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Profit and public health

June 4th, 2015

Amid the abandonment of tariff protection and the continued assaults on trade unionism, one union/lobby group has been consistently victorious. The Pharmacy Guild has managed to restrict competition so successfully that it’s impossible to open a pharmacy if it might hurt the profitability of an existing business, even if that business is failing to serve a significant group of customers. I ran into an example when I was at James Cook University in Townsville. A request for an on-campus pharmacy was rejected because it was within the market area claimed by a suburban pharmacy, more than a kilometre away and inaccessible by public transport.

Far more important to the Guild is the imperative of keeping supermarkets out of the pharmacy business. The key argument is that supermarkets are just businesses, happy to sell anything to make a buck, whether it’s cigarettes or cancer medications.

So, I was interested to read the Guild’s reaction to a proposal that medical professionals should stop prescribing homeopathic products. Whatever you might think about alternative/complementary medicines in general, homoepathy is plain quackery, combining a magical theory of medicine with the preposterous physics of water memory. Unsurprisingly, research has proved beyond any doubt that it’s no better than a placebo. So, the Royal Australian College of General Practitioners (RACGP) has formally recommended GPs stop prescribing homeopathic remedies and says pharmacists must also stop stocking such products.

The Guild’s reaction:

it is not a regulatory authority, and as such there will be no recommendation backing RACGP’s call for homeopathic products to be taken off the market.

In other words, selling medicine in the same shop as alcohol is unthinkable, but it’s entirely OK for a health professional to promote and sell water as a treatment for serious illness.

This episode demonstrates, to anyone who cares to look, that the Pharmacy Guild is (and in fact claims to be) nothing more than a rent-seeking lobby group, whose sole concern is the profitability of its members. As the Tobacco Institute of Australia would be quick to point out (if it were still around), there’s nothing illegal about that. But when profits and public health come into conflict, the Guild and the Institute are on the same side.

  1. Uncle Milton
    June 4th, 2015 at 11:07 | #1

    Most of what pharmacies sell has nothing to do with health. But it could be worse. In the US, pharmacies sell cigarettes.

    The Pharmacy Guild is the most powerful lobby in the country. Apparently every time there is a new Prime Minister they Guild sends him (once, her) a very clear message not to mess with them or they will unleash the mother of all campaigns against them. The Guild, as far as I am aware, has not placed a horse’s head in a PM’s bed (yet), but there’s been no need. No PM has ever taken on the Pharmacy Guild.

    The power of the Pharmacy Guild comes from the extraordinary and undeserved esteem that local pharmacists hold in local communities. How it came to this is a story that needs to be researched and told.

  2. Nevil Kingston-Brown
    June 4th, 2015 at 11:08 | #2

    Hear hear. If they want special rights they should accept responsibility for promoting public health. Some chemists are full of “magnetic” bandages, aromatherapy treatments, homeopathic remedies and who knows what else.

  3. bjb
    June 4th, 2015 at 11:42 | #3

    The “professional” organisations like pharmacists, surgeons, lawyers all wield much, much more power and market control than any trade union ever did, yet you never hear the business council types ever coming out decrying the lack of “flexibility” these organisations present in the market.

  4. Ikonoclast
    June 4th, 2015 at 11:54 | #4

    I agree. Homeopathy is plain quackery as are several other alternative medicine fields. And the Pharmacy Guild is a rent-seeking lobby group. I would argue for calling them a “guild” as indeed they call themselves. They are not a union. Pharmacists, or at least the pharmacists influential in the Guild, are not worker-employees, they are owner-employers of small to medium sized and even large enterprises. The predominating or very likely total influence of pharmacy owners in the Guild is clearly shown by this;

    “Full membership is offered to qualified, registered pharmacists who own their own pharmacy. Membership is comprised of a ‘proprietor’ and a ‘premises’ component. The ‘premises’ component is based on the number of pharmacy premises owned.” – The Pharmacy Guild of Australia website.

    Without further information one can only assume that voting rights are linked to full membership. I cannot imagine them permitting employees to run the employer’s guild.

    The other levels of membership are as follows;

    “Associate membership is available to those pharmacists who do not own a pharmacy. This includes pharmacy managers, pharmacy staff or graduates.”

    “Student membership is available to any student currently studying pharmacy, allowing pharmacy students to take the first step toward participating and contributing to their future professional association.”

    We can see from this setup how proprietor or capitalist rights must predominate and how pharmacist employees can possibly be encouraged or induced to join the employers’ guild rather than a genuine workers’ union.

    One can view The Constitution of the Pharmacy Guild of Australia.

    http://www.guild.org.au/docs/default-source/public-documents/tab—the-guild/About-the-Guild/The-Constitution/constitution-of-the-pharmacy-guild-of-australia.pdf?sfvrsn=2

    “At all meetings of the National Council each member except the National President shall
    have one vote.”

    I assume this means full members only. Where pharmacies or pharmacy chains are partnerships of pharmacist-owners, it looks like each partnership member gets a vote.

    Professional Pharmacists Australia (PPA) “is the union that represents non owner pharmacists who work in community pharmacies right across Australia”.

    I expect the SDA (Shop, Distributive and Allied Employees Association) represents non-pharmacist workers in the pharmacy industry.

    I hope people can see the good reasons for insisting on a strong definitional separation between the term “guild” and the term “union” in the modern IR landscape. Guilds are for capitalists. Unions are for workers.

  5. Ivor
    June 4th, 2015 at 12:00 | #5

    There is no real problem with establishing economic territories under some form of social regulation. Cooperatives may need such provisions.

    The real problem is that exclusion of other suppliers may create economic rent which then appears as a return on Capital after normal costs have been paid.

    Surely a government can review territories every so often based on financial data from the particular businesses.

    The real problem, at root, is rent seeking, not the symptoms.

  6. Stockingrate
    June 4th, 2015 at 12:22 | #6

    @Nevil Kingston-Brown
    Truth in labelling: Pharmacy and Quack Remedy Guild, a Less-Professional Organisation. That is to say less professional than the RACGP.

  7. Ikonoclast
    June 4th, 2015 at 13:30 | #7

    @Ivor

    Good points. Technically, a pharmacy or pharmacy chain owned and run entirely by pharmacist owner-workers would be a cooperative. A Guild of cooperatives could and almost certainly would also rent-seek by pressuring government to keep the licensed number of cooperatives down.

    The issue would then still be how to regulate to meet multiple stakeholder objectives. Stakeholders would include Guild members (be they cooperative or capitalist enterprises), workers where applicable, the community as a whole and other affected groups (e.g. health professionals in general).

    In turn the next question becomes how to regulate market competition. Markets never operate in a vacuum. All markets are regulated and conditioned by institutional arrangements. Competition law and regulation in the area of Pharmacies would have to consider what maximum permissible size of site or chain of sites constitutes the borderline for an oligopoly (locally or regionally). At the same time it would have to consider what minimum size supports a pharmacy which can meet all health, welfare and safety regulatory requirements for all stakeholders while still remaining a viable single-owner or cooperative business.

  8. paul walter
    June 4th, 2015 at 13:54 | #8

    Pithy. Exactly the sort of thing that has me back here again and again, year after year.

    God bless you, Big John.

  9. J-D
    June 4th, 2015 at 14:06 | #9

    @Ikonoclast

    You could have made your point much more simply just by quoting from the Constitution you linked to (emphasis added by me):

    ‘The Pharmacy Guild of Australia is a not for profit employers organisation registered under the Fair Work (Registered Organisations) Act 2009.’

  10. Donald Oats
    June 4th, 2015 at 14:53 | #10

    It always irks me when I walk into a pharmacy and see homeopathic crap for sale. The homeopathic industry will argue that, because placebos can be beneficial, their homeopathic rubbish should be allowed as well. It is a lousy argument for a product that can prevent people from seeking the help they really need, fooled into using something which, under the known laws of chemistry and physics, cannot work—except perhaps briefly, as a placebo. Placebo effect and cancer vs chemotherapy and cancer…I know which I’d choose. Same goes for chronic disease: see a GP, a specialist if need be, but don’t put faith in the physical impossibility of homeopathic water. Cue the anecdotal evidence stories…

    I have some sympathy for people who have not had success with the standard medical system, but that’s no reason to pour money into something that cannot work in the first place. Medicine, like other scientific and technological fields, advances through experiment, thought, analysis, and peer review, arguments, more experiment, etc. There are no shortcuts to knowledge. Homeopathy is a hustle which succeeds only because it promises a shortcut solution to often desperate people. Shame on the pharmacies that stock this shite.

  11. Sancho
    June 4th, 2015 at 15:17 | #11

    I wonder how much the war on drugs plays into this.

    Recently I asked for some over-the-counter analgesics that contain codeine, and they wanted to record my license details, claiming it’s a regulatory requirement, which it absolutely is not.

    The only way they can get away with that is if the public thinks it’s reasonable, and they only way it sounds reasonable is by invoking the spectre of drug users getting high off generic Panadeine.

    Does the Guild thrive on the belief that a small chemists’ market is necessary to keep close watch on schedule 8 drugs?

  12. Ikonoclast
    June 4th, 2015 at 16:08 | #12

    @J-D

    Perhaps, but there were related issues to be teased out I thought.

  13. Robertito
    June 4th, 2015 at 16:08 | #13

    @Ivor
    I don’t think rent seeking is the root of the problem. “Seekers gonna seek” as young people probably say. The root of the problem is that our institutions are too amenable to rent seeking. But then the same people who could reform those institutions are also harvesting the rents. That’s why I tend to think that every economic problem is a political economic problem. Break that influence of money on politics and reform becomes possible.

  14. J-D
    June 4th, 2015 at 16:41 | #14

    @Ikonoclast

    If you had read Rule 6, Rule 6B, Rule 7, and Rule 9, you would have found that they gave a clearer picture than you succeeded in doing. You wouldn’t have had to ‘assume’ this or that; the answers were all there in the document.

  15. hc
    June 4th, 2015 at 17:06 | #15

    I don’t know how the location laws work in Victoria. A pharmacy opened up across the road from another in my suburb of Melbourne this year. Generally in the suburbs there seems to be lots of competition. The newcomer is a discounter and clearly applying competitive pressure to the other firm.

    The original pharmacy runs a coffee shop and sells lottery tickets. At least half the store is devoted to the sale of high-profit lines such as cosmetics and perfumes.

  16. John Turner
    June 4th, 2015 at 18:01 | #16

    First let me declare that I have a specific interest in this area. As Business Manager of a large rural medical practice I prevailed upon the practice partners to invest heavily in what amounts to ‘super clinic’. Our practice facility is of a high standard, modern and with the latest equipment. We have co-located radiology and pathology collection.

    When we tried to introduce a Pharmacy as part of the overall service we were unable to do so because two other pharmacies existed in town and were not the minimum 500 metres away from our practice. However, there is absolutely no constraint on the pharmacies employing general practitioners or nurse practitioners and providing such services from the pharmacy.

    Then there is the matter of the price of prescription medicines. Basically the Australian PBS/public is being ripped off by the pharmaceutical industry and by pharmacists. Many common medications are substantially cheaper in the UK and even NZ. The difference in costs is for some medications a factor of ten times! This is literally costing the Australian government billions of dollars. In Australia generic medications provide a saving which I understand to be about 20% whereas in the UK generics are on average much much cheaper, in fact I understand that the average is closer to 80% cheaper.

    So there is plenty of room for competition to come in with lower prices and still be profitable. it is about time the industry was opened up more competition. If we need to preserve a pharmacy presence in small rural towns where there could be market failure then I suggest that these are subsidised directly. That should be possible with the massive savings that are possible.

    With regard to the comments about homeopathy and other quackery I could not agree more with JQ’s comments. However it surely should not go unnoticed that universities and TAFE colleges are churning out courses in this utter nonsense, courses that are subsidised by the public purse.

  17. Ikonoclast
    June 4th, 2015 at 18:39 | #17

    @J-D

    Well done! What is your summary of the clearer position?

  18. Uncle Milton
    June 4th, 2015 at 19:27 | #18

    @hc

    More than likely the newcomer owns the original pharmacy and will shut it down in due course.

  19. Donald Oats
    June 4th, 2015 at 20:46 | #19

    @Sancho
    As someone who deals with chronic pain, I would be pretty miffed if a pharmacist gave me the third degree like that. These days, it is extremely difficult to get good treatment for chronic pain, especially if there isn’t a clear external injury evident.

    My view is that so long as the pharmacist explains the risks associated with using a given painkiller, asked what other medications you are on, and told you what to do if the worst happens, then they have done what is necessary. If a drug is so dangerous that this isn’t enough, it shouldn’t be issued from a pharmacy without prescription. Quite frankly though, far more people seriously injure themselves or die as a result of car accident, smoking, drinking, and illicit drugs, than come a cropper using the over-the-counter pain medications as instructed (which isn’t to say there is no risk).

  20. June 4th, 2015 at 20:55 | #20

    @Sancho

    In Western Australia you have to show your license for items containing pseudoephedrine, as this can be used to make methamphetamine. I’m pretty sure it is a law.

  21. June 4th, 2015 at 22:02 | #21

    It is pretty obvious that pharmacies are a protected species. There are lots of them. They are well staffed. The staff are helpful. They have good opening hours.

    All of these things suggest an oversupply and a lack of competition. It also makes them quite nice places to go. They’ll do things like get stuff in for you and text you when it arrives.

    One of my friends knows someone who owns a pharmacy. They are rolling in money.

  22. J-D
    June 4th, 2015 at 22:20 | #22

    @J-D

    Only employers can be members; associates are not members and don’t have members’ voting rights; the National Council is the supreme governing body of the Guild, elected by its members (the fact that the National Council has a different name from the Guild should be a big honking clue, even for those who haven’t looked at the rules, that it’s a different thing from the Guild).

  23. Megan
    June 4th, 2015 at 23:00 | #23

    True story from a law firm I used to work at:

    One day a letter came in from an eccentric and elderly client. The handwriting was unintelligible and several people were trying to decipher it without any luck.

    I took a copy across the road to the pharmacy and asked the pharmacist to read it for me while I transcribed it. Worked a charm!

    The ability to read scribble is obviously a worthwhile talent, but that doesn’t justify the closed shop they run.

    Also, when I was a kid the local “Chemist” sold clove cigarettes. I suppose it was considered a healthy alternative to tobacco – plus it wasn’t regulated or taxed the same way.

  24. Ikonoclast
    June 5th, 2015 at 06:59 | #24

    I rather like the fact that the Pharmacy Guild call themselves a guild. It is quaintly accurate.

    Guild – an association of people with similar interests or pursuits; especially : a medieval association of merchants or craftsmen. – Merriam-Webster.

    “The continental system of guilds and merchants arrived in England after the Norman Conquest, with incorporated societies of merchants in each town or city holding exclusive rights of doing business there.” – Wikipedia.

    We see that the pharmacists retain the medieval notion that they ought to hold exclusive rights to do business in a given craft in a given area without regard for other community needs. Nevertheless, this discussion is modified by some of the issues Ivor and I mentioned. The rights of the guild or cooperative ought not be predominating. Rather, they should be balanced with those of all other stakeholders.

  25. derrida derider
    June 5th, 2015 at 09:24 | #25

    I’m old enough to remember the Hawke government trying to get rid of the exemptions for pharmacies under the Trade Practices Act. The campaign was vicious (pharmacists accompanying prescriptions for little old ladies with horror stories) and effective – Hawke backed down, much to the disgust of his Treasurer (maybe one reason for his jibe that Hawke was “a shiver looking for a spine to run up”).

    But then a couple of years earlier Fraser had tried to take on the newsagents, with a similar sequence of events. At least Fraser had the excuse for his backdown that his National coalition partners wouldn’t cop it (for the same reasons that no coalition government will take on the pharmacists ).

  26. Uncle Milton
    June 5th, 2015 at 09:38 | #26

    @derrida derider

    The current government has a report in their in-trays from Ian Harper recommending they take on the pharmacists. Whaddya reckon the chances are they do it?

  27. Jed
    June 5th, 2015 at 09:49 | #27

    I respect your right to your opinion regarding homeopathy (and clearly you are not alone). However I am concerned that you may have arrived at a strongly held opinion without being in full possession of the ‘facts’ (ie. background to the debate). To this end I refer you to the media release from the Australian Homeopathic Association addressed to the NHMRC (see link below). I acknowledge they obviously have a barrow to push (& we already live in a society drowning in ‘spin’), however I believe it is worth reading the letter.
    http://www.homeopathyoz.org/images/news/Open_response_letter_by_AHA_to_NHMRC.pdf

  28. Ikonoclast
    June 5th, 2015 at 10:47 | #28

    The case is;

    1,800 Studies Later, Scientists Conclude Homeopathy Doesn’t Work

    http://www.smithsonianmag.com/smart-news/1800-studies-later-scientists-conclude-homeopathy-doesnt-work-180954534/?no-ist

    Either your view of the physical world is informed by adherence to science or it is misinformed by adherence to magic. What other magical remedies and systems of magic should we admit to modern medicine? That’s a rhetorical question.

    Alternative remedies or folk remedies are sometimes found to have a basis in empirical fact. A clear set of cases involves traditional use of plants with medicinal or drug qualities (useful pharmacological properties). There are also biochemical reasons for certain pain reduction effects of acupuncture though it has to be said that the wider curative claims for acupuncture do not stack up.

    Homeopathy is based on magical thinking.

    “Edward Burnett Tylor coined the term “associative thinking”, characterizing it as pre-logical, in which the “magician’s folly” is in mistaking an ideal connection with a real one. The magician believes that thematically linked items can influence one another by virtue of their similarity.[5] For example, in E. E. Evans-Pritchard’s account, amongst the Azande[6] tribe members rub crocodile teeth on banana plants to invoke a fruitful crop. Because crocodile teeth are curved (like bananas) and grow back if they fall out, the Azande observe this similarity and want to impart this capacity of regeneration to their bananas. To them, the rubbing constitutes a means of transference.

    Sir James Frazer later elaborated upon this principle by dividing magic into the categories of sympathetic and contagious magic. The latter is based upon the law of contagion or contact, in which two things that were once connected retain this link and have the ability to affect their supposedly related objects, such as harming a person by harming a lock of his hair. Sympathetic magic and homeopathy operate upon the premise that “like affects like”, or that one can impart characteristics of one object to a similar object. Frazer believed that these individuals think the entire world functions according to these mimetic, or homeopathic, principles.[7] – Wikipedia

    It is worth reading the entire Wikipedia entry on Homeopathy. Here is a quote of the opening paragraphs;

    “Homeopathy (Listeni/?ho?mi??p??i/; also spelled homoeopathy; from the Greek: ?????? hómoios, “-like” and ????? páthos, “suffering”) is a form of alternative medicine created in 1796 by Samuel Hahnemann based on his doctrine of like cures like (similia similibus curentur), whereby a substance that causes the symptoms of a disease in healthy people will cure similar symptoms in sick people.[1] Homeopathy is pseudoscience.[2][3][4][5] It is not effective for any condition, and no homeopathic remedy has been proven to be more effective than placebo.[6][7][8]

    Hahnemann believed the underlying causes of disease were phenomena that he termed miasms, and that homeopathic remedies addressed these. The remedies are prepared using a process of homeopathic dilution, which involves repeatedly diluting a chosen substance in alcohol or distilled water, followed by forceful striking on an elastic body.[9] Dilution usually continues well past the point where no molecules of the original substance remain.[10] Homeopaths select remedies by consulting reference books known as repertories, and by considering the totality of the patient’s symptoms, personal traits, physical and psychological state, and life history.[11]

    Homeopathy lacks biological plausibility,[12] and its axioms are contradicted by scientific facts.[13] The postulated mechanisms of action of homeopathic remedies are both scientifically implausible[7][14] and physically impossible.[15] Although some clinical trials produce positive results,[16][17] systematic reviews reveal that this is because of chance, flawed research methods, and reporting bias. Continued homeopathic practice, despite the evidence that it does not work, has been criticized as unethical because it discourages the use of effective treatments,[18] with the World Health Organisation warning against using homeopathy to try to treat severe diseases such as HIV and malaria.[19] The continued practice of homeopathy, despite a lack of evidence of efficacy,[6][7][20] has led to it being characterized within the scientific and medical communities as nonsense,[21] quackery,[4][22][23] and a sham.[24]”

    It is very clear that the acceptance of scientific principles and the acceptance of homeopathic principles are incompatible. You must either accept science or accept magic.

  29. J-D
    June 5th, 2015 at 11:23 | #29

    @derrida derider

    Paul Keating used the description ‘a shiver waiting for a spine to crawl up’ of John Howard. He used the description ‘Old Jellyback’ of Bob Hawke.

  30. Troy Prideaux
    June 5th, 2015 at 12:23 | #30

    J-D :
    @derrida derider
    Paul Keating used the description ‘a shiver waiting for a spine to crawl up’ of John Howard.

    I think it was for John Hewson.

  31. James Wimberley WIMBERLEY
    June 5th, 2015 at 13:51 | #31

    In Britain, the big supermarket chains have won the battle to have in-store pharmacies. The sky has not fallen in. France and Spain don’t have them. I don’t know about other European countries.
    Homeopathic remedies and vitamins are essentially placebos. (It is possible to injure yourself with vitamins, but you have to take a lot.) But placebos are known to work for many minor ailments. What is the moral basis for denying people access to them?

  32. Tim Macknay
    June 5th, 2015 at 14:17 | #32

    @James Wimberley WIMBERLEY

    But placebos are known to work for many minor ailments.

    You’re assuming that the placebo effect is a real effect, rather than a statistical artifact.
    More obviously, the problems with marketing a placebo to consumers using false claims that it is an effective treatment for real medical conditions are that (a) this may lead to consumers foregoing effective treatment in favour of placebos for conditions that do not resolve themselves, causing harm to their health; and (b) misleading and deceptive marketing is unethical and, arguably, illegal.

  33. Tim Macknay
    June 5th, 2015 at 15:14 | #33

    @Tim Macknay
    The other question is, of course, whether expensive homeopathic medicines are the most appropriate type of placebo, when there are so many options available.

  34. J-D
    June 5th, 2015 at 18:32 | #34

    @Jed

    Why do you believe it is worth reading the letter? I don’t.

  35. June 6th, 2015 at 09:24 | #35

    @Tim Macknay
    “You’re assuming that the placebo effect is a real effect, rather than a statistical artifact.”

    Yes, I am. This is not controversial. WebMD for instance:

    There are some conditions in which a placebo can produce results even when people know they are taking a placebo. Studies show that placebos can have an effect on conditions such as: depression, pain, sleep disorders, irritable bowel syndrome, menopause.

  36. David C
    June 6th, 2015 at 09:25 | #36

    The NHS

  37. Ikonoclast
    June 6th, 2015 at 09:44 | #37

    @David C

    Best comment in the comments thread of that video:

    “I only watched a billionth of a nanosecond of this video, and now I believe in homeopathy.”

  38. sunshine
    June 6th, 2015 at 10:07 | #38

    If – ‘Unsurprisingly, research has proved beyond any doubt that it’s [homeopathy is] no better than a placebo.’ ,then homeopathy could be useful given the great power of placebo. It seems that anti-depressants and many other medications ,and some surgical procedures, may be no better than placebo too. (I am pointing out the status of placebo, not making an argument for homeopathy or against anti-depressants and surgery !).

  39. June 7th, 2015 at 00:34 | #39

    @sunshine

    I quite like the idea. For example, research shows that people in Perth who barrack for Freo or the Eagles are happier than people who don’t care for the footy. So just develop a belief in either team, and you’ll be happier. No logic to it, other than that it works.

    But as for placebo and anti-depressants being equivalent, I don’t believe it.

  40. June 7th, 2015 at 03:57 | #40

    @John Brookes
    “But as for placebo and anti-depressants being equivalent, I don’t believe it.”
    Unfortunately, there is evidence that for mild depression, they are. Brown W.A., Neuropsychopharmacology, 1994 Jul;10(4):265-9:

    . … among less severely depressed patients and those with a relatively short episode duration the placebo response rate is close to 50% and often indistinguishable from the response rate to antidepressants.

    This is a real issue. You can’t snigger it away.

  41. Val
    June 7th, 2015 at 05:48 | #41

    @John Brookes
    There’s been quite a lot of research (review of clinical trials) on this that suggests anti- depressants aren’t all that much better than placebos. I’m not going to search for it now but if you’re interested you can probably do so. This is one of the reasons why all clinical trials are now supposed to be registered and available, because of problems like selective publication.

  42. Val
    June 7th, 2015 at 05:53 | #42

    I said I wasn’t going to search for research now, but a quick google revealed one interesting abstract as a starting point http://www.nejm.org/doi/full/10.1056/NEJMsa065779

  43. Ikonoclast
    June 7th, 2015 at 08:11 | #43

    @John Brookes

    “research shows that people in Perth who barrack for Freo or the Eagles are happier than people who don’t care for the footy. So just develop a belief in either team, and you’ll be happier. No logic to it, other than that it works.”

    If that phenomenon were properly analysed in psychological and sociological terms (including political economy terms) I suggest that logical reasons could be found for it. Possibilities include;

    1. One might hypothesise the “Happy fool effect” which can also be called the “Sad Socrates effect”. In a nutshell, this hypothesis suggests that people who think more deeply are sadder. John Stuart Mill once argued, “It is better to be a human being dissatisfied than a pig satisfied; better to be Socrates dissatisfied than a fool satisfied.”

    The ancients noted it. “For in much wisdom is much grief: and he that increaseth knowledge increaseth sorrow.” – Ecclesiastes 1:18.

    That last quote has to taken in context. Ecclesiastes expounds that wisdom and foolishness both lead to grief; that futility attends all human efforts and there is finally no effective difference between the paths of wisdom and foolishness. This is while its reasoning remains on an effectively human and material plane and before its (rather conventional and unconvincing) introduction of “God” at the end to resolve its philosophical quandries. Talk about Deus ex machina. 😉

    People who are unintelligent enough or misled enough to believe that outcomes in elite sport really matter are likely to be “happy fools”. Most of us at some stage(s) in our development have been such happy fools. It’s difficult to escape this kind of enculteration until you become more society-critical and more self-critical.

    2. Consumer capitalism in a sense rewards those who consume un-reflectively. They feel validated (doing what everyone else does as directed by the moral entrepreneurs of capitalism and of ” tribalism”) and they are not shunned by their peers. This shunning is very real. If you don’t share the obsessions of a class or clique and if you express disinterest, reservations or criticisms about the obsessions you will be rapidly shunned and expelled. Those who don’t share the obsessions of their class are socially excluded. Exclusion tends to make people unhappy.

    So you can see, there are certainly logical reasons for the finding.

  44. Ikonoclast
    June 7th, 2015 at 09:33 | #44

    @Val

    Everyone should follow the rule of taking as few drugs as possible. The key thing to avoid is being on multiple drug courses. I take absolutely nothing recreational except coffee and nothing medicinal except a rare paracetamol (maybe 6 per year at most) and rare course of antibiotics if necessary (less than one course a year on average).

    Maybe I am lucky to some extent not needing constant medication of any kind at 60. However, if you get on the pharmacological merry-go-round your health will rapidly get worse and worse in most cases. There is plenty of evidence that painkillers, anti-depressants, blood pressure medications and arthritis medications (especially in combination) will all seriously mess up your physiology long-term. I actually believe all these medications now cause more damage than they prevent on a population wide basis though of course they do help some individuals when used “strictly in accordance” etc. etc.

    In many cases, people would get better results with a no-drug regimen combined with weight-loss, exercise, proper food, proper sleep etc.

  45. Jed
    June 7th, 2015 at 14:29 | #45

    @J-D
    Hi J-D,
    A couple of points made in the paper are:
    The author discusses a number of reasons that homeopathy does not generally lend itself to RCT’s. This is because there is generally not a 1:1 causality (eg. flucloxacillin kills golden staph). There are other methodologies that are more effective in examining the efficacy of homeopathy, these are briefly discussed in the paper. Unfortunately the NHMRC chose not to include these (see paper for more details).
    Also, the NHMRC chose to base it’s conclusions on the UK Committee findings, but ignored the finding of the Swiss Govt research which arrived at very different conclusions. I suggest that if one committee finds homeopathy to be effective and the other finds it to be ineffective, then it is presumptive to say that ‘research has proved beyond any doubt that it’s no better than a placebo.’
    Finally, I would just like to say that I do not want to enter into a debate, as that is a waste of everybody’s time. I respect your right to disagree with my opinion.

  46. J-D
    June 7th, 2015 at 15:35 | #46

    @Jed

    I interpret ‘This is because there is generally not a 1:1 causality (eg flucloxacillin kills golden staph)’ to mean ‘This because it doesn’t work (eg homeopathy does not kill golden staph)’.

    The Swiss government commissioned homeopaths to report on whether homeopathy works. It should come as no surprise that homeopaths report that homeopathy works.

  47. Jed
    June 7th, 2015 at 15:55 | #47

    @J-D
    I was unaware that the Swiss Govt commissioned homeopath’s for the investigation. If that is true then you make a fair point. It is also apparently true to say that the study NHMRC based its conclusions on included anti-homeopathy lobby groups, but refused inclusion of homeopaths. This is also pretty poor.
    Regarding your interpretation of 1:1 causality: This is understandable, however I should point out that this highlights a lack of understanding of homeopathy. (Very briefly; there are any number of homeopathic medicines that may treat a golden staph infection, and it depends upon the individual’s somewhat unique response to the infection. So there may be any one of (eg.)50 medicines that would be effective in any given circumstance, and it is the job of the homeopath to work out which one. It is difficult to adequately explain this and I don’t expect to accept this, but I offer it anyway.)

  48. J-D
    June 7th, 2015 at 20:16 | #48

    @Jed

    The efficacy of a treatment on a subset of the population is just as much testable by randomised controlled trials as efficacy with all patients. ‘It only works with some individuals’ is not a reason why it can’t be the subject of randomised controlled trials.

  49. June 7th, 2015 at 22:48 | #49

    @James Wimberley

    About 10 years ago I was depressed, and went on SSRI’s. Maybe it was just a placebo effect, but after 3 weeks I felt better. I noticed two specific improvements. Firstly I did not get upset as easily. Secondly, the confusion I had felt driving through even simple intersections was gone. I also noticed some changes in the, ahem, functionality below the waist. This was not welcome, but perhaps that too was a placebo effect? Luckily that bit was only temporary.

    I dare say that on some officially approved scale by which depression is measured, a placebo would have done just as well, but not, I think, in terms of real life functioning. And of course there is no guarantee that others would feel the benefits I felt.

    Anyway, I am now giving them up, not for really any other reason than I want to see how I go without them. Curiosity if you will. The withdrawal effects of the one I’m on are pretty mild, but definitely interesting, and today is a week since my last small dose. And while I feel fine, I do already notice that I get angrier at people more easily. The driving still seems fine though.

    I’m usually very keen on careful scientific studies, but on this one I will trust my experience.

  50. Tim Macknay
    June 8th, 2015 at 12:14 | #50

    @James Wimberley

    Yes, I am. This is not controversial.

    I don’t think it’s that simple. Obviously there is a well-established phenomenon observed in controlled studies that generally goes by the name “the placebo effect”.

    It’s also true that there’s a widespread belief (including, apparently, among many health professionals) that the “placebo effect” is some kind of actual therapeutic effect that arises from taking placebo medicine. But from what I’ve read of the medical research, it is far from clear that the latter belief is justified. There is an increasing body of research which suggests that this idea of the “placebo effect” is based on mistaken assumptions by early researchers, and which casts doubt on the proposition that any genuine therapeutic “placebo effect” exists.

    The WEBMD article you refer to contains some examples that illustrate some of the problems with the concept. For example, compare two of the studies mentioned in that article.

    One involved asthma sufferers and found that patients given placebo reported subjectively feeling better, but physiological testing did not reveal any improvement in respiration compared with no treatment. In another, subjects were given placebo while being told they were receiving either stimulants or sedatives. The subjects showed identifiable (non-therapeutic) physiological changes which varied depending on what they had been told. How does it make sense for the results of these two studies to be lumped together as illustrating the same effect? Aside from the superficial fact that both studies involved the use of placebos, they are entirely different.

    The first example also pretty clearly shows the ethical problems with selling placebos as over-the-counter medicines. Asthma patients using the placebo medicine from that study (assuming they responded in the same way as the patients in the study) would be likely to subjectively feel better, but without any genuine improvement in their risk of asthma attacks. In effect, they would be given a false sense of security, which is dangerous.

  51. Tim Macknay
    June 8th, 2015 at 12:30 | #51

    @Ikonoclast

    I actually believe all these medications now cause more damage than they prevent on a population wide basis though of course they do help some individuals when used “strictly in accordance” etc. etc.

    Given that life expectancy continues to increase, and morbidity and mortality rates from diseases like heart disease continue to decline, these belief doesn’t appear to be too well-founded. I agree with you point that we should try to use as few drugs as possible, though.

    In many cases, people would get better results with a no-drug regimen combined with weight-loss, exercise, proper food, proper sleep etc.

    This is probably true. I think the dilemma faced by many health professionals, though, is that it is very difficult to get people to change their eating, diet and exercise habits.

    A physician is more than likely to be aware that a given patient would get a good drug-free result by changing their diet and exercising regularly, but is equally likely to realise that the patient probably won’t do those things, and probably won’t persist with them long enough to get real results even if s/he tries. But if the physician prescribes a medication, it will deliver some genuine benefits and the patient is much more likely to keep up with a prescription than a diet-and-exercise regime.

  52. Tim Macknay
    June 8th, 2015 at 12:31 | #52

    Blarg. “this belief” not “these belief”. “Your point” not “you point”. Damn Mondays.

  53. Ikonoclast
    June 8th, 2015 at 13:05 | #53

    @Tim Macknay

    I assume you are talking about LEB (Life expectancy at birth). As Wikipedia notes;

    “The combination of high infant mortality and deaths in young adulthood from accidents, epidemics, plagues, wars, and childbirth, particularly before modern medicine was widely available, significantly lowers LEB.”

    Advances post-WW2 and continuing to this day have been particularly instrumental in increasing LEB by decreasing infant, childhood and young adult death rates. We can note better nutrition and health care, especially for infants and young children, along with immunisation and the defeat of major diseases like smallpox, diptheria, whooping cough, measles and polio.

    Thus, if you follow this argument, you can see that improved care at and beyond onset of old age is not necessarily all that significant in increasing the LEB of the whole population. Thus it is not necessarily inconsistent to suggest that (some) medications for old people essentially are doing more harm than good. Also, the harm might not result in aged deaths but simply decline in aged quality of life in some cases. I would even argue that today a proportion of prolonging life for old people is essentially just prolonging low quality of life. It can be pointless and even cruel.

  54. Tim Macknay
    June 8th, 2015 at 13:20 | #54

    @Ikonoclast
    I broadly agree with that. It’s rather more qualified than the statement I initially responded to.

  55. June 8th, 2015 at 22:32 | #55

    @Ikonoclast

    Maybe barracking for a football team is a tribal thing, and reflects our biological origins. Maybe it is actually good for us?

    What I find hard to understand is how barracking for the West Coast Eagles can be good for anyone. Their supporters have an insufferable sense of entitlement. The umpires love them. They are a blight on the competition, and should have their license taken away forthwith.

    Freo, on the other hand, are the source of all that is good in the world…

  56. Tim Macknay
    June 8th, 2015 at 23:44 | #56
  57. James Wimberley
    June 9th, 2015 at 03:49 | #57

    My remark on placebos has sparked a lively discussion. But so far nobody has properly responded to my challenge for a reason why people should not be free to buy them in pharmacies.

  58. Jed
    June 9th, 2015 at 08:00 | #58

    @J-D

    I agree, however the design of the RCT is crucial (although there are research methodologies which are said to more effectively measure the efficacy of homeopathy-see media release). To take the earlier example; whilst it is true that flucloxacillin can alleviate a chest infection, it would be naive to conduct a RCT which examined the effect of fluclox on everyone with a chest infection as there are only a very small number of chest infections for which it is indicated. The point I am trying to make is that any RCT into homeopathy needs to take into account the criteria by which homeopath’s prescribe. Western RCT are generally not inclined to do this very well. This will obviously skew the data.

    I am not interested in trying to convince anyone regarding homeopathy, rather I hope to encourage people to think beyond their biases (I obviously have biases also) rather than too readily accept conclusions based upon questionable research methodology because they match previously held beliefs. That is why I thought the original media release from AHA was worth a read.

  59. Ikonoclast
    June 9th, 2015 at 08:52 | #59

    @James Wimberley

    Your question perhaps has two parts. Why shouldn’t people be free to buy placebos? Why shouldn’t people be free to buy placebos IN pharmacies?

    It’s a general principle that we expect truth in labeling. We expect a packet labelled 1 kg Sugar to contain 1 kg Sugar. We expect a bottle labelled 500 mls distilled water to contain that. It is how we make decisions as consumers. The problem here is that if you label a placebo honestly it cannot be a placebo. The selling or application of a placebo requires deception. There are cases where placebo deception might be warranted. However, the open market place is not the place to deliberately permit such deception. The precedent is poor in terms of making it more difficult to maintain laws concerning truth in marketing and honesty in market transactions. In everyday language, you invite snake-oil merchants into the market.

    Pharmacies should be able to issue placebos where a doctor prescribes them. But these ought to be pure and safe placebos understood scientifically by the doctor and pharmacist to be exactly that. Homeopathic medicines are often (but not always) pure placebos. However, they do not reliably come out of a safe manufacturing facility. They may be impure. They are also priced with a premium which accompanies the claim that they are in reality active and efficacious. This claim and pricing is dishonest. By the same token, I don’t know how pharmacies price doctor-prescribed pure placebos.

    I can imagine for example the case of a belligerent elderly patient with early dementia who might frequently demand antibiotics for every sniffle. A doctor might find it expedient to prescribe placebo pills. A UK survey found 97% of doctors admitted prescribing placebos although only 10% of prescriptions were pure placebos. The rest were impure placebos – treatments that contain active ingredients but are not recommended for the condition being treated, such as antibiotics for flu.

    I don’t defend the above actions by UK doctors. It seems excessive. But I think doctors, if they act ethically, are the best placed to prescribe placebos. The general market place is not the place to make allowance for deliberately dishonest and misleading products and product claims.

  60. Tim Macknay
    June 9th, 2015 at 11:10 | #60

    @James Wimberley

    My remark on placebos has sparked a lively discussion. But so far nobody has properly responded to my challenge for a reason why people should not be free to buy them in pharmacies.

    This strikes me as disingenuous, James. You never gave any indication as to what you would regard as a “proper” response to your original comment.

    The question, or “challenge” as you now characterise it, that you raised was predicated on your belief that placebos are known to be effective for a range of ailments. I explained why I consider that belief to be dubious, and I also provided two other arguments against the sale of placebos on ethical grounds.

    You’re under no obligation to accept my opinion, but there was nothing “improper” about it.

    I wonder why you now want to pretend that no-one has really responded?

  61. June 9th, 2015 at 12:08 | #61

    @James Wimberley

    Actually, placebos are sold actively in pharmacies at the moment. Think of any condition for which there is no known treatment that works. Aging is one such condition. Now look for products in pharmacies that have “anti-aging” in their blurb. These are placebos.

    Of course, if you required them to say on the box, “doesn’t actually work – just a placebo”, that would actually ruin the placebo effect, at least partially. So for the good of all concerned, placebos are marketed as though they actually work. I’m not sure, but I think most pharmacies actually put all the placebo like products together, separate from the products that actually work. People buying placebos do have to suspend their disbelief a bit 🙂

  62. Sancho
    June 9th, 2015 at 13:06 | #62

    It’s correct that research shows a strong placebo effect for antidepressants. The proposed mechanism is that the regular assessments used to obtain data in the studies improve reported mental health. That is, talking to a clinician about depression makes people less depressed.

    That’s either a clinical finding or a “well, duh” moment, but the people who allocate funding look at the cost of a counseling session and the cost of a pill and make the economically rational choice.

  63. Tim Macknay
    June 9th, 2015 at 14:22 | #63

    @Sancho

    It’s correct that research shows a strong placebo effect for antidepressants.

    It’s not clear what you mean by this.

    Do you mean that it’s correct to say that research shows that the performance of antidepressants is no better than placebo, or do you mean that, in controlled studies involving depressants, the placebo effect (i.e. the reported improvement in symptoms in the control group) is particularly strong in comparison with studies of other kinds of medication?

  64. Tim Macknay
    June 9th, 2015 at 14:24 | #64

    Argh. Second paragraph, third line – should say “controlled studies involving antidepressants”. %#&@ Tuesdays!

  65. J-D
    June 9th, 2015 at 15:19 | #65

    @Jed

    I don’t see how the fact that randomised controlled trials are a ‘Western’ development is supposed to be relevant; homeopathy is just as much ‘Western’ as randomised controlled trials.

    The proper design of randomised controlled trials is an exacting task, but the findings of properly designed trials of homeopathy are just as reliable as the findings of properly designed trials of anything else.

  66. Sancho
    June 9th, 2015 at 15:24 | #66

    Do you mean that it’s correct to say that research shows that the performance of antidepressants is no better than placebo,

    That one.

  67. June 9th, 2015 at 16:39 | #67

    @Sancho

    The proposed mechanism is that the regular assessments used to obtain data in the studies improve reported mental health. That is, talking to a clinician about depression makes people less depressed.

    So in this case the placebo is not actually a placebo, but an alternative treatment.

    But I remain troubled by my personal experience of an SSRI versus some study that shows they are no better than a placebo – or a chat with a psych. The two appear to be in conflict. That is, in my case I’m sure that the SSRI had a positive effect on my ability to cope with life. As I pointed out above, it also had side effects that are definitely not a placebo effect.

    And I need to reconcile the personal with the scientific. How?

    There are many possible explanations. One is that for every positive experience like mine, there is a negative experience. So overall there appears to be no effect. Another is that positive experiences are rare, so that there is insufficient statistical difference between the treated and untreated groups to draw any inference. Another is that people don’t like feeling like failures, so on each testing they try to present as slightly better than on the previous assessment. And of course, it could be that when I started on sertraline, I was just about to get better anyway, so I have misinterpreted my improvement as being due to the drug when it wasn’t.

    Me, I always have doubts about how well studies are conducted, and whether they measured the appropriate things. I think it extremely unlikely that a study contradicting a wealth of anecdotal evidence is correct. And let me say that this is an entirely scientific approach. Bayesian statistics takes ones prior estimate and modifies it based on new data. In this case the prior estimate is based on the huge commercial success of anti-depressants. Basically, doctors think they work, or they wouldn’t prescribe them. Hence my prior is pretty strongly in the “they work” camp.

    Now of course I’m going to head off to confirmation bias, and conclude that the study showing no effect was in some way wrong. But I don’t know that unless I read the study and learn more about how you do these things.

  68. J-D
    June 9th, 2015 at 19:36 | #68

    @John Brookes

    To me it looks as if the research reports linked to by other commenters suggest that the effectiveness of antidepressants has been seriously overestimated.

    If this is true, it is important that the overestimate be corrected. However, that’s not the same thing as saying that the actual effectiveness of antidepressants is nil in all cases. If it turned out to be true that antidepressants don’t work nearly as well as supposed, but do still work sometimes, then it would be important to stop giving them to the people they don’t help, but still reasonable to give them to the people they do help. The question would be how to figure out which people those are, but it’s still possible you might be one of them.

    Obviously if the research findings turn out stronger than they seem to me at this stage, indicating that antidepressants don’t work at all, that would be harder to reconcile with your personal evaluation of your own experience.

  69. June 9th, 2015 at 22:44 | #69

    @J-D

    From the linked study:

    Our findings have several limitations: they are restricted to antidepressants, to industry-sponsored trials registered with the FDA, and to issues of efficacy (as opposed to “real-world” effectiveness33).

    We wish to clarify that nonsignificance in a single trial does not necessarily indicate lack of efficacy. Each drug, when subjected to meta-analysis, was shown to be superior to placebo. On the other hand, the true magnitude of each drug’s superiority to placebo was less than a diligent literature review would indicate.

    So I am somewhat happier, as the study does not show that SSRIs are only as effective as placebos.

  70. Sancho
    June 10th, 2015 at 00:42 | #70

    So in this case the placebo is not actually a placebo, but an alternative treatment.
    IIRC, the research required weekly check-in with a GP. So not treatment, but regular acknowledgement of depression.

    In this case the prior estimate is based on the huge commercial success of anti-depressants. Basically, doctors think they work, or they wouldn’t prescribe them. Hence my prior is pretty strongly in the “they work” camp.
    Doctors think they often work, and prescribe them because of requirements to provide the most efficient means of treatment, even if it’s not the most effective.

    If a patient demonstrates clear signs of clinical depression to a GP, the GP has a duty to prescribe an antidepressant (in addition to any referral). If the patient suicides two weeks later, the coroner is going to ask why they didn’t receive the cheapest, most widely-available treatment, and the doctor will probably be struck off. Hence, everyone sad gets an SSRI.

    Also, it’s difficult not to sound conspiratorial talking about “big pharma”, but it’s even more difficult to overstate the influence drug companies have on medical and psychiatric treatment in Australia. Policy needs to be based on research, and the drug reps have research coming out the wazoo. They’ve got billions to spend on carefully tailoring studies that endorse their product – and carefully cultivating relationships with policymakers – while every other treatment relies on PhD theses trickling out of universities to shore up findings that are often only reliable longitudinally.

    It simply doesn’t hold up legally if a health service chooses treatment that’s ten times more expensive than pills, with a tenth of the research to back it up. It would turn the health system into a backlogged festival of litigation. Cheap, fast and defensible is key.

    Oh, and the next big thing is using antipsychotics for everything. Over the next couple of years, watch how many people are prescribed quetiapine for anxiety or insomnia or depression. It’ll be the new normal, and it’s driven entirely by the quest for drug sales.

    I wouldn’t claim that antidepressants are useless (interesting essay to the contrary here), but they’re certainly over-prescribed, over-recommended, and contribute to over-medicalisation of the human experience.

  71. Sancho
    June 10th, 2015 at 00:44 | #71

    Bah! Wrestled with HTML and lost. VBulletin is popular for a reason.

    Easy to see where the quote is meant to end.

  72. June 10th, 2015 at 11:47 | #72

    @Sancho

    Like the link!

  73. Tim Macknay
    June 10th, 2015 at 17:38 | #73

    Oh, and the next big thing is using antipsychotics for everything. Over the next couple of years, watch how many people are prescribed quetiapine for anxiety or insomnia or depression. It’ll be the new normal, and it’s driven entirely by the quest for drug sales.

    Hasn’t that already happened? This article is from 2013.

  74. June 11th, 2015 at 12:40 | #74

    And no doubt the arrival of paracetamol was also the end of the world.

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