Editorial: Homoeopathy Stonewalled

Editorial: Homoeopathy Stonewalled^1,2

Jamie Oskin, ND, DHANP, and Eric Udell, ND

We write this article to expose the bias and stonewalling experienced while submitting an article for publication in the Journal of Evidenced Based Integrative Medicine (JEBIM).³ The article in question was a response to Nelson et al., The Bell Tolls for Homeopathy: Time for Change in the Training and Practice of North American Naturopathic Physicians,⁴ which contained so many factual errors and potential conflicts of interest as to necessitate our factual response. Our article was submitted to JEBIM on February 26, 2019.

The Editor-in-Chief sent his reply on April 16, 2019:

Unfortunately, while the comments from the reviewers were somewhat favorable, this is a response to another paper, and as such, it is way too lengthy. If you can revise [y]our response to be a letter of no more than 10 double spaced pages, stating factual and scientific studies to support your argument, then I would be happy to review a resubmission. . You will also be required to respond to the reviewer comments below. Please do this in your cover letter of the resubmitted manuscript . Because we are trying to facilitate timely publication of manuscripts submitted to the Journal of Evidence-Based Integrative Medicine, your revised manuscript should be uploaded as soon as possible.

In contrast to the Editor-in-Chief’s summation of reviewer comments as somewhat favorable, the actual responses from the blinded peer reviewers were, in our opinion, resoundingly favorable:

Reviewer 1: Excellent Article -which addresses adequately the issues raised in Nelson’s et al. paper, but many other issues concerning Homeopathy as well. The Literature research is more than efficient. I think this paper will be a significant point of reference in this area over the next years. I really enjoyed reading it. I am really happy for being among the first ones having the privilege to read it. Many thanks to the authors. Congratulations for their good job!

Reviewer 2: This is a clearly organized and timely response to an earlier publication. Though there are a few minor errors and some colloquial phrases, it is generally well-written. The following suggestions are designed to strengthen the manuscript. Overall, there are some points that require greater clarity, detail or support, as well as additional details in Nelson et al.’s article that should be addressed explicitly.

Reviewer two went on to list his or her recommendations for improving the paper. All fifteen of the suggestions requested that we expand our paper and provide greater detail, which is in stark contrast to the Editor-in-Chief’s perplexing direction to cut the length of our paper by nearly two-thirds, from twenty-seven pages double-spaced to ten pages double-spaced. Further, this rejection was inconsistent with JEBIM’s own Manuscript Submission Guidelines. Our article was submitted as a Topical Review Article, for which there is no limit on word count according to the guidelines.⁵

Let us be clear here, there is no word limit imposed by the journal as a matter of policy, yet a severe word limit was selectively imposed on us by the Editor-in-Chief. In our opinion, this decision was arbitrary and, in hindsight, seems to have been a way to reject the article, despite overwhelmingly positive peer review and a request on the part of one peer reviewer to lengthen the article. Two additional factors worthy of mention: (1) JEBIM is a pay-to-play journal, meaning we would have been asked to pay $1,200 upon acceptance for publication; (2) JEBIM is an electronic format only journal, so the cost of printing should not be a limiting factor.

We wrote to the Editor-in-Chief on April 18, 2019 (two days after his decision to impose a word limit on the original article), but when we did not receive a timely reply, made contact with his Publishing Editor, who responded in a polite and timely manner. Before submitting a new, highly condensed version of our article that would require significant revision on our part, we wanted to know if the Editor-in-Chief had any intention of publishing our rebuttal. The Publishing Editor assured us (by phone) that he was open to our resubmission and welcomed debate over the Nelson et al. article.

The Editor-in-Chief finally replied to our correspondence almost one month later in an email dated May 14, 2019. This time he stated the following: If your intent is to respond to Dr. Nelson’s paper, then it should be in a letter form. 3 pages would be sufficient. Two months prior, when he rejected the original article and requested that we cut our article to ten double-spaced pages, he gave us a deadline of 2 months, adding: If it is not possible for you to submit your revision within a reasonable amount of time, we will consider your paper as a new submission, yet he took a month to respond to our inquiry about his intentions. When he finally did respond, he required us to reduce the article length even further to three pages and to submit it as a Letter to the Editor, no longer as a Topical Review Article.

Here we have a remarkable turn of events: An Editor-in-Chief, who has no expertise in the field of homoeopathic medicine, directing us, the authors, as to the length and nature of our response, and, overruling his own reviewers, who called for a more detailed extension of our original submission.

Nevertheless, our revised three-page (double spaced) article was then resubmitted to JEBIM on June 10, 2019. The next day, we noticed on the submission portal that its status was listed as, Awaiting Reviewer Selection, indicating that a new set of peer reviewers unfamiliar with the original article had been asked to review our Letter to the Editor. It seemed to us rather unusual for a Letter to the Editor to be subjected to peer review, which, after all, is merely a brief statement of opinion. We, therefore, immediately wrote to ask the Publishing Editor for clarification. Below is her response (sent by email):

Typically for major revisions we ask the same reviewers from before to review the new version. If they’re not available, we’ll invite new ones. However, I’m not sure what the Editor’s thoughts are in this case since it’s a Letter to the Editor now. He may just want to review it himself. I do not like to give estimates on timelines for submissions as they can vary widely. I would give it a month at the very least before checking in the first time.

The Publishing Editor’s email displayed a clear understanding that the status had changed to a Letter to the Editor and indicated that it is common for the Editor-in-Chief to review such submissions himself, without further peer review.

In the end, five peer reviewers were assigned to our Letter to the Editor. Two accepted the letter outright and a third requested only that we make a minor formatting change related to some citations. None of the five peer reviewers rejected the letter. The complete comments of each of the five peer reviewers can be found in the end notes to this article.⁶

In hindsight, the decision to require a second round of peer review begs the following questions:

1. Why was peer review requested for a simple Letter to the Editor?
2. Why was the three-page Letter to the Editor subjected to five peer reviewers when the original twenty-seven-page article was reviewed by only two?
   
   

The Editor-in-Chief treated our article as if it were a new submission, despite indicating to us that if we made the recommended changes within the requested timeline, the letter would be considered a resubmission of the original article. The JEBIM’s Manuscript Submission Guidelines state, [t]he journal’s policy is to have manuscripts reviewed by two expert reviewers. 5 Clearly, the decision to have our three-page Letter to the Editor examined by five peer reviewers was a deviation from the journal’s stated policy. And, as already stated, the journal’s Publishing Editor admitted in an email correspondence that the Editor-in-Chief often reviews letters of this nature on his own.

We will never know the real answer to either of these questions; however, when taken in the context of the handling of our article by the Editor-in-Chief, it is our opinion that subjecting our Letter to the Editor to peer review was yet another attempt at stonewalling. In essence, it appears to constitute a refusal on the part of the Editor-in-Chief to publish an article that offered a counter-opinion to the Nelson et al. paper, but absent the transparency of stating his true intention from the start. While we acknowledge that the Editor-in-Chief has the right to reject any submission regardless of the opinion of peer reviewers,⁷ his behavior suggests an unwillingness to consider our manuscript seriously due to the opinion it expressed, rather than the quality of its content.

Our letter was rejected outright on September 19, 2019. Our revised and drastically shortened Letter to the Editor took three-and-a-half months for the JEBIM to review. Nelson et al.’s original paper, a minefield of inaccuracies and fallacies, went through peer review and acceptance in two months. In the rejection letter, the Editor-in-Chief succinctly stated, Unfortunately, the paper has not introduced sufficient science of good merit to support the practice of homeopathy. This statement runs counter to the views expressed by seven of the journal’s peer reviewers. The Editor-in-Chief over-ruled the opinions of his expert peer reviewers while not himself an expert in homoeopathy.

The assignment of five peer reviewers to our Letter to the Editor represents a more rigorous peer review of a three-page Letter to the Editor than was required of either our original full length review article or, likely, Nelson et al.’s original paper, as the stated policy of the journal is to have manuscripts reviewed by two peer reviewers. As such, it seems that the Editor-in-Chief stacked the deck against our paper utilizing the facade of peer review. Of the five peer reviewers, only reviewers two and three provided any critical feedback, though neither rejected the article.

So, why did the Editor-in-Chief reject our paper outright without giving us the opportunity to incorporate the suggestions offered by reviewers two and three? Once again, we can merely speculate, but the unusually rigorous peer review process applied to our paper coupled with the swift acceptance of the Nelson et al. article, despite its poor level of scholarship, suggests bias on the part of the journal and its Editor-in-Chief against homoeopathy.

During the scientific peer review process, authors expect to receive constructive criticism intended to improve their original manuscript. Authors also expect to revise their manuscript, often multiple times, in order to conform with peer reviewer commentary and the recommendations of the journal’s editors. We received feedback from the Editor-in-Chief and the first two peer reviewers two months after submitting our original manuscript. It took the Nelson et al paper two months from submission to acceptance. If we assume that two months is a fairly standard time frame for initial review of a new submission to JEBIM, then it is logical to conclude that little to no revision was required of the Nelson et al. paper following initial review, or that its initial review was carried out far more rapidly than ours.

Given the number of inaccuracies we pointed out in our own rebuttal of Nelson et al., this constitutes a complete failure of their peer review system and the editorial process. In addition to the fact that the Editor-in-Chief assigned five peer reviewers to our three-page Letter to the Editor, these peer reviewers were allotted three-and-a-half months to perform their review. This suggests that the level of scrutiny applied to our Letter to the Editor and the Nelson et al. paper was not one and the same. The sheer length of the review process to which our article was subjected is incompatible with the timeliness standards of the medical journal industry and the Editor-in-Chief’s own comments concerning timelines quoted at the beginning of this article. According to the International Committee for Medical Journal Editors (ICMJE),⁷ whose standards the JEBIM publicly purports to follow:

Editors should do all they can to ensure timely processing of manuscripts with the resources available to them. If editors intend to publish a manuscript, they should attempt to do so in a timely manner and any planned delays should be negotiated with the authors. If a journal has no intention of proceeding with a manuscript, editors should endeavor to reject the manuscript as soon as possible.

The facts as presented here strongly suggest that the Editor-in-Chief of JEBIM never intended to publish our manuscript, yet he strung us along for seven months and requested two massive revisions of our manuscript before finally rejecting the paper as lacking in scientific merit. If our paper truly lacked sufficient science of good merit to justify publication, then this was as apparent when reviewing the original full-length manuscript as it was upon reviewing the highly condensed three-page Letter to the Editor.

This is a clear example of the shortcomings of the current system of scientific peer review and demonstrates that the process is not immune to bias. This sentiment has been expressed by the former editors of two of the world’s most esteemed peer reviewed medical journals, The New England Journal of Medicine (NEJM), and The Lancet:

Marcia Angell, MD, former editor of NEJM stated:

It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as editor of The New England Journal of Medicine. ⁸

Richard Horton, editor of The Lancet, expressed the following opinion:

The case against science is straightforward: much of the scientific literature, perhaps half, may simply be untrue. Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness. ⁹

There is one final suspicious twist to this story. The lead author, Nelson, was, at the time of publication, a naturopathic medical student who had never previously published a peerreviewed article in a scientific journal. Two of the other authors were naturopathic doctors. The last author, Martin A. Katzman, MD (MAK), has been widely published and his conflict of interest statement indicated that he has been on the dole of just about every major pharmaceutical company on the planet. Nelson et al.’s paper lists the following conflicts of interest:

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: ACL has received consultancy fees from Genuine Health, Toronto, Canada and speaker’s fees from Health World Inc, Queensland, Australia. MAK has been a consultant or advisory board member of GlaxoSmithKline, Lundbeck, Eli Lilly, Boehringer Ingelheim, Organon, Astra Zeneca, Jannsen-Ortho, Solvay, Bristol-Myers Squibb, Shire, Sunovion, Pfizer, Purdue, Merck, Astellas, and Bedrocan; has undertaken research for GlaxoSmithKline, Lundbeck, Eli Lilly, Organon, AstraZeneca, Jannsen-Ortho, Solvay, Genuine Health, Shire, Bristol-Myers Squibb, Takeda, Pfizer, Hoffman La Roche, Biotics, Purdue, Astellas, Jannsen-Ortho, and Forest; has received honoraria from GlaxoSmith-Kline, Lundbeck, Eli Lilly, Boehringer Ingelheim, Organon, Astra Zeneca, Janssen-Ortho, Solvay, Bristol-Myers Squibb, Shire, Sunovion, Pfizer, Purdue, Merck, Astellas, and Bedrocan; and has received research grants from CIHR, Sick Kids Foundation, Center for Addiction and Mental Health Foundation, Canadian Psychiatric Research Foundation, Canadian Foundation for Innovation, and the Lotte & John Hecht Memorial Foundation. DHN and JMP declare no conflicts of interest.

None of these authors appear to have any specific expertise in homoeopathy, which they sought to discredit. The authors of the Nelson et al. paper propose to jettison from the naturopathic profession one of its core therapies. This position is both bold and presumptuous. That such a proposition is made by a group of non-experts and supported by a highly flawed and scientifically untenable paper that appears to have been published by JEBIM with little scrutiny, makes it all the more concerning for anyone who cares about the future of naturopathic medicine in North America. While we can only guess at the authors’ true motivations in publishing the Nelson et al. paper, MAK’s listed conflicts of interest certainly could lead many in our profession to suspect either an effort to pander to the dominant school of medicine in order to seek acceptance, or, perhaps, the authors are merely acting as shills of the pharmaceutical industry. Regardless, this attack on one of the core therapies of naturopathic medicine by a group of proselytizing crusaders for science, one of whom happens to be a widely published researcher who has been generously supported by a Who’s Who of pharmaceutical behemoths, smells fishy and bears many of the hallmarks of astroturfing¹⁰ in promotion of a hidden agenda.

Our three page Letter to the Editor has been published in the Naturopathic Doctor News and Review³ and is available online at: https://ndnr.com/pain-medicine/setting-the-record-straight-homoeopathys-rightful-place-in-naturopathicmedicine/#.

Aude sapere (Dare to be wise)

About the Authors: Jamie Oskin, ND, DHANP and Eric Udell, ND are board members of the HANP, adjunct faculty in the homoeopathy department at Southwest College of Naturopathic Medicine in Tempe, AZ, and are in private practice at Arizona Natural Health Center in Phoenix, AZ.

References

1. Definition from Miriam Webster Online Dictionary Accessed December 11, 2019: S t o n e w a l l , verb, stone · wall | \ ˈstōn-ËŒwȯl \ : to be uncooperative, obstructive, or evasive.
2. Attkisson, S. Stonewalled: My Fight for Truth Against the Forces of Obstruction, Intimidation, and Harassment in Obama’s Washington. New York, NY: Harper Collins; 2014.
3. Oskin, J, Udell, E., et al. Setting the Record Straight: Homoeopathy’s Rightful Place in Naturopathic Medicine. NDNR. Posted Online July 3, 2020. Available from: https://ndnr.com/pain-medicine/settingthe-record-straight-homoeopathys-rightful-place-in-naturopathic-medicine/#
4. Nelson DH, Perchaluk JM, Logan AC, Katzman MA. The Bell Tolls for Homeopathy: time for change in the training and practice of North American naturopathic physicians. Journal of Evidence-Based Integrative Medicine. 2019;24:1-11. doi 10.1177/2515690X18823696. This paper was received by the JEBIM on October 17, 2018, accepted December 17, and published January 16, 2019, i.e. less than three months from submission to final publication.
5. Journal of Evidenced-Based Integrative Medicine [Web page].https://journals.sagepub.com/author-instructions/CHP#WritingYourPaper. Accessed March 9, 2020.
6. Here are the full comments from the reviewers:
   • Reviewer 1: Very nice reply to the article, with sound and upto-date literature.
   • Reviewer 2: Given the three points that you make, please note each section more clearly by saying first… second… third.
   • Reorder section 1 to provide a more persuasive, cohesive argument.
   • Increase your explanation of the claims that you are disputing (e.g., your paragraph on naturopathic medical education).
   • In the following places, please explain, tie-in or omit:
     • Paragraph on The history of homeopathy (tie-in to first point about placebos or place in the introduction and spell out the potentially positive role )
     • Explain why placebos in animal studies are controversial
     • Justify your point about the heterogeneity of what is called ‘homeopathy’
     • Individualized homeopathy makes sense, but clarify individual conditions
     • Provide an example of procedural and scientific misconduct
   • Reviewer 3: The Authors should clarify and discuss why homeopathy is to be included in Naturopathy as most definitions (Oxford Dictionary, Collins English Dictionary etc) clearly mention that no drug should be used in naturopathy treatment. Again, in the definition given in Wikipedia Naturopathy’ is defined as pseudoscience and they are not included as evidence-based medicine . Thus, the Authors may add at least one paragraph regarding this in the manuscript.
     
     As millions of people at present are utilizing homeopathic medicines for their treatment thus there should not be any doubt regarding their action, however, as it is a neglected branch of medicine detailed studies are required for its standardization. About one third papers mentioned in the references belonged to only one group of Authors which indicates clearly there is paucity of scientific literature in this area and again use of so many references from only one group also indicates chance of biasness.
     
     The Author has rightly mentioned that there is no conclusive proof of the mechanism of action of homeopathic medicines till now, although the Author discussed nanoparticle concept to some extent.
     
     Without mentioning in details the author may cite many other concepts which are associated with the probable mechanism of action of the homeopathic medicines. There are evidences of many physico-chemical, molecular, biological (TLRs, cytokines, oxidative stress molecules, Jak-stat pathway) changes that at present; it is very difficult to call it as a placebo.
   €¢ Reviewer 4: Accept
   €¢ Reviewer 5: Correct the references in terms of number an standard abbreviation of Journals for example page 1, line 31, reference number should be 13-36.
7. International Committee of Medical Journal Editors (ICMJE). Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals [Web page]. www.icmje.org/icmje-recommendations.pdf. Accessed March 9, 2020.
8. Angell M. Drug Companies & Doctors: A Story of Corruption. The New York Review of Books magazine. [Accessed December 13, 2019]. Available from: www.nybooks.com/articles/archives/2009/jan/15/drug-companies-doctorsa-story-of-corruption/
9. Horton R. What is medicine’s 5 sigma? Lancet. April 11, 2015; 385: 1380. [Last accessed December 13, 2019]. Available from: www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736%2815%2960696-1.pdf
10. Definition from Miriam Webster Online Dictionary Accessed December 13, 2019: A s t r o t u r f i n g, noun: organized activity that is intended to create a false impression of a widespread, spontaneously arising, grassroots movement in support of or in opposition to something (such as a political polic y) but that is in reality initiated and controlled by a concealed group or organization (such as a corporation).