Saturday, 31 August 2019

Homeopathes Sans Pitié

A group of Canadian homeopaths calling themselves Homéopathes de Terre Sans Frontières (HTSF) claim to have been active in Honduras for 15 years. This is bad enough but one of their objectives is to treatment/prevention of Chagas disease with homeopathy. Worse, the activities were mostly funded by the Canadian government (through Global Affairs Canada - GAC). 

Understandably, there was an outcry from clinicians and scientists. There was reporting in the Canadian media and it was even picked up by the BBC. Steve Novella and Scott Gavura wrote about it for SBM too. It didn't take very long to for government funding to be stopped.

It turns out to be an even uglier story than reported. Unpicking the story was hard and there are still many unknowns. Anyone familiar with the antics of other Western homeopaths in the developing world will not be surprised by HTSF's disregard for research ethics and ethics in general. Homeopaths have a tenuous grasp on facts. Exaggeration and misrepresentation are common. Homeopaths think that laws don't apply to them.

Worryingly, HTSF seem determined to carry on treating/preventing diseases with magic pills and potions and even expand in some ways. 

Honduras is poor. Estimates vary but the World Bank states more than 60% of the population live below the poverty line and in rural areas 20% live in extreme poverty. Inequality is a real problem and there is a pronounced rural/urban divide, especially with healthcare and education. An estimated 17% do not have regular access to healthcare according to the Pan American Health Organisation. The Honduran government to have plans to improve things. It's focus is on developing primary care and vaccination is very important.

It has very high vaccination rates. 100% for certain diseases. 

Honduras is a civil law jurisdiction. Unlike Canada (barring Quebec - see below), there is no common law right to practice medicine. Guidance from various voluntary groups that send practitioners to Honduras reveals that only licensed medical practitioners can practice in Honduras, that they must apply submit credentials well in advance and practice under the supervision of a Honduran physician.

Chagas disease
The decision by HTSF to target Chagas disease is strange given that numbers of new cases have been decline for many years (one reason is explained below). In terms of insect borne infectious diseases dengue, malaria and leishmaniasis are more of a problem. Chikungunya and zika have also appeared. Chagas is more of a problem is parts of South America, particular in Bolivia where 1 million out of a total population of 11.5 million are infected. That's not to underplay the impact of Chagas in Honduras. This video is from Bolivia.

Chagas is a horrible disease. It is caused by the protozoan parasite Trypanosoma cruzi. T cruzi has a complex life cycle. This diagram from the Center for Disease Control is helpful.

After being bitten by a bug, bug faeces being rubbed into the eye etc, trypomastigotes cause the intial acute stage. Some patients are totally asyptomatic, but when symptoms occur, they are generally mild and similar to those of other less serious conditions. The acute stage can be severe in those with weakened immune system (such as those living with HIV/AIDS) and very rarely it can kill by causing inflammation of the heart or brain.

T. cruzi remains in the body. It doesn't go away. The infection is said to enter the chronic phase. Many patients (60-80%) will never display any symptoms but symptoms can manifest years or even decades later. Typical symptoms include gastro-intestinal problems as well as heart problems. Heart problems can be fatal and even if not, result in a very poor quality of life. 

What triggers the onset of chronic symptoms, T. cruzi to become more active in the body is a mystery. The same is true of some other parasitic infections.

There's an astonishing story about the spread of Chagas in Central America. The primary vector Rhodnius prolixus is not native and is likely to have been accidentally released from a laboratory in San Salvador. It doesn't exist in the wild, only in domestic settings and is likely to have been spread by migrant labour. 

R. prolixus can be controlled by indoor spraying of insecticide. There were dedicated eradication programmes and it is likely that similar programmes for malaria had an an effect too. Improved housing (eliminating places where R. prolixus can hide itself) has an effect. By 2011, R. prolixus surveillance in Central America had not detected any specimens for a couple of years. 

Of course, eradication of R. prolixus does not mean that Chagas has been eradicated but new cases have been drastically cut in Honduras. There is another vector Triatoma dimidiata which is endemic to Central America. Unlike R. prolixus, T. dimidiata can be found in the wild. Certain mammal species can be infected with T. cruzi and act as a reservoir but only because humans introduced Chagas to the area. T. dimidiata would be impossible to eradicate with insecticide, although biological controls might work. Even so, spraying of insectide, use of bed nets, improving housing (replacing thatched roofs with tin sheet or tiles), keeping animals out of homes reduce the risk of infection.

Blood transfusions were one source of infection but screening is now in place in all Central and South American countries where Chagas is endemic. In other countries where Chagas is not endemic, screening is increasingly common, due to migration.  Maternal transmission in the womb is also a problem. 

Treatment with benznidazole (and less commonly nifurtimox) has varying effectiveness. In infants, a 90% cure rate. It is less effective in adults.  It is more effective in the acute stage, much less so in the chronic stage - which is why early detection is so important. Even if can not totally eliminate T. cruzi, it can slow or stop its progression. Treatment is lengthy and there are often unpleasant side effects - photo-sensitivity is particularly awkward to those who work outside.

Because it can take decades for the chronic stage to manifest, even if new infections were reduced to zero, Chagas will still be a drain on health systems for many years. 

There are very limited funds for research. The emphasis is on new anti-parasitics, particularly those that are effective in the chronic stage. There are candidate vaccines at a very early stage of development. Vector control and education are still very important.

Who are Homéopathes de Terre Sans Frontières?
HTSF are not the same organisation as Homeopaths without Borders.They have no staff or volunteers in common. Nor has HTSF anything to do with Homeopaten Zonder Grenzen. HTSF. HTSF was formed around 2005-06.

The HTSF website is not very informative - it's "under construction". But -
The objective sought by HTSF is the autonomy of local communities in terms of their financial and logistical capacity, and their knowledge of integrated health. HTSF therefore works primarily on the practical transfer of homeopathic knowledge with the goal of creating sustainable development in regions and communities of developing nations. The priority of HTSF current fundraising is to achieve sustainability in Honduras where a network of homeopathic dispensaries has been set up serving 6 communities and some 10,000 people. This work has been unexpectedly and prematurely impeded by an unfair funding cut from the Canadian government.
Descriptions of their goals appear in various places. Most (if not all) of the volunteers seem to be faculty/graduates/students of Montreal Institute for Classical Homeopathy (MICH) and members of Syndicat professionnel des homéopathes du Québec (SPHQ). Most are based in Quebec. None are medically qualified.

Martine Jourde
This biography suggests that she has been involved in community projects in Africa and Latin America for some 35 years, has a background in epidemiology as well as having been a "professional homeopath" for over 40 years. This tends to be code for not medically qualified. Jourde's involvement with Honduras dates back to 1999, if she is to be believed.

Jourde claims to be president of the Agency in Research & Development and Education in Homeopathy of Quebec (company was formed in 2001). No evidence of this being anything other than her own homeopathic practice can be found. Jourde is behind Labo Solidago which produces homeopathic veterinary products. These are complexes or combination remedies - they contain multiple homeopathic ingredients. There are regulatory problems with Labo Solidago and its projects.

This document mentions Jourde and HTSF at length. Swine flu is mentioned. 

Strangely for someone who stresses research, Jourde does not seem to have published any. The closest is just a mention in the infamous Cuban leptospirosis paper (along with Isaac Golden - but the full text is behind a paywall). Jourde turned up at Nosodes 2008 and sometimes appears at other homeopathy conferences.

Although "Dr Jourde" is seen in a few places, she is not registered as a physician in Quebec. 

Carla Marcelis
Marcelis is originally from the Netherlands. It appears that she studied medicine but never started practical training. Marcelis has "qualifications" in homeopathy and naturopathy. Marcelis is "mission leader" for HTSF. From a (less than successful) fundraising page -
As a mission leader, my role is to do community development work in Honduras, to guide and train the Canadian homeopaths and homeopathic interns who are on the mission and to coordinate the logistics. The  background, training and experience required to be a mission leader, puts me among the privileged few who can do this job. I'm looking for your support to help the Honduras missions in providing sustainable health care to Hondurans. 
It is unknown whether Marcelis held (and still holds) AIDS denialist views, but she was co-author of Uncommon Questions: A Feminist Exploration of AIDS. The paper says help was given by Health Education AIDS Liaison (HEAL) - an AIDS denial group set up by the late Christine Maggiore.  Marcelis has shared a platform with the likes of Charles Geshekter (a cohort of David Rasnick who worked for Matthias Rath at one point). Honduras has the highest prevalance of HIV/AIDS in Central America.

Marcelis is listed as a tutor at MICH.

Josée Grenier
Grenier is a microbiology laboratory technician at l’hôpital Pierre Le Gardeur as well as a homeopath. Medical Technologists are regulated by l'Ordre professionnel des technologistes médicaux du Québec.  Grenier's involvement with Jourde and HTSF goes back to 2006-2007. 

Grenier penned an article that appeared in OPTMQ's magazine Le LabExpert. It is a valuable source of information.

Norbita Medina
Medina's entry on the MICH website is odd to say the least. It shows her as resident on in Montreal but she may be in Venezuela. Medina is a graduate of MICH. Her LinkedIn profile suggests that her role in HTSF's activities was considerable - Spanish language and IT set up for one thing.

The identities of the majority of the other HTSF volunteers are known but none are very interesting.

Which organisations funded HTSF?

Terre Sans Frontières
TSF has its origins in evangelical missions by the Brothers of Christian Instruction. Its current mission statement doesn't mention any religious activities. Currently, a lot of its work is associated with UNHCR (the UN refugee agency). Funding of HTSF is minor compared to their other work. TSF has a project that sends Canadian medical professionals which is funded by GAC.

TSF have deleted a lot of content related to HTSF and unfortunately not all of it has been archived. It hasn't deleted annual reports but not all seem to have been made available. Their dealings with HTSF go back to at the latest 2007/08 (see below though). TSF were funding HTSF before the GAC grant was made and they also funded HTSF with funds from other sources.

The 2014/15 report mentions an additional mission in Cuba. The 2016/17 report  -
These developments were made possible thanks to the 15 Homéopathes de Terre Sans Frontières volunteers who went to Honduras as part of the GAC program, and 10 others who became involved through the regular program.
So TSF were funding HTSF above and beyond the GAC grant.

Global Affairs Canada
There have been multiple reorganisations and re-namings of various parts of Canadian government. GAC has responsibility for diplomatic relations, consular services and international trade and development. It also provides travel information to Canadian citizens. It rates Honduras as high risk. But -
Canada and Honduras have enjoyed a positive relationship since the establishment of diplomatic relations in 1961. Canada’s largest and most important development program in the Americas America is in Honduras. It is a hallmark of the expanding scope of bilateral relations between our two nations. Underscored by the entry into force of the 2014 Canada Honduras Free Trade Agreement, trade and investment also continues to grow.
The Terre Sans Frontières (TSF - which HTSF was part of) project profile can be seen here. It reveals that the project is to run over (roughly) five years and the maximum contribution for that period is CAN $1,161,040. 25% of that figure was intended for HTSF activities.
This Volunteer Cooperation Program allows for the sending of 60 volunteer advisors, mainly dentists, optometrists and homeopaths mission. The program aims to 1) strengthen the individual capacities of local partners; 2) improve the practices of health and education professionals; and 3) improve the day-to-day practices of managers and staff of partner organizations. These health professionals will aim to help alleviate, on a volunteer basis, some of the most urgent health deficiencies among the poor, starting with children and school-aged children and their mothers, in regions lacking access to care. This will significantly increase the learning capacity, job performance and income of beneficiaries. In addition, the Canadian volunteers contribute to community management of certain health problems by promoting the establishment of fruitful and lasting collaboration between organizations from within the community and the services provided by public health institutions. The program also supports a public engagement program to form a body of Canadian citizens who are more educated, informed and engaged.
There is no mention of "pilot studies" or "research".

The project started in 2015. The application and its approval took place under the Conservative Harper administration but HTSF were active long before then.

Freedom of Information requests have been made to try get hold of application documents, internal documents relating to the decision to award of TSF grants, etc but there has been no response. It is unknown whether the application made any mention of what HTSF intended to do. It's unknown whether the decision was made by a civil servant or a politician, and if the latter what advice they were given.

Confédération des Syndicats Nationaux
CSN is the second largest confederation of trade unions in Quebec. CSN set up Alliance syndicats et tiers-monde (ASTM) in 1986. ATSM has at various points received money from predecessors to GAC, but the Harper administration cut funding, making ATSM more reliant on funding from CSN. A list of all projects reveals -
Project for the early detection, education, prophylaxis and homeopathic care of three prevalent diseases - Malaria, dengue and Chagas disease (2006)
CSN facilities have hosted SPHQ and HTSF meetings.

Homeodel are a Quebec based homeopathy manufacturer, owned by Swiss manufacturer Schmidt Nagel. They donated money to TSF more than once. Very likely that money was intended for HTSF activities. They did more than donate money.

Canadian medicines regulation is at the Federal level. Homeodel do have a site license and some of their products are licensed by Health Canada but not Jourde's complexes. Unlicensed products can be compounded on receipt of a prescription from a registered medical professional Pharmacy is regulated at the Provincial level and rules regarding pharmacy compounding vary but Homeodel is not a pharmacy and HTSF aren't registered medical professionals.

Homeodel are in breach of the Natural Health Products Regulations. A complaint was raised but  whether Health Canada will take any action is another matter.

Some HTSF volunteers have tried to not very successfully crowdfunding to support their trips. (The use of) a vehicle was donated. 

Which organisations are/were involved with HTSF?
There are other organisations that might not have donated money but certainly supported HTSF's activities.

Montreal Institute for Classical Homeopathy

MICH offers online courses in homeopathy and naturopathy. There does not seem to be any classroom training. Unlike some other homeopathy training providers it does not have a clinic where students can practice. Instead, students will practice at the premises of "mentors".

MICH qualifications aren't recognised by the larger North American homeopathy associations. Not that this matters except in Ontario, where only homeopaths registered with the College of Homeopaths of Ontario (CHO) can represents themselves homeopaths (which has lead to some rebranding themselves as Heilkunst practitioners). CHO doesn't recognise MICH qualifications. 

MICH is very closely associated with SPHQ and L’Association des Naturopathes Professionnels du Québec (ANPQ). 

Syndicat professionnel des homéopathes du Québec
This is a small organisation. It probably has around 80 members if the search facility is anything to go by. It tries to appear professional. It has a Code of Ethics but...

Quebec is a civil law jurisdiction, the rest of the Canada is made up of common law jurisdictions. The practice of medicine of any kind other than by a regulated medical professional is a criminal act there. The Collège des médecins du Québec (CMQ) has powers to initiate action against lay persons practicing medicine without a license. If harm occurs, it may be a matter for the police. Generally, Quebec tolerates unlicensed practitioners but there have been high profile prosecutions.

SPHQ is affiliated to CSN, which is odd given the illegality of lay persons practicing homeopathy in Quebec. This article on the CSN website suggests SPHQ has lost a lot of members since 2006.
"If there are people who have been fighting in Quebec for ages to protect the public against quacks, it is the 300 or so homeopaths who are members of the Quebec Professional Homeopaths Syndicate (SPHQ), grouped together in the Fédération des professionals of the CSN (FP-CSN), "said Martine Jourde, President of SPHQ.
It also demonstrates that homeopaths do not understand irony.

McGill University
The involvement of McGill staff came as a surprise. McGill is home to the National Reference Centre for Parasitology (NRCP). NRCP is part of the J.D. MacLean Centre for Tropical Diseases which is world-renown. NRCP offers diagnostic tests for tropical diseases, including Chagas. It is worth looking at the requisition formMomar N'dao is the laboratory director and has an extensive publication list.

Grenier's article tells us she was directed to N'dao by Dr. Amir Khadir. Grenier claims N'dao provided her with all the tools to perform serological diagnosis of Chagas as well as understanding of T. cruzi etc. Does this mean that equipment and supplies were donated to HTSF? Google translate mangles French but -
Some homeopathic colleagues and I, with the collaboration Scientific and Technical Center of the National Center of Reference in Parasitology have therefore developed two remedies or homeopathic nosodes from lysates of Trypanosoma cruzi. Only a laboratory at the clinical level CNRP could achieve the isolation and deactivation of strains needed for the initial phase of development nosodes, including a world first for fitness trypomastigote of the blood parasite!
Another page deleted from the TSF website stated -
Scientific collaboration agreements can be signed between the UNAH-NRCP (National Reference Centre for Parasitology of McGill University, under the direction of Dr. N’Dao) and HTSF. Honduras can become independent in the early detection, prevention and care of Chagas patients thanks to homeopathy.
UNAH is the Universidad Nacional Autónoma de Honduras. It is curious that neither McGill or UNAH make mention of such a collaboration. 

It is difficult to believe that anyone from McGill would have anything to do with homeopaths, let alone those attempting to treat/prevent Chagas with magic potions. 

What have HTSF done?

Set up
HTSF have a clinic in Valle de Angeles. They have set up an a number of dispensaries, there were seven in 2017. They travel to various villages as well.

This video explains what went on in 2017. It seems that there are "barefoot homeopaths" in these dispensaries. 

Treating patients
In most Western countries, clients of homeopaths tend present without much (if anything) wrong with them. 

HTSF volunteer Lauren Trimble's blog reveals Marcelis treating what sounds like infant respiratory distress syndrome. It gets worse. A publicly accessible list of 3556 identifiable patients was found online - a gross breach of confidentiality to say the least and in most jurisdictions it would land a practitioner in very hot water. There is a list of Jourde's combinations and what they are purported to treat/prevent it mentions Homeodel. 

Even with years of exposure to the claims of homeopaths and hubris orders of magnitude beyond their competence, this sort of thing still has the capacity to shock. 

Are patients aware that HTSF are not doctors? Do they explain to patients the nature of homeopathy? Homeopaths are not always forthcoming when it comes to explaining homeopathy. In their home countries, they often stress that it is "natural" and "has no side effects" and conveniently forget to mention that is is a form of vitalism using inert sugar pills/various liquids that contain nothing of the substance that remedies are named for. They forget to mention that there is no evidence of efficacy. It can be argued that in Western countries homeopathy vendors and practitioners depend on lack of consumer knowledge. The US Federal Trade Commission (FTC) Staff Report on the Homeopathic Medicine & Advertising Workshop points to this. Homeopathy is not well known in Honduras and access to education is an issue. It is important to remember that some of the HTSF volunteers do not speak Spanish and communication would be through an interpreter. Not to mention cultural differences. Some homeopaths have very patronising attitudes towards patients in the developing world. Informed consent would be difficult.

Preventing disease - homeoprohylaxis
Homeoprohylaxis is the erroneous belief that homeopathic remedies can prevent disease. It is homeopathic "vaccination" even if proponents go to great lengths to explain why it isn't. Phrases like "immune system education" are used. Homeoprophylaxis is a form of isotherapy. Isotherapy postulates that the exact same substance that causes disease, when shaken and diluted to the point of containing no molecules of the original substance, will cure it. It's a literal minded interpretation of "like cures like". Homeoprohylaxis takes that one step further and claims it can prevent disease. Despite the claims of homeopaths, there is no compelling evidence for it. The infamous Cuban study which homeopaths most frequently point to has been thoroughly debunked. This study demonstrated that homeoprophylaxis does not evoke an antibody response whereas vaccines do. 

The homeopathic remedies used are called "nosodes". Most of them are made from diseased tissues, exudates such as pus and in some cases actual pathogens or even vaccines.

Homeoprophylaxis is controversial even in homeopathy (but sometimes for bizarre reasons). Some homeopathy/naturopathy associations have banned members from using, others frown on it but don't seem to do anything about members offering it.

Does being vaccinated against an infectious disease change behaviour? Does it mean that recipients no longer take precautions against infection?  In some cases, yes, but there are other insect borne diseases in Honduras and precautions against those infections also protect against Chagas to a large degree.

Apparently, the volunteers use them as well.

But it's not just Chagas. Nor is it just infectious diseases. Some of the potions seem to be for prevention of cancer. 

This BBC report and subsequent follow ups had an impact in the UK. Homeoprophylaxis makes homeopathy an easy target for media stories. It's not just the implausibility though. There's the yuck factor of nosodes and also the strangeness of its proponents. When the media report on homeoprophylaxis, regulators often make statements. Health Canada have made strong statements against homeoprophylaxis but some Canadian homeopaths still offer it. Health Canada seems unwilling to take action (but that's another story).

Homeopaths are not renown for their grasp of research ethics, especially the ethics of conducting medical experiments in the developing world. The Declaration of Helsinki means nothing to homeopaths and their ilk.

Medical research carried out in the developing world can be exploitative. The standard of care in trials can be lower than in the researcher's home country. There are also concerns that lack of enforcement in host countries can be exploited. Researchers who work in academia would have to gain ethical approval from their university and depending on the nature of the research, get authorisation from their home country's medicines regulator in addition to whatever requirements that the host country has. 

HTSF and its members are not affiliated with a recognised body that could give ethical approval. It's very unlikely a body would approve such a trial but it if did, because of the nature of the trial, Health Canada approval would be required.

HTSF were conducting research into homeoprophylaxis for Chagas and possibly other tropical diseases. Translated from a now deleted document on the TSF website -
Chagas disease is caused by a microscopic blood parasite called Trypanosome Cruzi, it is one of the principal cause of death, and touches almost a quarter of the population of Central and Latin America. There is no vaccine for this plague. Early detection is difficult, analysis uncertain, and prophylaxis inexsistent. It is one of the worst attributes of poverty. In 2007, the Chagas project was born, partly funded by the ACDI and a donation from the Third World Alliance Trade Unions (CSN), and an extraordinary inter-professional collaboration between HTSF (led by Josée Grenier, microbiology technician and homeopath, and Martine Jourde, director of HTSF – Homeopathie de Terre Sans Frontieres) and Dr Momar N’dao, director of the National Center in parasitology of Mc Gill University (NCRP) at the Montreal General Hospital. The first goal was to set up a clinical laboratory allowing the detection and the transfer of analysis of Chagas disease in the targeted population from Valle de Angeles.Two homeopathic nosodes were then made by the NRCP, including one which was a world premiere. In the first phase of the pilot project, a population of over 500 people, mostly children under fifteen years and women of childbearing age were tested, received prophylaxis and training as to how to identify and avoid transmitting agents of the trypanosome, and a general homeopathic consultation.
"Pilot project" can't disguise that what went on was unethical (and possibly illegal) medical experimentation. It was research. Although it is extremely to conform to recognised standards, for practical purposes, it was a medical trial. ACDI is l'Agence Canadienne de Développement International -  French for Canadian International Development Agency (CIDA). It's now part of GAC. There is no record on the GAC online project database of the project. There's more -
Because of this success, we are putting in place the second phase of this project which is the extension of this approach to other communites at risk, where the prevalence of disease is worse than the one in Valle, especially in remote areas. Through this project, we can save and improve the health of many communities at risk, especially the young and women, in other areas of Honduras and in all the Americas. For this, we need to continue our collaboration and we invite our inter-professional to get involved.
Second phase? So the pilot project was successful and further ethical approval was granted?

Nothing in the way of a design study or results has been made public. Honduras has drastically reduced new cases of Chagas with its R. prolixus eradication programme. If results were published, of course, the reason that those in the trial did not develop Chagas disease is because of homeoprohylaxis.

HTSF claim to have set up a laboratory for the diagnosis of parasitic diseases. These kind of facilities are lacking in Honduras. Here is a photo of it -

It is possible to detect trypomastigotes in blood samples using fairly basic microscopy techniques. Their movement is easily seen if they are present in sufficient numbers. It isn't possible to detect amastigotes directly but antibodies can be detected. ELISA is the preferred technique. There are commercially available kits. Some are more sensitive than others and the costs vary, especially across different markets. Some are for research rather than diagnostic purposes. This WHO evaluation from 2010 suggests prices per test around US $1. Some currently US prices are around $3. Typically, commercial kits have 96 wells (corresponding to as many tests). It must be pointed that results can be inclusive and testing may need to be repeated. It is also worth pointing out that in infants, tests will detect maternal antibodies if the mother is infected even if the infant is not. 

Some equipment is required -
  • Refrigeration
  • Incubator
  • Microplate reader
  • PC
  • Manual or automatic equipment for rinsing wells
  • Pipettes to deliver volumes between 10 and 1000 µL
  • Vortex tube mixer
  • Disposable tubes
Ideally, tests should be carried out under Good Laboratory Practice. Some kit manufacturers are very firm on this and are selective in who they will sell to.

What would HTSF do if someone tested positive for Chagas? They would not have access to benznidazole. Would they attempt to treat it with homeopathy? 

HTSF talk about setting up a "laboratory" at UNAH to manufacture remedies but doesn't look as if any progress has been made. Such a facility and its products would need to be registered with Agencia de Regulación Sanitaria de Honduras.

Why HTSF, especially though a translator, think that they can educate the Honduran public on health matters is a mystery. From this document, something chilling -
When engaging a community, the organization starts by training the mothers for self-care and persuades the government to endorse the programs. Due to the contributing factors of illiteracy, lack of telecommunication and transportation between villages, and lack any of other forms of conventional medicine, the protocols for treatment have to be easy to use with people who have minimal education. Because many acute diseases have a sudden onset and rapidly become critical, combination remedies are necessary in order to gain time. Accordingly, HTSF has developed a kit of 12 combination remedies to address a variety of acute  situations. These first line homœopathic remedy complexes had been developed over the years from experiences in working with stock animals and then further with people. Each complex is designed to address different phases and etiologies of acute disease. HTSF then trains two people per village in a two day course to get familiar with the remedies, what is in them, and their indications for use. In different diseases, more than one combination remedy may be indicated, depending on the presenting condition. many of the combination remedies have nosodes in them, in addition to the common homœopathic remedies indicated for that particular condition (eg. Carbo-v., China, Cupr. etc. for the diarrhea remedy). HTSF has developed protocols for the treatment of rotavirus, dengue fever, hemorrhagic dengue, bacterial infections, parasitical diseases and viral infections.

Homeoprophylaxis goes hand in hand with often extreme anti-vaccination sentiment. The likes of Andrew Wakefield and Del Bigtree are now endorsing homeoprophylaxisHonduras has eliminated a number of diseases through its vaccination programme. Anti-vaccination sentiment and belief in homeopathy are strongly linked to rejection of medical treatment . Marcelis' prior involvement with AIDS denialists rings alarm bells. HTSF could have done real damage to public health in the area. 

HTSF future plans
HTSF had an Extraordinary General Meeting in April 2019. It wants to continue its activities in Honduras. It has some accumulated funds (although donors may want to claw that back if they read this article).

HTSF intends to set itself up as a Non-Governmental Organisation (NGO). They should register with both Corporations Canada and Revenu Québec as a non-profit - no sign of registrations yet. There are tax advantages for donors if a non-profit registers as a charity. Applications would need to be made to Canada Revenue Agency (CRA). It is no longer necessary for charities to register in Quebec as well.

Foreign NGOs aren't always a good thing. Some governments are taking a much firmer line with them although sometimes it is more about politics than dealing with bad NGOs. More authoritarian regimes clamp down on NGOs that are seen as subversive. In Honduras, NGOs are required to register with the Dirección de Registro y Seguimiento a las Asociaciones Civiles (DIRSAC). One criticism made of certain NGOs is that they exist more to spread the beliefs of their backers rather than deliver any public benefit.

Some homeopaths in Ontario want to set up a "chapter" of HTSF. Homeopathy is a (self) regulated profession in Ontario. It would place CHO in a difficult position.

It seems getting Health Canada to license Jourde's complexes is a priority for HTSF.  A site license is required and Labo Solidago isn't on this list. The product licensing process is complicated to say the least. 

Damage Control
HTSF isn't going to voluntarily stop its activities. It takes an incredibly rigid and delusional mindset to believe that homeopathy is of any utility to the developing world in the face of evidence. It requires an overwhelming righteousness to be oblivious to the potential harms of your actions. Pathological altruism is an apt description.

It is extremely unlikely that HTSF members will face any sanctions in Quebec. Homeopaths tend to lionise hubris and arrogance. When faced with external criticism, they close ranks. An "attack" on one, is an attack on all - and often not just homeopathy but "natural medicine" in general. Quebecois authorities are unlikely to act. The really bad things are happened outside of Quebec and they are unlikely to assert extraterritorial jursidiction.

HTSF may find funding more difficult to come by but that Western homeopaths operate in the developing world without government, trade union, etc funding suggests they might able to find some. They have generated some monies by crowdfunding but it's never very much. Volunteers can self-fund as well.

Health Canada can prevent the supply of complexes by Homeodel. They can refuse to register any of Jourde's potions. In theory, they could put Homeodel out of business.

Honduran authorities probably aren't even aware that HTSF have been active and operating illegally in Honduras but they could be made aware. Given that Honduras is going through a period of civil unrest, it is unlikely that any action would be taken but on the other hand, because of the unrest, HTSF would be foolhardy to send any volunteers there. Countries can declare foreign individuals and groups persona non grata and forbid them from entering.

A thorny question is whether there is a moral responsibility to deal with the harms caused by HTSF? If there is, who does it lay with? What should be done to remedy the situation and who pays for it?

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