conditions in veterinary medicine beyond the placebo effect.

In delving further into the RCVS statement and its supporting evidence, there has clearly been little attempt to present a balanced, unbiased view of CAM.  The RCVS Council avoided communication with the College’s own CAM qualified members.  It ignored positive studies in homeopathy and totally excluded consideration of all other forms of holistic modalities. Instead, to the detriment of animal welfare, they chose to lean on the side of denialism.

If you haven’t already done so, please sign the CAM4animals charter

References

• Americans for Homeopathy Choice, (2019) Why Veterinary Homeopathy Matters in Animal Health Care in the USA
• Bell, I (2018) A Bibliography of basic research in homeopathy
• British Acupuncture Council, New NICE guidance on urinary incontinence should include acupuncture, says membership body
• Camerlink I, Ellinger L, Bakker EJ, Lantinga EA. (2010) Homeopathy as replacement to antibiotics in the case of Escherichia coli diarrhoea in neonatal piglets. Homeopathy. Jan;99(1):57-62
•  CDC, (2012) Grand Rounds: Prescription Drug Overdoses a U.S. Epidemic
• College publishes complementary medicines statement (2017)
• CORE-Hom, Homeopathy Research Institute
• Faculty of Homeopathy: No evidence homeopathy is a risk to animal welfare
• Faculty of Homeopathy (2017) Response to RCVS statement on complementary and alternative therapies
• Fearon, R, (no date.) BMJ, No Evidence for Homeopathy says RCVS
• Graham, G: (2017): Hpathy.com: Clarification of the basic homeopathy principles
• IAHV: (2017) How can homeopathy make a difference in the AMR issue?
• Iatrogenesis
• Marino, FV: Homeopathic data base of veterinary research studies
• NIHM, (2018): Herbs key in the fight against antimicrobial resistance
• RCVS (2017): Homeopathy only seems to work because of perceptual errors
• Salter, C, (Dec 2018) The Aurum Project, Plausible Homeopathy- Science on the edge
• Sign the charter, CAM4animals
• Stone and Matthews, (1996) Stone J, Matthews, J, Complementary Medicine and the Law. Oxford University Press, Oxford
• The College of Medicine and Integrated Health (2018) GP’s trained in complementary medicine less likely to prescribe antibiotics
• The Royal College of Veterinary Surgeons
• Vets Österreichische tierärztekammer, (2019) Positionen & Stellungnahmen
• Walach, H. (2001), The efficacy paradox in randomized control trials of CAM and elsewhere. Beware of the placebo trap. Journal of Alternative and Complementary Medicine,7; p.213-218).