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Sometimes, I tend to say that every time a quack loses their license, a hungry kitten gets a bowl of milk. So I could say I’m doing it all for the kittens, but in reality, I like seeing quacks struck off for far more prosaic reasons. Deep down, I do believe that there is a public law duty incumbent on professional bodies – even where the ‘profession’ they regulate is of a professionality as dubious as naturopathic ‘medicine’ – to maintain certain key standards within their regulated practitioners. But this is also a story about the insufficiency of self-regulation, and what can go wrong with it – the pitfalls inherent in the idea that the profession will regulate itself, and keep dangerous actors out of the sphere of public practice. It is the story of a case where the system worked well, and yet remains insufficient to protect the public, raising serious questions as to whether regulation of health professions should indeed be delegated to secondary bodies, whose ultima ratio is to expel a member, but who are powerless once the quack in question perpetrates their quackery outside their aegis. I present you… the Zimmermann affair.
A few months ago, you might have heard of a Canadian naturopath, Ms Anke Zimmermann,1 published a rather interesting little article on her blog, recounting a story of a 4-year-old with behavioural problems whom she claimed to have cured with… behavioural therapy? Paroxetine? Psychotherapy? DBT? Benzos? Nope. Those are all bad, evil Big Pharma products. Nope, she went for a state-of-art treatment (about 250 years old) called lyssinum. Which is exactly what you think it is: the saliva of a rabid dog.
When the inimitable 6E23, everyone’s best resource on just how delusional homeopaths are, has reposted it, I was genuinely convinced that this must be a troll.
At this point, I saw two scenarios. Either Ms Zimmermann was administering a placebo that did not contain what it claimed to have contained (that is, she was bullshitting her marks2), or, worse, she was administering an extremely harmful pathogen to a child, before even giving the proper medical subspeciality (child behavioural psychology) a chance.3 If it was the latter, something very bad was going on.
You see, rabies is one of the worst diseases in existence. Personally, I’d rather have Ebola haemorrhagic fever than symptomatic rabies, having seen both. There are all of six known cases of survival of symptomatic rabies, using the controversial and largely hit-and-miss Milwaukee Protocol. It’s not to be trifled with. It’s also a controlled biological agent. I do suppose I don’t need to point out that administering it to anyone, least of all a child, is not so much bad medicine as pure, blank insanity.
Giving her the benefit of the doubt, I asked Ms Zimmermann some straightforward questions – namely, is she lying or is she insane? Obviously, something better than the ‘memory of water’ was expected here. Alas, it was not forthcoming – insults, on the other hand, were.
It was clear I was not to receive answers. And so, my walk through the muddy roads of Canadian homeopathy/naturopathy regulation began.
In British Columbia, the locus delicti (where the act has taken place), ‘naturopathic physicians’ (“naturopaths“, because I’m loath to dignify them with the title ‘physician’), practice under the statutory instrument B.C. Reg. 282/2008 (the “Regulation“), made under the authority delegated by the Health Professions Act 1996, R.S.B.C. 1996 c. 183 (the “Act”). Part II of the Act defines regulated health practitioners, including ‘naturopaths’, their discipline and registration being subject to the Regulation. The Regulation further appoints the College of Naturopathic Physicians of B.C. (the “College“) as the responsible regulatory authority for naturopaths, although you might be forgiven for finding ‘responsible’, ‘regulatory’, ‘authority’ and ‘naturopaths’ in the same sentence more than a little oxymoronic. Even without the oxy-.
On 17 April 2018, I lodged a formal complaint with the Registrar of the College. In it, I recited the pertinent facts. These bear repeating here.
Facts: Chronology of events
3. The Practitioner owns, among others, the domain drzimmerman.org (the “Website”) and the Twitter account @drzimmermann as well as the Facebook profile at @doctorzimmermann.
4. On 08 February 2018, the Practitioner posted on the Website, under the section “Successful Cases”, a case report titled “A Child with Aggression and Behavioural Problems” (the “Case Report”). The Case Report was available, at the time of this Statement, under the URL https://www.drzimmermann.org/successful-clinical-cases/a-child-with-aggression-and-behavioural-problems. It is also exhibited as Exhibit 1 to this e-mail.
5. In the Case Report, the Practitioner describes, in her words,
“A 4-year-old boy with sleep and behavioural problems, including aggression and violence towards school mates, hiding under tables and growling, improves nicely with a homeopathic remedy made from the saliva of a rabid dog, Lyssinum.”
6. The Case Report concerns a “nearly 5-year-old” boy named Jonah (the “Patient”). Jonah was, according to the Case Report, brought into the Practitioner’s care on 06 October 2018 with complaints of “sleep and behavioural problems”. Patient exhibited, according to the Case Report, “an inability to fall asleep at night, a fear of the dark, of wolves, werewolves, ghosts and zombies … [t]here is a history of a dog bit [sic] which drew blood.”
7. The Practitioner states that she “decided to give a homeopathic remedy made from rabies”. This is based on the theory that the “The dog who bit him may have recently been vaccinated with the rabies vaccine or the dog bite in and of itself may have affected the boy with the rabies miasm”.
8. The Practitioner describes the administration of Lyssinum 200CH, 2 pellets, and at a follow-up meeting, a “dose” (unspecified quantity) of Lyssinum 10M. The Case Report does not discuss a referral to an appropriate secondary referral service, such as a child psychotherapist, developmental psychotherapist or a psychiatrist experienced in early life affective and social integration disorders.
Facts: Rabies, “rabies miasm” and Lyssinum
9. Rabies is an infection of the central nervous system caused by the rabies virus (RABV) and, in rare cases, the Australian Bat Lyssavirus (ABLV). Rabies is a typical zoonotic virus that can exist in some animals without symptom, but is characteristically symptomatic – and almost always fatal – in canids and primates, including humans. RABV and ABLV are genetically related, and constitute part of the genus Lyssavirus, a genus of the family Rhabdoviridae, of which RABV is the type species. They belong to Group V (negative-sense single-strand RNA) of the Baltimore classification of viruses.
10. Rabies in the human is transmitted typically by bite, specifically by transfer of the virus through the saliva of an infected animal, with dogs being frequent carriers throughout the world, except in the Americas, where widespread vaccination of pets and strays has led to a vastly reduced prevalence of RABV in canines, with most cases caused by chiropteran (bat) bites. Rabies causes over 17,000 deaths per annum.
11. In humans, rabies has a widely varying incubation period, ranging from several days to up to six years, but typically around two to three months. During this period, rabies cannot be detected, as the virus is safely ensconced in nerve tissue. Post-exposure prophylaxis (rabies immunoglobulin and/or the rabies vaccine) is usually highly successful and not connected to severe side effects.
12. Symptomatic rabies initially manifests as non-specific viral symptoms, including headaches and fever. It eventually evolves rapidly to a meningoencephalitis or encephalitis, with the clinical course mirroring this as focal neurological deficits, anxiety, agitation, altered mental state and hallucinations as well as the characteristic aversion to water (hydrophobia). This is inevitably followed by delirium, coma and demise of the infected person, within 2-10 days after symptoms have first presented. A low number of patients (six, to be specific) have survived owing to a treatment developed by Rodney Willoughby, Jr. M.D. (the Wisconsin Protocol), in which a coma is induced using midazolam and ketamine and high-dose antivirals – ribavirin and amantadine – are administered. The overall survival rate of this treatment is, according to an ITT analysis, approximately 8%, and many patients survive with moderate to severe neurological sequelae. The above ought to recapitulate the seriousness of what is a fortunately only rarely seen infectious disease in the Western Hemisphere.
13. Rabies is not particularly infectious, but it is categorized as a BSL-2 agent. It is not a Select Agent but subject to export restrictions. Most health authorities recommend BSL-3 treatment.
14. The concept of rabies miasm is not known to any branch of science. It is not an acknowledged medical phenomenon. It is not an acknowledged biological phenomenon. It has no acceptable biological explanation that is in line with the current state of science.
15. The rabies prophylactic vaccine is an inactivated (killed) viral vaccine. Upon injection subcutaneously, it disperses in the subject’s bloodstream, stimulating the creation of antibodies. Neither antibodies nor the inactivated RABV antigen are present in any appreciable number in an animal’s saliva after vaccination. Nor are either RABV antigen or anti-RABV immunoglobulin associated with behavioural-cognitive symptoms that are in line with those reported in the Case Report for the Patient. The Practitioner’s theory that the history of dog bite may have caused his behavioural issues is unsupported by any clinical evidence or feasible scientific mechanism. It is also not an acknowledged medical phenomenon. It is not an acknowledged biological phenomenon.
16. Lyssinum, from the Greek lyssa ‘rage’ referring to rabies, also known as Hydrophobinum, referring to the characteristic symptom of hydrophobia in rabies, is described as a ‘nosode of rabies’ and is described as a trituration (solution of a water-insoluble substance in lactose in homeopathy) of the saliva of a rabid dog, according to the National Center for Homeopathy.
17. It is unclear whether Lyssinum contains any active viral particles. The dilutions described are 200CH and 10M. CH refers to centennial dilutions, in which the original substance, known as the “mother tincture” in homeopathy, is diluted to 1:100, and vigorously shaken. 200CH therefore amounts to 1:100^200, a vast number: there are approximately 10^80 atoms in the entire observable universe, therefore, a mere 40C dilution of a single small molecule would occupy the entire observable universe. In other words, it is unlikely that Lyssinum contains anything other than its excipients, and no active viral particles were present.
18. At the same time, the Practitioner claims that the vaccine was made “from the saliva of a rabid dog”. The probability may be infinitesimally small that any of the RABV in the original substance or “mother tincture”, if it ever existed, would remain in the substance, if we assume a uniform distribution of particles. But it cannot be conclusively excluded that this would not, in fact, be the case. For instance, it is improbable but not impossible for all the viral particles from the “mother tincture” to end up in a single, extremely infectious, granule. In that sense, the Practitioner is administering a high chance of an inert placebo or an extremely low but nonzero chance of a potentially fatal illness, to a 4-year-old with behavioural problems.
19. Practitioner’s responses to questions about her practice and her use of a substance that may potentially infect a patient with an incurable and virtually always fatal illness consisted of insults, the threat to use the scientific position – that her practice of using Lyssinum is either falsely stating that it is anything but lactose or otherwise it may carry a small but nonzero risk of an incurable and virtually always fatal illness – as proof of “ignorance” of homeopathy at a conference, as well as threats to report the Complainant to “the authorities” for “harrassment [sic]”.
20. It remains open what the Practitioner’s beliefs were as to the contents of the granules. If the practitioner believed that they were indeed made by sequential dilutions of a highly infectious substance, then she could not exclude with 100% certainty that she was not administering a pathogen causing an incurable and virtually always fatal illness. On the other hand, if she did not believe that the granules were created by sequential dilutions of a highly infectious substance, then she had no reason to make therapeutic or other claims, including the very claim that they were in fact made “from the saliva of a rabid dog”. These possibilities are mutually exclusive but jointly complementary.
On the same day, the College accepted jurisdiction in all five questions posed in my submission, namely:
21. Complainant hereby requests your consideration of the above outlined facts in order to determine whether
a. the use of Lyssinum was in compliance with the Practitioner’s duty towards the Patient,
b. the Practitioner has discharged her duty of care towards the Patient by treating him with a questionable remedy that has no scientific validity or evidence-based track record in treating aggression or childhood affective or social disorders instead of referring him to a more appropriate professional assessment,
c. the Practitioner has discharged her duty of care towards the Patient by the use of a homeopathic medicine ahead of excluding a possible psychiatric, psychological or neurological aetiology,
d. the Practitioner has endangered the Patient’s health by using a treatment that may potentially cause a lethal and untreatable infectious disease, or
e. the Practitioner has made claims about the origin of the treatment that are intended to present Lyssinum as having a therapeutic potential that is not warranted by suitable, clinically validated scientific evidence.
Truth and consequences
On 27 November, I received a communication from the College, notifying me of a consent order between Ms Zimmermann and the College:
The Committee determined pursuant to section 33(6)(c) of the Act that this would be an appropriate case in which to seek a consent order in view of the Committee’s concerns of the Registrant’s professional conduct.The Registrant consented to the immediate cancellation of her registration with the College. She agreed not to apply for reinstatement or otherwise seek registration with the College for a minimum period of five (5) years from the date of the Consent Order. As such, the Registrant is not permitted to practice naturopathic medicine. The Registrant is further not permitted to use the reserved titles: “naturopath”, “naturopathic physician”, “naturopathic doctor”, “physician” or “doctor’.
As the Registrant’s Consent Order pertains to a “serious matter” as defined in the Act, it requires public notification. Accordingly, a notice regarding the cancellation of the Registrant’s registration has been placed on the College’s website, at www.cnpbc.bc.ca. Please note that the public notification does not contain any identifiable information about you. The Registrant’s Consent Order will be disclosed to the Inquiry Committee, the Discipline Committee and/or the Registration Committee in the event of any future proceedings following consideration by those committees of the merits of any future complaint or application.
The public notice is available here and the College’s Notice of Disposition is available to press and interested parties upon request. And ideally, the story were to be over here. But it’s not.
Self-regulation and its insufficiency
What, then, is the outcome of l’affaire Zimmermann? It’s not merely a potentially dangerous and/or deluded homeopath who stood at trial, and was judged by a jury of her peers. Rather, the whole case is a sad and disappointing verdict on the Regulation and the self-regulatory regime of SCAM (supplements, complementary and alternative medicine) industry. In this case, self-regulation ultimately failed due to its own set boundaries: they may strip Ms Zimmermann of her fancy postnominals and the right to call herself a naturopathic physician, but can continue without a shred of a license as a homeopath, selling the same snake oil to the same clientele of the desperate, the crunchy and the credulous. What could have been a chance to get an immensely harmful practitioner of pseudoscience and make-believe medicine off the street who herself cannot honestly answer whether she is deluding her customers or gambling with a child’s life has been traded for a cheap consent order, under which she might not practice under the College’s aegis, and with that, that’s all done. Clearly, this proves that the naturopathic ‘profession’ cannot be trusted with self-regulation.
In the end, this is another sad story about the regulation of alternative “medicine”, and the state it is in. It is another story of missed opportunities, of could-have-beens and should-have-beens, and of a government that disclaimed all responsibility for the lives of the citizens who put it into power, delegating it to colleges of make-believe medicine who are fine with all sorts of pseudomedicine as long as it does not happen under their purview and with their name on the leaflet – and to hell with patient welfare, right?
Watch this space. I doubt this is the last we’ve heard of Ms Zimmermann. We can only hope that her next foray will not end up with consequences that are harder to repair than a child whose anger issues never got the adequate treatment but instead where inefficiently soothed by some balls of lactose.
References [ + ]
|1.||↑||Naturopathic doctorates are not doctorates in any sense of the word, and I am not going to degrade my doctorate, or yours, by treating them as such|
|2.||↑||Homeopaths and naturopaths do not have patients. Doctors and nurses have patients. Homeopaths and naturopaths, like all fraudsters, have marks.|
|3.||↑||Funny that. Isn’t it the same crowd who complain about ‘allopathic medicine’ or ‘Schulmedizin’ trying to treat everything with drugs? Or is that not the case if globuli are involved?|