In Germany, a Heated Debate Over Homeopathy

In 2016, Christian Lübbers met a sobbing 4-year-old girl at his private medical practice in the south of Germany. The ear, nose, and throat physician quickly identified the source of the girl’s problem: acute inflammation of the middle ear. Though the condition is common, this particular visit was unusual. “You have to imagine, the ear canal was basically completely blocked — pus is coming out,” says Lübbers, “and as I was extracting it, I saw that the goop contained more or less intact white pieces.” Some were still the size of about half a Tic Tac. Others had partially dissolved, melded with the pus. He remembers turning to the girl’s parents and asking, “Have you, by any chance, put globuli in the ear?”

Globuli, the German term for tiny white balls comprised of sugar, are the main vehicle for administering homeopathy, a more than 200-year-old practice originally developed by a German physician named Samuel Hahnemann. In his day, Hahnemann experimented with a wide variety of substances that cause illness or symptoms in a healthy person. He believed that these substances — when given to a sick person — could cure the illness or lessen the symptoms that they would otherwise cause in a healthy person. Crucially, most of the time homeopathic products contain no traceable elements of the original substance. Instead, that original substance is diluted with water or alcohol. Practitioners claim that the substance’s “spirit-like power” is stored in water’s “memory.”

Homeopathy became wildly popular during the 19th century. The practice offered an alternative to mainstream medicine, which at the time, included ineffective and harmful treatments, such as bloodletting. Of course, over the past two centuries, the fields of medicine and public health have advanced dramatically. Vaccines, antibiotics, anesthesia, and a host of other interventions have all been rigorously tested and proven to be effective at saving lives and lengthening lifespans. Homeopathy, however, has not developed along similar lines. After a systematic review of 176 individual studies, Australia’s National Health and Medical Research Council found that not a single high-quality study “reported either that homeopathy caused greater health improvements than placebo, or caused health improvements equal to those of another treatment.”

In a 2014 survey, 60 percent of Germans reported trying homeopathy.

And yet reliance upon homeopathy is common, particularly in Europe. In Hahnemann’s native Germany, homeopathic treatments are prescribed by medical doctors, covered by 70 percent of government medical plans, and available in almost every pharmacy. In a 2014 survey, 60 percent of Germans reported trying homeopathy. The country’s homeopathic drug market is worth around $750 million (670 million euros), with consumers paying largely out of pocket. Consultation fees account for hundreds of millions more.

The practice is now at the center of a bitter political discussion, with some legislators, insurers and doctors saying homeopathy should not be included in the public insurance programs that cover most European citizens. In France, the health minister recently announced that she would phase out insurance reimbursement by 2021, following a review of more than 1,000 scientific studies that found no evidence for homeopathy’s effectiveness. In 2018, Austria’s Medical University of Vienna stopped teaching homeopathy to medical students.

But Germany appears likely to continue to support it — in a move that critics say could cause real harm to unwitting patients who forgo other treatments, believing homeopathy will cure them. Not only that, critics say, when homeopathy is covered by insurance, it’s a waste of the contributions the public is mandated to pay. Though physicians and researchers readily admit that homeopathy can yield some benefits by leveraging placebo effects, as well as practitioners’ empathy and listening skills, it’s a hefty sum for medications that have no active ingredients.

“In Germany,” Lübbers says, “we have a system in which we can register ‘sugar balls’ as medicine” and government insurance plans will pay for it. In his view, this represents nothing less than a national scandal.

After extracting the pus and globuli from the ear of his 4-year-old patient, Lübbers explained to the girl’s parents that the pills contain no active agent. At best, they work through a placebo effect, which can’t cure an infection. Upon hearing this, Lübbers says, the parents abandoned their belief in homeopathy and readily accepted his prescription for antibiotics.

Research suggests that the majority of patients are unaware that they’re being treated with sugar. In a 2009 survey in Germany, only 17 percent of respondents knew how homeopathic medicine was produced. The rest believed it to contain some sort of natural active agents. Lübbers says that he encounters this misconception in his office every day. “Roughly three-quarters of the people I tell that homeopathy isn’t natural medicine see their house of cards collapse; their support of homeopathy disintegrates,” he says.

For patients — especially those with undiagnosed diseases — this wrong belief can cause real harm. In Italy, a 7-year-old boy eventually died from encephalitis caused by a common ear infection. He had for a couple of weeks been treated with homeopathy, and, according to Italian media reports, his parents only called an ambulance when he lapsed into a semi-unconscious state. In Germany, a woman received homeopathic and other alternative treatments for her breast cancer for three years before consulting a medical doctor. The doctor confirmed the lump she had was malignant and recommended chemotherapy, but she continued with alternative treatments. The cancer eventually became fatal.

“If you receive these little balls directly from a globuli producer or from a witch, it doesn’t matter,” says Nikil Mukerji, a professor at Ludwig-Maximilians University in Munich, who studies the philosophy of parascience. “You can even throw them over your right shoulder, but be careful,” Mukerji continues jokingly, “that it’s exactly five pieces and that they have the right spin.”

Mukerji says that many people turn to homeopathy after hearing that it “worked” for a friend or a family member. But, he says, it’s all too easy to assume correlation means causation. “If you’ve consulted a homeopath for a strong headache, then chances are — unrelated to what this person does with you — that your headache won’t be as strong the next day,” he says. In this kind of situation, it’s the passage of time that leads to physical improvement, not the sugar balls.

For some patients, the passage of time can exacerbate an underlying health problem. This was true for 4-year-old girl in Lübbers’ clinic. When she returned 2 days later, the antibiotics were working. The pus and tears were gone.

Lübbers has since gone on to become an outspoken homeopathy critic. He joined the Information Network Homeopathy, a loosely linked group of German experts hoping to educate the public about homeopathy, and has retold his story countless times on German radio, in newspapers, and on some of the country’s biggest talk shows. In November, when the government of Bavaria, the second-most populous German state, signed off on a $448,000 study to research whether homeopathy could reduce the use of antibiotics, he penned a scathing article in Zeit Online titled “Globukalypse now!” Since then, the study’s budget has doubled to nearly $900,000.

And yet, for all the passion on both sides of the issue, German Health Minister Jens Spahn said in September 2019 that that topic wasn’t worth fighting over, in part because insurers themselves spend relatively little — approximately $22 million a year — for homeopathic treatments. “I’ve decided on: It’s OK the way it is,” Spahn told reporters in 2019.

In an email to Undark, the health ministry added that it needed to accommodate “a large number of doctors and a wide group within the public who follow an ideological approach that is different from the scientifically-informed, conventional medicine” and act in line with German law.

That law has its roots in the 1950s, when a West German pharmaceutical company created thalidomide, a sedative that became popular among pregnant women because it reduced morning sickness. However, the drug had not been tested for its effects on embryonic development, and in 1960s, thalidomide was found to cause malformed limbs. Globally, over 10,000 children were affected. Ultimately, the German government went on to introduce a new law to regulate the pharmaceutical industry. Known as the Medicinal Products Act — the law stipulates that medicines need to be proven safe and effective before they are allowed on the market.

But lobbyists pushed to exempt homeopathy. Currently, the manufacturers of homeopathic medicine simply need to show that the ingredients in their products do not cause any direct harm. And if a company wants to market a homeopathic medicine for treatment of specific disease, it is sufficient for a group of homeopathic practitioners to attest to the products’ effectiveness based on a handful of case studies. The process is known as “internal consensus” and is one of the most ardently debated aspects of homeopathy.

So far, the German medical establishment has weighed in with mixed messages. In a joint communique from its 2018 federal meeting, the German Medical Association called on the government to reconsider privileges given to alternative medicine, criticizing the industry for operating without any evidence or standards. In the same communique, however, the association listed guidelines on how doctors could earn a professional distinction in homeopathy by training with homeopaths and taking an exam in front of other homeopathic practitioners.

“That’s like saying that unicorn riding is now going to be offered as a special professional distinction, with exams administered by unicorn-riding doctors,” quips Natalie Grams, a physician and head of Information Network Homeopathy.

Grams knows what she’s talking about. As one of roughly 7,000 German physicians also accredited in homeopathy, she used to spend weekends on professional development with other homeopathic practitioners. “Everything was awesome. The patients were satisfied and so was I,” she recalls. As criticism of homeopathy grew, she began writing a book that would present all of the evidence in support of homeopathy. The issue: She found none. In hindsight, she attributes her patients’ improvement to the placebo effect and the benefits of having a caring, unhurried practitioner.

With initial consultation fees of around $220, Grams was able to speak to her patients at length, sometimes for three hours or more. In contrast, doctors like Lübbers deplore the ever more efficient, tight schedule they are expected to follow in order to see all their patients. Primary care physicians in Germany spend, on average, just under eight minutes per patient, according to a systematic review published in the medical journal BMJ Open. In the United States, that figure is above 20 minutes.

Though homeopathic medicines are not as popular in the U.S. as they are in Europe, the federal Centers for Disease Control and Prevention found that about 5 million adults and 1 million children used homeopathy in 2012. Even though the U.S. Food and Drug Administration attempts to better regulate the market, major retailers like Walmart, CVS, and Walgreens sell homeopathic products that resemble conventional flu and cold medicines and can be found in the same aisle. The Center for Inquiry, a science education nonprofit headquartered in Amherst, New York, has filed lawsuits against Walmart and CVS, accusing them of fraud for their sale and marketing of homeopathic products.

Eventually, Grams began writing a book that would present all of the evidence in support of homeopathy. The issue: She found none.

Matthew Burke, a neurologist at Sunnybrook Health Sciences Center in Toronto, says the placebo effect could explain why many patients report improvement after taking homeopathic medicines or other products without active ingredients. In these cases, it’s not the medicine that stimulates healing, says Burke. Instead, improvements are driven by other factors, such as prior beliefs, or trust in one’s health care provider. And while some might place their trust in an Ivy League hospital, others might turn to vitamins from the Himalayas or homeopathic globuli.

Studies have shown that the placebo effect is more powerful than previously believed and that it can modulate certain areas of a patient’s brain, making it plausible that a placebo might relieve the symptoms of some conditions, says Burke. And beyond that, “The whole patient interaction — hearing somebody empathizing with them, developing a good therapeutic relationship, relieving some of their anxieties and worries, that’s really important and that’s something that unfortunately we don’t do as much as we should in medicine,” he says.

Both Lübbers and Grams agree that placebo effects are powerful and wish that medical doctors could spend more time with each patient. “As good as our medicine is scientifically,” Lübbers says, mainstream medicine has “completely ignored” the importance of spending clinic time with patients. But, he adds, for no other issue are the facts as crystal clear: Aside from the placebo effect, homeopathic medicines don’t work.

“If we don’t succeed in kicking homeopathy out of medicine and banning it to the kingdom of esoterica,” Lübbers asks, “then how can we even begin to talk about unnecessary back surgeries?”

As he leaves the clinic each day, Lübbers passes a glass cabinet that houses a collection of historic medical devices: pillboxes, a knife for bloodletting, and a mask onto which doctors dropped ether to anaesthetize patients.

Perhaps, someday, Lübbers will be able to lock globuli behind that door, too.

Denise Hruby is a bilingual reporter and editor who covers the climate crisis and environmental crime, politics, and social and human rights issues. Her reporting has appeared in National Geographic, CNN, The Washington Post, The Guardian, the LA Times, Nature, and the BBC.