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Alliance Boots – DC's Improbable Science

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gphc

The General Pharmaceutical Council (GPhC) has been the statutory body responsible for the regulation of pharmacy since 2010. It’s status is similar to that of the GMC and. heaven help us, the GCC. Before that the regulator was the same as the professional body, the Royal Pharmaceutical Society of Great Britain (RPS). The RPS proved to be as useless as most other regulators, as documented in detail in my 2008 post, At around the time it stopped being a regulator, the RPS started to condemn quackery more effectively, but by then it had lost the power to do much about it (I hope the latter wasn’t the cause of the former). The body that could do something, the GPhC has done essentially nothing. as described in this post.

I did a 2 year apprenticeship in Timothy White’s and Taylor’s Homeopathic (yes, really) Chemists in the 1950s.
My first degree was in pharmacy. I got my interest in pharmacology from reading Martindale’s Extra Pharmacopoeia in the shop. I soon decided that I didn’t really want to spend the rest of my life selling lipstick and Durex. The latter was quite a big seller because the Boots across the road didn’t sell contraceptives (they changed their minds in the 1960s).

In those days, we spent quite a lot of time making up (almost entirely ineffective) ‘tonics’ and ‘cough mixtures’. Now the job consists largely of counting pills. This has exacerbated the ‘chip on the shoulder’ attitude that was present even in the 1950s. For a long time now, pharmacists have wanted to become the a ‘third tier’ in the NHS, alongside GP practices and hospitals., after hospitals and doctors". . Here are a few comments on this proposition.

First let me say that I’ve met some very good and ethical pharmacists. I did a vacation job in a hospital pharmacy where the boss had an encyclopaedic knowledge of the effects and side effects of drugs, and of their dosage. His advice was often sought by doctors, and rightly so. He had no way of knowing at the time that his advice to replace barbiturates with thalidomide would lead to such a tragedy, because the evidence had been concealed by the manufacturer. Some of the problems alluded to here have already been highlighted by two excellent pharmacists, Anthony Cox and @SparkleWildfire, neither of whom work in pharmacists shops. They are absolutely spot on but they seem to be in a minority among pharmacists.

The problems seem to lie mostly in retail shops. Their shelves are laden with ineffective pills and potions. And the pharmacist has every incentive to sell them. His/her income depends on it directly if it’s a privately owned pharmacy. And his/her standing with head office depends on it in chain store pharmacies. This conflict of financial interest is the prime reason why pharmacists are not qualified to form a third tier of healthcare. The avoidance of conflicts of interest among doctors was one of the great accomplishments of the NHS. In the USA there are huge scandals when, as happens repeatedly, doctors order expensive and unnecessary treatments from which they profit. It’s no consolation that such problems are creeping back in the UK as a result of the government’s vigorous efforts to sell it off.

Here are few examples of things that have gone wrong, and who is to blame. Then I’ll consider what can be done.

Ineffective medicines

In any pharmacy you can see ineffective ‘tonics’ and ‘cough medicines’, unnecessary supplements with dishonest claims and even, heaven help us, the ultimate scam, homeopathic pills.

What’s worse, if you ask a pharmacist for advice, it’s quite likely that they’ll recommend you to buy them.

I was amazed to discover that a number of old-fashioned ‘tonics’ and ‘cough medicines’ still have full marketing authorisation. That’s the fault of the Medicines and Healthcare Regulatory Auhority (MHRA) who are supposed to assess efficacy and totally failed to do so, Read about that in “Some medicines that don’t work. Why doesn’t the MHRA tell us honestly?” . It’s hard to blame a pharmacist for the bad advice given by the MHRA, but a good one would tell patients to save their money.

benylin

Big corporate pharmacies

Companies like Boots seem to have no interest whatsoever in ethical behaviour. All that matters is sales. They provide “(mis)educational” materials that promote nonsense They advertise ridiculous made-up claims in the newspapers, which get shot down regularly by the Advertising Standards Authority, but by that time the promotion is over so they don’t give a damn. See for example, CoQ10 scam and the ASA verdict on it. And "Lactium: more rubbish from Boots the Chemists. And a more serious problem". And "The Vitamin B scam. Don’t trust Boots"

Recently the consumer magazine Which? checked 122 High Street pharmacies. They got unsatisfactory advice from 43% of them, a disastrously bad performance for people who want to be the third tier of healthcare.

Even that’s probably better than my own experience. Recently, when I asked a Sainsbury’s pharmacist about a herbal treatment for prostate problems, he pointed to the MHRA’s kite mark and said it must work because the MHRA approved it -he was quite unaware that you get the THR kite mark without having to present any evidence at all about efficacy.

mhra

Of course that is partly the fault of the MHRA for allowing misleading labels, but nevertheless, he should have known. See “Why does the MHRA refuse to label herbal products honestly? Kent Woods and Richard Woodfield tell me” for more on how the MHRA has betrayed its own standards.

When I’ve asked Boots’ pharmacists advice about persistent diarrhoea in an infant, saying I wanted a natural remedy, I’ve usually been guided to the homeopathic display. Only once was I told firmly that I should use rehydration not homeopathy (something every good parent knows) and when I asked that good pharmacist where she’d been educated, she said in Germany (mildly surprising given the amount of junk available in German pharmacies)

Regulators

Anthony Cox, a pharmacist who has been consistently on the side of right, says

"This is something that needs to be dealt with at a regulatory and professional body by the whole profession, and I am certain we have the majority of the UK pharmacy profession on side."

But the regulator has done nothing, and it isn’t even clear that there is a majority on his side.

At a 2009 meeting of Branch Representatives of the RPS a motion was proposed:

“…registration as a pharmacist and practice as a homeopath are not compatible, and that premises registered with the Society should not be used for the promotion of homeopathy”

Although that is obviously sensible to most people, the proposal was followed by a speaker from Leicester who thought it right to keep an open mind about Avogadro’s number and the motion was defeated. So much for the "scientists on the High Street" aspiration.

There have been two major scandals surrounding homeopathy recently. Both were revealed first by bloggers, and both came to wide notice through television programs. None were noticed by the regulators, and when they were brought to the attention of the regulator, nothing effective was done.

The malaria scandal

A lot has been wriitten about this here and on other blogs e.g. here and here. The idea that sugar pills can prevent or cure malaria is so mind-bogglingly dangerous that it was condemned by the Queen’s Homeopathic Physician, Peter Fisher. It was exposed on a BBC Newsnight programme in 2006. Watch the video.

The Gentle Art of Homeopathic Killing was an article that originally appeared on the excellent Quackometer blog produced by Andy Lewis. "The Society of Homeopaths were so outraged about one of their members flouting the code of ethics so blatantly that they took immediate action. That action was, as expected, not to do anything about the ethics breach but to threaten Andy and his hosting ISP with legal action for defamation. The article is reproduced here as a public service".

Some of the people involved in this bad advice were pharmacists, Very properly they were referred to the RPS in 2006 qnd 2009, the regulator at that time. They sat on the complaint so long that eventually the RPS was replaced by the GPhC as regulator. Nothing much has happened.

The GPhC did precisely nothing. Read their pathetic response.

Homeopathy for meningitis

An equally murderous fraud, "homeopathic vaccines" by Ainsworth’s has long been targeted by bloggers. In January 2013, Samantha Smith made an excellent BBC South West programme about it. Watch it and get angry.

Anthony Pinkus, pharmacist at Ainsworths, has been referred to the then regulator, the RPS, in 2006 and 2009. It’s said that he took "remedial action", though there is little obvious change judged by the video above. No doubt some of the most incriminating stuff has been removed from his web site to hide it from the ASA. It’s safer to mislead people by word of mouth. Since the last video more complaints have been made to the GPhC. So far, nothing but silence.

Why doesn’t the regulator regulate?

This pamphlet is reproduced from the July 2011 Quackometer post, “Ainsworths Pharmacy: Casual Disregard for the Law

ainsworth

It’s almost as though those royal warrants, enlarged on right, acted as a talisman that puts this dangerous company outside the grasp of regulators. I hope that the GPhC Council , and Duncan Rudkin (its chief executive and registrar), are not so worried about their knighthoods that they won’t risk upsetting the royal family, just to save patients from malaria and meningitis. Their CEO, Robert Nicholls is only a CBE so far.

warrants

Another reason for their inaction might be that the GPhC Council members, and Duncan Rudkin (its chief executive and registrar), lack critical faculties. Perhaps they have not been very well educated? Many of them aren’t even pharmacists, but that curious breed of professional administrators who inhabit the vast number of quangos, tick their boxes and do harm. Or perhaps they are just more interested in protecting the income of pharmacists than in protecting their customers?

Education

The solution to most problems is education. But there is no real knowledge of how many pharmacists in the UK are educated in the critical assessment of evidence. A recent paper from the USA did not give cause for optimism. It’s discussed by the excellent US pharmacist, Scott Gavura, at Science-based medicine. The results are truly horrifying.

“Few students disagreed with any CAM therapy. There was the greatest support for vitamins and minerals (94%, mean 4.29) which could include the science-based use these products. But there was strong support for demonstrably ineffective treatments like acupuncture, with 64% agreeing it was acceptable. Even homeopathy, which any pharmacy student with basic medicinal chemistry skills ought to know is absurd, was supported by over 40% of students.”

If the numbers are similar in the UK, the results of the Which? magazine survey are not so surprising. And if they are held by the GPhC Council. their inaction is to be expected. We just don’t know, and perhaps someone should find out.

I suspect that sympathy for quackery may sometimes creep in through that old-fashioned discipline known as pharmacognosy. It is about the botany of medicinal plants, and it’s still taught, despite the fact that very few drugs are now extracted from plants. At times, it gets dangerously close to herbalism. For example, at the School of Pharmacy (now part of UCL) a book is used Fundamentals of Pharmacognosy and Phytotherapy  by Michael Heinrich, Joanne Barnes, Simon Gibbons and Elizabeth M. Williamson, ot the Centre for Pharmacognosy and Phytotherapy at the School of Pharmacy. The introductory chapter says.

“TRADITIONAL CHINESE MEDICINE (TCM) The study of TCM is a mixture of myth and fact, stretching back well over 5000 years. At the time, none of the knowledge was written down, apart from primitive inscriptions of prayers for the sick on pieces of tortoise carapace and animal bones, so a mixture of superstition, symbolism and fact was passed down by word of mouth for centuries. TCM still contains very many remedies, which were selected by their symbolic significance rather than proven effects; however, this does not necessarily mean that they are all ‘quack’ remedies!”

Well, not necessarily. But as in most such books, there are good descriptions of the botany, more or less good accounts of the chemical constituents followed by uncritical lists of things that the herb might (or might not) do. The fact that even the US National Institutes of Health quackery branch, NCCAM, doesn’t claim that a single herbal treatment is useful tells you all you need to know.

Joanna Barnes is Associate Professor in Herbal Medicines, School of Pharmacy, University of Auckland, New Zealand. She has written a book, Herbal Medicines (“A useful book for learning holistic medicine”) that is desperately uncritical about the alleged theraputic effectiveness of plants. ("Simon Gibbons is on the editorial board of The Chinese Journal of Natural Medicine. Elizabeth Williamson is editor of the Journal of Phytotherapy Research, a journal that has a strong flavour of herbalism (take the infamous snoring remedy). These people aren’t quacks but they are dangerously tolerant of quacks.

The warning is in the title. "Phytotherapy" is the current euphemism for herbalism. It’s one of those red light words that tells you that what follows is unlikely to be critical. Exeter’s fantasy herbalist, Simon Mills, now describes himself as a phytotherapist. What more warning could you need?

Perhaps this explains why so many pharmacists are unworried by selling things that don’t work. Pharmacy education seems not to include much about the critical assessment of evidence. It should do.

Chemist and Druggist magazine certainly doesn’t help. It continually reinforces the idea that there is a debate about homepathy. There isn’t. And in one of its CPD modules Katherine Gascoigne says

"Homeopathic remedies are available, but are best prescribed by a homeopath"

Ms Gascoigne must be living on another planet.

Conclusions

The main conclusion from all of this is that the General Pharmaceutical Council is almost criminally negligent. It continues to allow pharmacists, Anthony Pinkus among them, to endanger lives. It fails to apply its own declared principles. The members of its Council, and Duncan Rudkin (its chief executive and registrar), are not doing their job.

Individual pharmacists vary a lot, from the superb to those who believe in quackery. Some, perhaps many, are embarrassed by the fact that their employer compels them to sell rubbish. It’s too much to expect that they’ll endanger their mortgage payments by speaking out about it, but the best ones will take you aside and explain that they can’t recommend it.

The GPhC itself is regulated by the Professional Standards Authority, the subject of my last post. We can’t expect anything sensible from them.

In the USA there is a shocking number of pharmacists who seem to believe in quackery. In the UK. nobody knows, though judging by their failure to vote against the daftest of all scams, homeopathy, there is no cause for complacency here.

It seems that there will have to be big improvements in pharmacy education before you can have much confidence in the quality of the advice that you get in a pharmacy.

Follow-up

Yesterday a talk was given at the School of Pharmacy, organised by the “The Centre for Homeopathic Education” (an oxymoron if there ever was one). The flyer had all the usual nonsense. Its mention of “Remedies & Tonics for Cancer Recovery” might well have breached the Cancer Act (1939). When I asked whether the amount received in room rental was sufficient to offest the damage to the reputation of the School of Pharmacy resulting from hosting a nutty (and possible illegal) event, I had the greatest difficulty in extracting any sort of response from the school’s director, Duncan Craig. I’m told that he considers “the policy on space rental to be a UCL management issue, rather than a matter of discussion on scientific ethics with a colleague”. Oh dear.

Jump to follow-up

I don’t know about you, but I’m bored stiff with homeopathy. There are a lot more important things. Nevertheless, it remains a gross insult to reason, and there has been such enormous success in combating it over the last five years so, this is not the moment to stop.

Hats off to the Merseyside Skeptics Society. I admit that when I first heard about the 10:23 campaign, it seemed to be a bit of a gimmick, but in fact it turned out to be an enormous success., not just in the UK but also in Canada, Australia and New Zealand

10:23 Leeds

The campaign was focussed on Boots, the UK’s biggest pharmacy chain, In particular the fact that Boots sell homeopathic pills. and regularly gives appallingly bad advice about all forms of quackery that they stock.

I’ve been criticising Boots for years now, starting with Mis-education at Boots the Chemist in May 2006. was largely about homeopathy, but Boots’ quackery is not restricted to homeopathy, In November 2007, Don’t Trust Boots described Boots’ promotion of vitamin pills that were
advertised by Boots to increase your energy, and also the appallingly bad advice given by shop staff on this product.

In March 2008, Boots did it again, with a big promotion written up as Boots reaches new level of dishonesty with CoQ10 promotion. The strategy seems clear by now. Launch an enormous publicity effort, and rely on journalists to parrot the press release. Put mendacious advertisements in every newspaper. Eventually the advertisements are found to be inaccurate by the Advertising Standards Authority. Boots are told to stop using the advertisement, but suffer no penalty at all.  By that time the advertising campaign is over anyway, and they can rely now on inaccurate advice from "Boots expert team"; face to face in the store, to continue the promotion in a way that evades all regulation.

Boots is deeply involved too in the great ‘detox’ scam, as recounted, for example, in “Detox”: nonsense for the gullible, along with the Prince of Wales.  And, most recently, Lactium: more rubbish from Boots the Chemists. And a more serious problem.

The nauseating hypocrisy of Boots’ Corporate Social Responsibility statement beggars belief. The same stuff is repeated on the current Alliance Boots site.

“Trust – The essence of the way we do business. We are trusted because we deliver on our promises.”

You must be joking.

Who owns Boots?

Boots started in 1849 as a single shop in Nottingham. Within my lifetime, they were rather ethical pharmacies (my recollection is that they didn’t sell homeopathic pills). They were also an ethical pharmaceutical company.  They developed ibuprofen, which was launched in 1969.   But since then the company was involved in a complicated series of acquisitions. Now it is a supranational conglomerate with presence in 20 countries, and almost beyond the reach of the law. Boots’ executive chairman is Stefano Pessina, who, with private equity firm Kohlberg Kravis Roberts in a £11.1 billion deal last year, took the firm private in 2007.   In 2008 they announced a 20% increase in profits, to £771 million In 2008 they moved their headquarters out of the UK, to Geneva, partly, it seems, so they can be closer to other giants of Big Pharma, and partly, no doubt, to put pressure on the UK government not to tax them too much,   On the other hand, tax may not be a big consideration because, according to The Times, the ultimate owners of Boots are based in Gibralter

The disgraced head of HBOS, Andy Hornby, was appointed as chief executive of Alliance Boots in June 2009. Before playing his part in ruining the UK economy he used to work for grocery chain, Asda. I’d guess that he has limited interest in pharmacology.

The economics of such organisations are beyond most people. a bit like the two cow economics joke perhaps.

"VENTURE CAPITALISM – AN ICELANDIC CORPORATION

You have two cows.

You sell three of them to your publicly listed company, using letters of credit opened by your brother-in-law at the bank, then execute a debt/equity swap with an associated general offer so that you get all four cows back, with a tax exemption for five cows. The milk rights of the six cows are transferred via an intermediary to a Cayman Island Company secretly owned by the majority shareholder who sells the rights to all seven cows back to your listed company. The annual report says the company owns eight cows, with an option on one more. You sell one cow to buy a new president of the United States, leaving you with nine cows. No balance sheet provided with the release. The public then buys your bull."

Clearly there is not the slightest chance of an organisation like this will have any sort of conscience about selling useless pills, The only way that they can be influenced is by public mockery of their outrageous behaviour. If the publicity harms their image enough they may decide to cut their losses, because it pays, not because it is right.

10:23 a great success

The campaign was a success because it got good coverage in the newspapers, radio and TV. Boots, rather like vice-chancellors, seems to be uninterested in reason or morals, but will certainly be sensitive about its public image, There is a partial list of coverage at the 10.23 site.

Laura Donnelly had a good account in the Telegraph, "Homeopathy: medicine that’s hard to swallow?".  And Hadley Freeman in the Guardian showed that fashion journalists can spot nonsense too, in "Me and my homeopathic overdose. How I knocked back a bottle of homeopathic ‘medicine’ and lived to tell the tale"

The spoof published on the NewsArse site (despite the name, it is excellent) hit the nail on the head, because it uses exactly the naive sort of post ho ergo propter hoc argument that homoeopaths love.,

Homeopathy proven to work after overdosing protesters eventually fall asleep

Homeopathic practitioners are today claiming victory for the efficacy of their remedies, after a protest by the 10:23 group who overdosed on homeopathic sleeping pills, left each participant asleep within just 36 hours of taking the remedy.

Funniest of all though, was the bleating by homeopaths themselves. Try, for example, Homeopathy Heals. Like all the others it alleges a conspiracy by big Pharma: “it seems to be driven by those working for Pharma behind the scenes”. It seems to have escaped the attention of these conspiritorialists that the demonstration was aimed at Boots and Boots IS Big Pharma. The two are inextricably linked and both use the same tactics to increase sales.

My small contribution

Apart form contributing to Laura Donnelly’s piece in the Telegraph, "Homeopathy: medicine that’s hard to swallow?"., I had a few more calls.

Mary English, homeopath and astrologer

The most interesting was a talk show on Radio 5 live, where I was was pitted against a homeopath, Mary English [play the mp3 file, 4.4
Mb]. Having come across Mary English before, I was well-prepared to talk about her record not only in homeopathy, but also in astrology. The presenter didn’t give me time to raise these points but he did a pretty good job himself in asking her the relevant questions.

Mary English’s website is a delight. "Homeopathy and Astrology can heal you".

" If you eat a whole bottle of them it wouldn’t make any difference because it’s the dose that you have, not the quantity of the tablets"

"It’s the frequency of dose . . .because it’s vibrational medicine"

The host asked "what’s vibrational medicine?"

"it works with your bodies systems as opposed to against it"

No doubt Mary English is quite sincere, She just, like so many homeopaths, seems to be quite unaware that these words don’t mean anything at all. Just pure gobbeldygook.

Some of her claims are bizarre, even by the standards of homeopaths.  She has researched the birth charts of Indigo Children, and written a book, "How to survive a Pisces"  Her claim to homeopathic fame is that she has done "provings" of "remedies" including thunderstorm, and shipwreck  and Stanton Drew Stone Circle, and Old Wardour Castle. Ahem, suddenly Arnica 30C sounds quite sane.

Less excusably, Mary English went on to claim that there is good evidence that homeopathy works. She just hasn’t read, or hasn’t understood the evidence. But since she earns her living as a homeopath
and astrologer, she hasn’t got much incentive to read the evidence. if she did, her income would dry up.

The presenter put directly to Mary English the recommendation of homeopathy for malaria prevention. "You wouldn’t condone that would you?". Quite disgracefully that question was avoided. She
changed the subject without answering the question.  The quackometer’s classic post on The Gentle Art of Homeopathic Killing came to mind (see also here for links to full text)

Some herbal stuff

Herbal medicine rather than homeopathy was the topic of the other two weekend gigs. That arose from the Pittilo proposals for statutory regulation of herbalists and Chinese medicine.

The BBC TV interview, together with a herbalist, Rhona Edmonds, is now in YouTube. A Welsh member of the European parliament, Jill Evans (Plaid Cymru) , has been backing herbalists on the grounds that they are a “well-respected profession”. Oh yes?  The Prince of Wales has also had support from another MEP. Mike Nattrass (UKIP).  It seems that our fringe parties have even more trouble with science than the Labour and Conservative parties (and, tragically, that includes the Green party too).

There was also an early morning talk show interview on Sunday 31 January, against the same herbalist [play mp3 file] She claims "we treat all sorts of conditions",. Yes indeed, that’s the problem. "If we were recognised it would give the public even more confidence". And that is the problem too. They don’t deserve that confidence.

The analogy between alternative medicine and religion is often striking. Both involve blind faith, and both are characterised by tendency to split into sects that war with each other even more viciously than they war with unbelievers. All the discussions of herbalism ignore the fact that an enormous number of herbalists (2536 as of 4th February) have signed a petition opposing the idea of statutory regulation, even in the ineffective form that is being proposed.

The Prince of Wales declares war on . . . the Enlightenment

That was the headline of an article in The Times (February 4th, 2010).  There can be no more high profile propagandist for every form of magic medicine than the Prince of Wales. Nothing seems to stretch his credulity.  But even I was taken aback by his latest pronouncement.  It seems he’s been called an enemy of the enlightenment (yes, by me among many others).

“I was accused once of being the enemy of the Enlightenment,” “I felt proud of that.”

“We cannot go on like this, just imagining that the principles of the Enlightenment still apply now. I don’t believe they do. But if you challenge people who hold the Enlightenment as the ultimate answer to everything, you do really upset them.”

So it seems he wants to return medicine not just to 1800, but to 1500, the dark ages. Can he really think that life in 1500 was some sort of utopia?  Of course one suspects that his disapproval of the enlightenment is restricted to medical matters.  He hasn’t been seen to reject other products of the enlightenment, like cars, aircraft, telephones, radio, TV and the internet.

I suspect that the Prince of Wales needs a history lesson.

Follow-up

Thanks to a colleague for pointing out an excellent sketch from the Newsjack show on BBC Radio 7, broadcast on 4th February 2009. [play mp3 file, 2.4 Mb]. I quote.

“Last weekend, people up and down rhe country engaged in a mass anti-homeopathy protest, swallowing whole bottles of remedies outside Boots.”

“It’s very easy to sneer at homeopathy but we at Newsjack believe it’s important to listen to both sides of the debate. So to put the case for homeopathy we have invited on a ridiculous charlatan who extorts money from innocent people while providing no services of any actual value.”

“Will you please welcome His Royal Highness, the Prince of Wales”