Translation by Martha Greiner-Jetha, and with assistance from Maria Chorianopoulou and the IACH
Professor Martin Dinges has been a researcher and archivist at the Institute for the History of Medicine of the Robert Bosch Foundation in Stuttgart since 1991, deputy director since 1997and also Adjunct Professor at the University of Mannheim since 2000. He studied jurisprudence, history and political science in Cologne, Mainz, Bonn, Free University of Berlin and in Bordeaux. He got a degree in education for grammar schools in1982, achieved his doctorate (Dr. phil.) in 1986, and passed the second state examination for archivists in 1991. In 1992 he passed his Habilitation – advanced research degree – in Modern History at the University of Mannheim.
Prof Martin Dinges
The Institute for the History of Medicine (IGM) © was established in 1980 and is the only institution of its kind in Germany with no university affiliation. At present, research at the institute centres on two main areas, both of which have yet to become established at German universities: the history of homeopathy and social history of medicine. In both areas the focus currently is on patients and their treatment in the course of history. The Institute owns a research library with more than 50,000 volumes as well as the homoeopathy archives with the Estate of Samuel Hahnemann and his important students and successors, and in particular, Clemens von Bönninghausen. The archives also hold the records of international and national homoeopaths’ organisations.
Siegfried Letzel: Thank you very much Professor Dinges for your willingness to share your opinion on topics in the field of homeopathy and conventional medicine, which our readers of Homeopathy 4 Everyone are increasingly interested in. Current political events disturb the general public. As one of the most high-profile medical historians worldwide and archivist of the Institute for the History of Medicine of the Robert Bosch Foundation in Stuttgart, we hope to get a neutral view – so to speak “from above” on where homeopathy stands today and will perhaps stay in the future within the medical sciences and within the public health system. Before it gets political, we would like to ask some questions about your core work.
How did you end up working in the field of the history of medicine?
Prof. Dinges: Through this position here.
Siegfried Letzel: Was interest in the history of medicine sparked by your job?
Prof. Dinges: Yes, indeed, I have been employed as archivist here. Previously I had been busy with matters relating to poverty and hospitals, but the fact that the Institute had looked for an archivist led me to dealing with topics that are special for this job, as is often the case with the position of an archivist. I could have ended up in a public archive, e.g. the State Archive in Sigmaringen, Germany, or perhaps in an archive of a company. One then approaches a field with a formal professional competence and you find out the specific peculiarities of the subject. Subsequently, I see these things positively and deal with them. I find it very interesting.
Siegfried Letzel: Which activities do you, Prof. Robert Jütte and your team, cover in a normal working day for? Do you constantly dig around in all these historic and unique books of your collection?
Prof. Dinges: First of all, you have to bear in mind that we both cover homeopathy and medical pluralism on the one side and social history of medicine on the other side, which means we are also working a range of other fields. One of the most recent things for which I have also been responsible was a very nice survey about Gustav Jäger (1832-1917) and homeopathy in order to find out their relation. In addition to burying myself in heaps of books, which you are hinting at, there is a second task of supervision of dissertations. One of these was the dissertation on homeopathic laymen associations, which, after collecting their written records for many years, gives a very good overview of the factual 150 years of the laymen associations. The publication of this overview is now accessible to the public in our book series.
In addition to this organisation of research work, the extension of our collection is a further field of activity. For example, last Tuesday, I was in Berlin at an auction of autographs (handwritten works) and was able to acquire some interesting artefacts for our collection. Unfortunately, you have to go there personally, as it is difficult to do this from afar, and some questions can only be cleared on site. I will publish an article about these autographs, among others, a Hahnemann’s ode to Mélanie and a letter to the French physician Jean-Marie Dessaix (1781-1844). And tomorrow, I travel to Ulm to take over some objects from a collection on the history of pharmacies for our artefacts collection on the history of homeopathy. Thus, the additions to the collection are an important field of activity which definitely can occupy whole days. In addition, I am co-editor of the Magazine for Classical Homeopathy ).
The objective in this role is to acquire manuscripts and in this connection we have succeeded in obtaining a wonderful essay by Behnke on the history of sceptics, which vividly illustrates with which procedures the sceptics tried to campaign against homeopathy even one hundred years ago. This essay provides a valuable insight into their methods which can be observed even today.
Siegfried Letzel: Is there any flow of information between the history in your institution and the outside world of the present? If that is the case, how and where does your expertise reflect outside the walls of your Institute for the History of Medicine? Who has access to this knowledge?
Prof. Dinges: Beyond our scientific publications, we communicate the results of some of our research to the general public. For example, I would like to mention my book about Bettina von Arnim, who was very active as representative of homeopathy in public and in many areas of the society of Berlin. This certainly shows people, who otherwise are not interested in homeopathy, how one could have come to such a decision and how this decision is carried on to others within the family, partly accepted by their own children, or partly not.
These are ways to find a broader audience for this topic in a less direct way. Finally, I would like to point out our exhibitions which are probably a very good medium to give people visiting their local banks or in centres for adult education an understanding of this topic in passing. In this context, it is important for us to make clear, not that homeopathy can do everything, but that homeopathy is an important and interesting alternative, which is efficient in certain areas. I think this is an important statement which you can very well represent and which will be mostly accepted as far as we can observe.
Siegfried Letzel: Will the tasks which are presently carried out by the Institute for the History of Medicine retain its importance in a science which is increasingly digitalized, database-oriented and thus “omniscient”?
Prof. Dinges: Well, in this respect one has to ask oneself where we are. You refer to a medicine which can be described in such a way, as is done here. However, this is already another field than the history of medicine. My observation is that the questions by medical doctors exclusively refer to knowledge available on the internet, and then also ask “Have you published this somewhere in the internet?” We definitely work in that direction but our activities are markedly less than those by the medical doctors.
Naturally, they organize their papers more often in smaller pieces and partial steps, in publications according to their logic in medical research, different from medical historians who often publish long articles or whole books. This means, the way of publishing differs slightly. You have to bear that in mind when comparing the methods of publication, that one academic discipline does not work like the other.
One thing is important in this connection: During the last decade, the homeopaths as doctors who engaged in research, have made an enormous effort to increase the standards of their research and have tried to follow what are sort of standards of medical research and, in doing so, they definitely have made progress. This applies both to their study designs and the quality control, and so on. This means that the current medical research in the field of homeopathy increases in value. To some extent, this is the direct corresponding partner of the medical science, whereas we, with the history of medicine, are on a somewhat different ground.
Siegfried Letzel: What can homeopaths learn from history in dealing with criticism and with opponents of homeopathy?
Prof. Dinges: Homeopathy has been attacked from the very beginning and naturally one can see quite different patterns. A decisive argument has always been the fact that homeopathy has evaded a critical review. You must have a critical view on every single case, as for example in clinical reviews of the 19th century, what failed why and how and who manipulated how. That is why you cannot generalize easily. However, I think that in general you can take the view, that homeopathy, similar to conventional medicine, does not profit from bragging. For example if homeopathy claims it can heal everything and everybody – and – you know the current discussions – it can heal every type of cancer and I do not know what else. Naturally, these are things, which, in my opinion, rightfully trigger criticism. A little bit of modesty in managing diseases would be good for all doctors and therapists – and for the homeopaths as well. I think this is what you can learn from history in any case and apart from that you have to have a closer individual look at the points of criticism. Then you can surely reject something by answering as factually as possible and as little as possible in an ideological way.
Siegfried Letzel: The 19th and 20th centuries brought forth some of the best homeopaths who have ever lived. Which forces or preconditions gave rise to such talented homeopaths? Do such preconditions still exist today?
Prof. Dinges: The question here is which standards and criteria should be applied. Well, for me as a patient, I am neither a medical professional nor a physician, a great advantage of homeopathy has always been its strength to listen closely to the patient and to get involved in his/her description of symptoms. To some extent this is one of the foundations of homeopathy, and this ability to listen to the patient and not to resort too quickly to any drugs, pseudo-solutions or further diagnostic measures. I consider this as one of the strengths of homeopathy in general and of good homeopaths in particular.
In order to be a good homeopath it is probably decisive to have a good knowledge of remedies. As I mentioned before, the third precondition is something true of every profession, also for physicians and homeopaths, knowing one’s own limits and then admit at which point you cannot help anymore. I think this procedure will also be accepted by patients in the end, unless they have such ideas about physicians having magical forces. Or, there is a transfer of expectations to therapists and healers to fulfil the patient’s wishes, to free him or her from the evil, from the pains or whatever. However, in my view, the necessary distinction is the better way to be a good physician.
Siegfried Letzel: Based on propaganda against homeopathy, most of the homeopathic hospitals in Great Britain have been closed. The governments of Great Britain and Australia are no longer prepared to finance homeopathy within the framework of the public health system. In the USA, homeopathic remedies must bear a label which states that homeopathy is not based on science. If the present trend continues more governments could deny their support for homeopathy. Will homeopathy be able to survive if it is no longer associated with governments or supported by them?
Prof. Dinges: Well, this does not correspond to my knowledge. According to my information, and you are welcome to update me on that matter, the attempt to push homeopathy out of the National Health System (NHS) failed. At that time I found it quite interesting that this committee for the evaluation of technologies, which is staffed with people who had earned their money in the pharmaceutical industry by writing expert opinions, have also engaged themselves with homeopathy. Almost ten years ago, the government had recommended to no longer finance homeopathy within the framework of the NHS. And then the government opposed the recommendation of the supposed expert committee and declared that, firstly, there were reasonable medical doctors in Great Britain and, secondly, the patients also would know what they can benefit from. Thus, the arguments were traditionally liberal and that the government will abstain from taking away the freedom of choosing the therapy, knowing that the medical doctors are competent and the patients know what they want. And in that respect, at that time, the attempt failed to exclude homeopathy from the NHS. It was only afterwards that these massive campaigns of sceptics about the Avogadro number 10-23 and so on began in order to make an impression on the public. These supposed experts did not succeed to “turn around” the government stand on a political consulting level. Perhaps one should have a closer re-look.
I do not know the current situation in Australia. And this American labelling requirement is really a clever method of the pharmaceutical industry to work there with terms of scientificity, which brings only the mechanism of action of homeopathy to the fore, and disregards everything else. As is generally known, homeopathy does not fare badly in studies on the provision of medical care. However, to some extent, this is a phenomenon of the public discussion, meaning: an implied agreement on what is important and what is right. In recent years, the pharmaceutical industry has increasingly succeeded in placing a very narrow concept of science in the public discussion as exclusively significant and displacing other ideas. This is the reason the discussion suffers. The question is whether and how we will succeed in getting out of this narrow definition or understanding of science, which, after all, is debatable.
Siegfried Letzel: How do you see the future development of public health?
Prof. Dinges: Of course, this is a huge issue. There will be an increasing number of elderly people, which means, there will be an increase in the number of chronic diseases. This will show more clearly the limits of allopathic treatments. Homeopathy is successful in chronic diseases, which means, homeopathy will have many opportunities with patients who have reached the end of their options with conventional therapy. One should try to make this clear.
There are quite a few reasons that a second element becomes important, which is a medicine with less side effects. Indeed there are discussions in various forms in different countries about side effects. I found it quite interesting that there are discussions in India about this matter and how vivid they are. This is also a good argument in favour of homeopathy.
Siegfried Letzel: How can anyone argue against homeopathic drug provings which are tests on healthy people and elicit their individual reactions?.
Prof. Dinges:, A scientific concept has taken over the public discussion which disproportionately emphasizes quantities. To begin with, numerics are, by all means, a helpful orientation, for example, if you can say that this remedy helps reducing the symptoms of common cold in so-and-so many people. As a start, this is a reasonable way. In contrast to that, a qualitative orientation, as you point out – individual case etc. – is something less likely to be accepted.
Moreover, a second differentiation, which you make, is also important; namely that between objective parameters and subjective perception. You can measure the intensity of a common cold, which then is an objective parameter. However, you can also listen to an individual report. We have to consider two things here.
In the meantime, conventional medicine has realized how remarkably little it was interested in how patients actually feel, and that it was almost exclusively interested in the extent to which objective parameters will improve. For example, it was noticed in the field of psycho-oncology that one got a good grip on oncological matters, however, patients still had depressions or other problems afterwards. This means that the subjective experiences of the patient have also become more important in medicine. In this respect, the question about the feeling and well-being of the patient has generally to be taken into consideration during treatment.
The question that may arise is whether you can do completely without objective parameters. To me, that does rather not seem to be the case. If you look at courses of disease, I think, it is indeed useful to be able to resort to objective parameters by which you can illustrate the changes.
The exclusive orientation towards the subjective state of health calls more strongly for criticism However, despite that I would never claim that a qualitative course of action which highly appreciates subjective evaluations is unscientific. Within the fields of science everywhere there are both qualitative and quantitative methods, and in medicine, in the field of so-called scientific research there we find a strange one-sided development in the direction of quantitative methods. In the end, medicine always deals with individuals: You don’t do yourself any favour if you state that you only use subjective parameters.
Siegfried Letzel: In Germany, the number of deaths associated with multiple medications has been estimated at 16,000 to 25,000 a year. For comparison, in 2016 about 3,400 people died in traffic accidents. Is there a way out of this increasing problem?
Prof. Dinges: There are appropriate methods in which treating physicians note which different drugs their patients take. In doing so, they take into consideration the problem of ignoring the combined effects of drugs when several drugs are given simultaneously. This is an initiative organised essentially by the treating physicians and not by the pharmaceutical industry which, first and foremost, wants to sell drugs. If you take a close look at how many daily doses elderly patients are administered on average, it is understood that this is a gigantic problem. Without wishing to comment on the number of deaths – as these are always political numbers in one or the other direction – it is clear that there is an urgent need for action. However, this need for action should be supported publicly and also by the health insurance schemes which should have an interest in reducing unnecessary drug prescriptions. Reducing the costs alone is an argument that should immediately be comprehensible to them.
Siegfried Letzel: Wouldn’t it be helpful to test and monitor these drugs under real conditions in practice, before they are administered to patients and prior to approval of a drug? Often, side effects become only obvious after many, many people have been harmed.
Prof. Dinges: Yes, is this a question about the number? You surely know that clinical trials are a normal part of such an approval protocol. I am not a pharmacologist who could make well thought out comments, as e.g. how many cases it takes in order to be able to evaluate whether a sufficient assessment for the approval exists. So, how can you verify the effectiveness of a medical procedure? In this connection, you have to think about the setting. So far, this has happened far too little. Of course, it is clear that a conventional doctor, who takes time for his patients and their ailments, gives them his attention and shows his interest will have more successful results in treating his patients than one who doesn’t do this. The exciting placebo research gives us a lot of knowledge about increasing the healing probability, whether this is the colour of the pills or whatever.
There are different minimum numbers of test persons and minimum durations, which are presumed, however, this means we are in the field of study designs and double-blind research. The real difficulty lies in the fact that the social discourse is not shaped by the homeopaths. Especially in the last ten years, we have just experienced it with the sceptics, how talking about homeopathy has increasingly turned into a talking about scientificity, about a certain type of scientificity. During this process, homeopathy is falling through the mesh. The sceptics have succeeded in shifting such discussions.
What do patients gain under a particular therapeutic system? What are the costs of such a system for the society? I think, in this respect, homeopathy is still in a very good position, even with regard to health care costs, which today is often the main argument – what does medical treatment cost?
Siegfried Letzel: Meta-analyses of randomized clinical trials (RCTs) indicate the highest level of evidence for homeopathy within the framework of Evidence Based Medicine (EBM). Four out of five global meta-analyses on homeopathy (all indications, all remedies), which have so far been published tend to show that potentized remedies have specific effects beyond the placebo effect. According to a thorough statistical analysis, the total result is only negative if a great number (90 – 95 %) of the available data has been excluded or if dubious statistical methods have been applied. What can be done to protect homeopathy from the damage caused by lobbyists and “professional” sceptics (paid by the pharmaceutical industry)?
Prof. Dinges: We are dealing here with highly selective data. It is well known how the political use of certain trials have been manipulated. You suggest that the effects of homeopathy are greater than in the case of a placebo. This is, indeed, normally the case, though not everywhere. The question is what you can do with it? Well, I think, it is very important, especially in this public discussion which focuses on the topic scientificity, to point out that there are reviews and that, in part, there is quite good evidence that firstly, homeopathy works better than a placebo, and secondly, that conventional medicine does not achieve better results in numerous areas.
In this respect, every healthcare provider is well-advised to maintain homeopathy as a further option of treatment for patients. I think that is important. The problem rather lies in the narrow-minded concept of science in public discussions and how we should deal with it. The relevant reviews of Shang et al. revealed the big manipulations in it. The study which the Australian evaluation had been based on was also highly manipulated. These studies are already known and thoroughly proven as false. The pharmaceutical industry and their accomplices, which means the sceptics [Letzel: “And the lobbyists”] who are paid by them have very big resources and they have a surprisingly good access to the so-called quality media which influence opinions. And this is a pity, whether it is the “Süddeutsche Zeitung” (German newspaper) or “Der Spiegel” (German news magazine) acting in concert.
Siegfried Letzel: What authority can protect homeopathy from unfounded accusations? Can the historians of medicine with all their knowledge establish s which methods of treatment have been most successful?
Prof. Dinges: The only authority which are you asking for and which is able to protect homeopathy from unfounded prejudgement is, in the end, not the history of medicine, but public opinion and politics, which you have to win over. God knows that this is difficult. This problem was also experienced by the German Carstens Foundation and by manufacturers of homeopathic remedies.
Siegfried Letzel: From the viewpoint of history, you get a good sense of what is ethically correct and what is ethically incorrect. Can you form an opinion based on history?
Prof. Dinges: Ethics is always a value-related behaviour. You have to agree on values. Of course, you could claim that normative is defined by how the pharmaceutical industry acts, which means deception to a high degree and which is not very acceptable. However, you won’t win any prizes with that in public.
Siegfried Letzel: The quantity of evidence in favour of homeopathy, even among the best studies, is quite surprising.
Prof. Dinges: Well, this depends. I think, as the available studies are mixed, which means sometimes they are better, sometimes they are less good. The available evidence shows that homeopathy is efficient in some areas and less efficient in other areas. And then there is a rule that you concentrate on areas in which you are efficient in order to be able to be competitive in the market.
Siegfried Letzel: Based on the proven evidence, would conventional medicine be prepared to accept that homeopathy can be effective if only the mechanism of action would be more plausible?
Prof. Dinges: From discussions with medical professionals which I have quite often, it is obvious that then they would rather be prepared to accept the effectiveness of homeopathy. If you could prove homeopathy’s own mechanism of action, this would correspond to scientific thinking. Naturally, if you don’t know how it works and surprisingly it works nevertheless, this will evoke questions. It is clear that conventional doctors would rather tend to accept it. The Robert Bosch Foundation has been struggling for a long time to prove the mechanism and failed to do so.
Earlier you raised a general criticism about evidence based medicine. The Evidence Based Medicine was an attempt to get away from a situation, where all kinds of people claimed what they could do. The attempt is to prove by very exact studies and evidence whether and to which extent medical drugs and therapies have an effect. This is what it essentially is all about. To start with, I think that this attempt to research into the effectiveness of different medical services in a controlled manner is progress. In contrast to this, is a situation in which everybody can go to the marketplace and blatantly claim: “I can do everything”.
The next question then is what do results in the field of EBM exactly mean. In order to answer this you must have a closer look at the individual studies. However, it is clear that clinical pharmacological trials, the way they are done – keyword double-blinded multi-arm trials – do, of course, not reflect reality. Like any trial, they can reflect reality only within certain limits. The fact that these trials cannot reflect the medical care situation is quite decisive. In this respect, you can discuss questions about study designs, statistics, etc. but I don’t find this interesting. I find it much more important to consider whether or how you, as homeopaths, can deal with the statement that you practice individualized medicine. Then you can carry out medical care studies. We look at a certain number of patients with particular symptoms and whether we can improve them or not – with a point of time at zero and a period of one month or one year, as you usually do this – and then we see the result.