A bitter pill to swallow

The sketchy evidence for the effectiveness of homoeopathic medicine has no scientific basis, and pos

There was an outcry in September when we learned that children in Scotland were being given a homoeopathic "MMR vaccine", a product that offered no protection against the serious dangers posed by measles, mumps and, for pregnant women, rubella. This had echoes of the discovery a few years ago by Sense About Science, Simon Singh and Newsnight that some pharmacists were offering homoeopathic pills for protection against malaria to people travelling to Central Africa. Such practices may be disturbing, but they occur because we tend to think there is no harm in indulging the clamour to maintain the alternative health market.

Reading the 11 October issue of the New Statesman, I was shocked by an advertisement in the accompanying supplement, "Social Care: Who Pays?", referring to me and my work. Rarely had I seen an advert so inaccurate and borderline libellous in a respected publi­cation. The advert, which appeared to breach the British Code of Advertising, was by a lobby group called Homeopathy: Medicine for the 21st Century (H:MC21). It contained unjustified attacks on myself and colleagues, including statements that gave a dangerously false impression of homoeopathy's therapeutic value.

As the advert questioned my own competence, I should address this first. I started my medical career in a homoeopathic hospital, where I was trained in homoeopathy for several months. Many years later, it became my job to apply science to this field and I felt I had a duty to keep an open mind - open but not uncritical.

A critical mind would notice that the two basic principles of homoeopathy fly in the face of science, logic and common sense. The first assumption is that "like cures like". For instance, if onions make my eyes and nose water, homoeopathic remedies derived from onions can be used to treat my patients' hay fever, which sometimes causes runny eyes and noses. The second assumption proposes that diluting remedies homoeopathically makes them not less but more potent, even if the final preparation no longer contains a single molecule of any active substance. These theories are not based on anything that remotely resembles fact. Like does not cure like, and endlessly diluting remedies certainly does not render them stronger, but weaker. But is there some entirely new energy to be discovered that we do not yet comprehend? Not understanding homoeopathy does not necessarily mean that it is useless.

The best way to find out is to determine whether homoeopathic remedies behave differently from placebos when patients use them. In other words, we need clinical trials.

Data gap

About 150 such studies (mostly conducted by homoeopaths) and well over a dozen syntheses of this research are available. Their results are sobering: the totality of the most reliable evidence fails to show that homoeopathic remedies work better than placebos. So, after about 200 years of research, there is no good data to convince non-homoeopaths that homoeopa­thic remedies are any different from pure sugar pills. Pro-homoeopathic lobby groups such as the one that placed the advertisement therefore have to employ propaganda to try to convince consumers who may not know better. This is perhaps understandable, but surely not right.

What of patients' experience, some might ask. Thousands of people across the world swear by homoeopathy. Are they all deluded? Clearly not. People undoubtedly do get better after seeing a homoeopath. There are many observational studies to show that this is true. Homoeopaths therefore keep telling us that their treatments work, regardless of the implausibility of homoeopathy's principles and the largely negative trial evidence.

When we rationally analyse this apparent contradiction of evidence versus experience, it quickly dissolves into thin air. The empathic encounter with a homoeopath is just one of many factors that provide ample explanation for the observation that patients can improve even when they receive placebos. A case in point is Bristol Homoeopathic Hospital's 2005 study, cited in the offending advert. The 6,500 chronically ill patients might have im­proved because of the concomitant use of conventional treatments, or because of the attention they experienced, or because of their own expectation to improve, or because the disease process had come to an end. In fact, they might have improved not because of, but despite, the homoeopathic remedies they were given.

Still, some people ask what is wrong with using placebos as long as they help patients feel better. The answer is that it prevents clinicians telling the truth to patients. Being honest would defeat any placebo effect: if I tell my patient, "Take this remedy; it contains nothing and the trial data shows nothing," she is unlikely to experience a placebo response. Hence, homoeopaths, knowingly or unknowingly, deprive patients of informed consent. This paternalistic approach is recognised as unethical. Also, placebo effects are unreliable and normally short-lived; they happen occasionally but often do not. Even if placebo responses are generated, they are usually small - certainly too small to compete with effective therapies.

Twin-track effect

Endorsing homoeopathic placebos would mean that people might use them for serious, treatable conditions. In such circumstances, homoeopathy can even cause (and has caused) the death of patients. Furthermore, if we allow the homoeopathic industry to sell placebos, we must do the same for "Big Pharma". Imagine a world where pharmaceutical companies could sell us placebos for all sorts of conditions just because some patients experience benefits through a placebo response.

Crucially, and paradoxically, we don't need placebos to generate placebo effects. If I, for instance, prescribe an antihistamine for a patient suffering from hay fever, with empathy, time and understanding, that patient benefits from a placebo effect as well as the pharmacological action of the antihistamine. If, by contrast, I prescribe a homoeopathic remedy, I deprive her of the latter, crucial benefit. It is difficult to argue, as most homoeopaths try to, that this approach would be in the interest of my patient.

What follows is straightforward: there is no good evidence that homoeopathy does more good than harm. This is not just my conclusion after 17 years of researching the subject, but a fact based on the best available evidence, which is supported by virtually all experts who are not homoeopaths. The recent decision by the coalition government to continue homoeopathy on the NHS is thus puzzling, to say the least.
The advertisement that prompted this article is misleading about the work of experts which has conclusively shown that homoeopathy can have no place in evidence-based medicine. It is an insult to our intelligence.

Edzard Ernst is professor of complementary medicine at the Peninsula Medical School, University of Exeter, and co-author, with Simon Singh, of "Trick or Treatment? Alternative Medicine on Trial" (Corgi, £8.99)

Here comes the non-science

Homoeopathy was developed in 1796 by the German physician Samuel Hahnemann. He based his treatments on the twin ideas that "like cures like" and "less is more". The latter notion was implemented by taking a substance and diluting it over and over again, so that the final product generally contains not a single molecule of the original active ingredient.

Homoeopaths accept that most of their remedies are devoid of pharmacologically active principles, but they argue that the pills contain a "memory" of the original ingredient. The memory is supposedly imprinted in the diluting agent, which is used to moisten sugar pills.

Although homoeopathy defies the laws of physics, chemistry, biology and therapeutics, there have been numerous attempts to test its impact on patients through clinical trials. In 2005, Aijing Shang and seven colleagues from the University of Berne published an analysis of the best trials in the Lancet.

Their findings confirmed many other such published assessments. Commenting on the paper, they wrote: "This finding is compatible with the notion that the clinical effects of homoeopathy are placebo effects." An accompanying editorial entitled "The end of homoeopathy" said: "Doctors need to be bold and honest with their patients about homoeopathy's lack of benefit."

This article first appeared in the 08 November 2010 issue of the New Statesman, Israel divided

Chris McGrath/Getty Images
Show Hide image

Fight to the death in Mosul

The street-by-street battle against Islamic State for control of Iraq’s second city.

The men of Iraq’s special forces map their victories over Islamic State (IS) by tracing the scars on their bodies. “These four bullets were from a sniper in Ramadi,” said one soldier, lifting his shirt to show a pockmarked torso. A gap-toothed gunner called Ahmad turned a wrist and revealed his wound, a souvenir from Fallujah. Their commander’s close-cropped hair has deep furrows, the result of a rocket-propelled grenade (RPG) attack in the same city.

Both Ramadi and Fallujah were retaken from IS this year, which restored the confidence of the Iraqi military after its humiliating retreat from the terror group. Two years ago, the Iraqi army ran from Mosul and a caliphate was declared. Now, the soldiers’ task is to build on their recent gains and liberate the country’s second-largest city.

At the tip of the spear in Mosul is the Iraqi Special Operations Forces’ 1st Brigade, also known as the Golden Division. It is commanded by Major Salam al-Abeidi, the man who survived the RPG attack in Fallujah and led the offensive against IS in Ramadi. He is a compact figure, a black streak of ­motion in his special forces uniform, never at rest. (“He would exhaust 20 soldiers,” said one of his men.) He prefers to be on the offensive. “It’s when we are in defensive positions that we take the most casualties,” he told me.

Al-Abeidi does not smile much, but he enjoys a joke. In his hands is always one of three things: a walkie-talkie, a can of Red Bull, or a cigarette. His seven-month-old German shepherd, named Caesar, has recently joined him at the special forces headquarters. Most of his men, fearless when fighting IS, are terrified of the puppy.

The major leads from the front. In the morning, he is on patrol; in the afternoon, he is on the roof guiding air strikes. One evening, I found him climbing into a tank, heading out to defend a road. “Do you ever sleep?” I asked.

“Sleep? I drink 20 cans of this a day,” he joked, holding up the energy drink.

The Golden Division is making slow but steady progress through the eastern residential neighbourhoods of Mosul. This city is different from the ones in his previous campaigns, the major told me.

“Most of the areas we fought in while in Ramadi were nearly empty of residents,” he said. “Here, it’s heavily populated, making the security forces very cautious while advancing, so as to avoid civilian casualties. The enemy uses a lot of car bombs.”

The Zahra (formerly known as Saddam) and Qadisiya 1 districts of eastern Mosul are the battlegrounds of the moment. IS has blocked the streets with concrete barriers to impede the Iraqi military advance, and the Iraqi army has constructed earthen berms with the aim of slowing down the IS car bombers. The gunfire is constant; so, too, are the boom and thud of suicide attacks and coalition air strikes.

“Here come the French,” said al-Abeidi, as fighter aircraft roared overhead while another explosion shook the eucalyptus and citrus trees of the neighbourhood’s gardens.

On the front line, a four-lane road separates the Golden Division’s Bravo Company from IS. On the lookout in an abandoned house, a young sniper named Abbas pointed out a dead IS fighter lying a few hundred metres away. “Over the last four days, I killed three Da’esh [the Arabic acronym for IS]. But my buddy, he killed four or five,” he said.

A car bomb detonated nearby, the shock wave blowing out what was left of the room’s windows. A French photographer accompanying us, who had refused to wear a helmet, almost dropped his cigarette.

Abbas fired into IS territory, a precaution in case the car bomb was followed by attackers on foot. He continued: “Here, the difficult thing for us is that IS fighters carry babies in their arms, and all of them look the same – they have beards.”

Outside, it looked and smelled like a war zone. Shops had been destroyed and I saw a burnt-out suicide truck that had crashed into a storefront. The street was littered with the remnants of another car bomb.

Car bombs are the IS equivalent of cruise missiles. The militants have no aircraft, so they rig up and deploy these heavily armoured high explosives on wheels instead. The unit I was with had at least two a day aimed at it. They move fast and are often hidden, lying in wait. Only when the military think that a neighbourhood is clear do they appear, driven at speed and often with deadly precision.

None of the forces fighting IS – the Iraqi army, the Kurdish peshmerga, the Shia militias – releases casualty numbers. If any ever does, these will show that many of their men were killed by car bombs.

To avoid the militants’ RPGs and sniper fire, Bravo Company created rat runs through homes and backyards. My guide to the front line was called Sergeant Haider. Rooms and upturned domestic life flashed past us. The sergeant’s Frank Zappa moustache and wraparound shades were complemented by a grey knitted beanie. He looked like he should have been snowboarding, not touring a front line.

“There are many more Da’esh here than in Anbar,” he said, referring to the province where Fallujah and Ramadi are situated. “Because this area has been under its control for two and a half years, Da’esh has really taken control. This looks like just the beginning of [retaking] Mosul.”

Iraq’s prime minister, Haider al-Abadi, wants Mosul “liberated” by the end of the year. That is unlikely to happen. It will take a month at least, perhaps more, to make it to the banks of the Tigris, which runs through the city. And IS is concentrated in the west. Across the river, there is worse to come.

***

The scar that Rana Ibrahim Hamad carries is not visible. It is a memory of the baby she lost shortly after giving birth during IS rule. “I lost the baby because doctors were not available. The baby had a brain haemorrhage and died,” she told me, standing on the street. We could hear the sounds of a gun battle nearby but Rana didn’t blink – she had grown used to it.

It was the first time that she, her husband, Amer, and their three-year-old daughter, Azel, had left their home in five days. Until then, the fighting around them had been too fierce.

Rana was pregnant again and ready to give birth any day. After detailed questioning by the military, the family would be allowed to leave for a hospital in Erbil. An armoured Humvee would be their ambulance.

She told me that she hoped that having the new child would help her forget her loss. “Life is difficult,” she said. “We all live in fear. Pain is coming from fear. I pray it gets better.”

In October, I flew over Mosul with the Iraqi air force. It was not on a combat run, but on a propaganda mission. Under a bomber’s moon – full and bright – the planes dropped leaflets by the million, sometimes still in their cardboard boxes, from the side doors of a C-130 cargo plane. Below, the land was lit up, roads and buildings illuminated and stretching for miles in the dark. From 17,000 feet, Mosul didn’t look like a city under occupation. It looked alive.

Later, in its industrial suburbs, I found a few of the leaflets in the dirt. Some, at least, had found their target.

“Nineveh, we are coming,” they proclaimed, a promise to Mosul and the surrounding province. They encouraged people to stay away from IS buildings. And the Iraqi government told people not to flee. It feared that there would be a humanitarian crisis if the city, which has more than a million residents, were to empty.

As Mosul’s fight enters its second month, however, services are still largely absent. “The army brought us food and lentils but there’s no government,” said Bushra, a woman from the city of Tikrit who is now trapped in Mosul. “We are living, but [we have] no water or electricity. We sleep at eight. We don’t have any services. I didn’t get my husband’s salary this month. We live off his pension.”

As the men of the Golden Division move through houses and parts of the city, they find more than just IS dead, weapons and supplies. They also discover records of rule. Although the group is cruel and murderous, it keeps tidy books and distributes welfare. We found dozens of the militants’ ledgers, recording payments made to widows, the poor and the sick.

***

Across Iraq, senior military and police commanders complain that Baghdad is not moving fast enough to fill the gaps left by the fighting, and that although they distribute water, food and medicine to local people, their men must come first.

In the war against IS, no city has been bombed more than Mosul. The coalition air strikes come day and night. The only let-up is during bad weather, which also results in ground operations being paused.

According to some monitoring groups, as many as 1,300 civilians have been killed in coalition air strikes so far. Yet it is Islamic State that is doing most of the killing, through executions and sniper and mortar attacks. The militants have murdered and continue to murder hundreds of people inside the city each week.

During one patrol, an IS sniper pinned down the unit I was with inside a house. One by one, the soldiers ran to their armoured vehicles – me among them – and to safety. The bangs sounded especially loud. We soon discovered why. The marksman was firing armour-piercing bullets. One managed to penetrate the turret of a Humvee and the gunner inside it was wounded.

Mosul, the beautiful, once-cosmopolitan centre of northern Iraq, became a mystery under IS. The fighters cut off its contact with the outside world. At the edge of the city, I walked through a former IS workshop. There, between 20 and 30 men had cast and milled mortar shells every day. Thousands of the steel casts remained in piles, waiting to be finished. The roof of the foundry had been peppered with shrapnel. IS had tried to conceal the factory from passing aircraft by burning oil fires through the roof.

It struck me then that the militants had spent their two years in Mosul with one priority in mind: preparing for this battle. Who knew how many mortar shells, filled with explosives, were now inside the city, ready to be fired? This was weapons production on an industrial scale.

“Isis was scared shitless of the Iraqi soldiers. Believe me, we saw. They pissed their pants,” said Alaa, an English teacher who lives near the front line. White flags were hanging from homes along the street. He described to me the past few days of fighting and how the Iraqi special forces had ­arrived in his neighbourhood.

“Now I feel safe, because they are here,” he said. “And if they need any support, all these people will be with them. Even the people who were influenced by the Isis talk, now they are not, because they endured two years of suffering, two years of depravation, two years of killing, mass killing.”

At the mosque across the street from Alaa’s house, males over the age of 13 were being lined up for security screening, to see if they were IS supporters. The soldiers kept their distance, fearful of suicide bombers. The local people carried their identification papers. Some had shaved off their beards but others had not. They did not share Alaa’s optimism, and said they were afraid that IS could return.

***

Safar Khalil’s wound had no time to heal and become a scar. The bright red hole in his chest came from an IS sniper round, his brothers said. A medic tried to plug it with his finger and stabilise him but the damage inside was too great. Safar’s lungs were gone.

He spewed out dark, thick blood. His face was covered in it. And there, in front of me, he died.

Two of his brothers – one a small boy, the other a young man – stood screaming nearby. They had left their home only a few moments earlier to sell eggs. An army sleeping bag was brought to cover Safar’s face. At first, I thought he was a teenager, because the blood and gore made it difficult to tell how old he was. On his right hand, he wore a heavy ring with an amber stone. Afterwards, I learned that he was 26.

They took his body on a cart back to his home. From inside the house, grief exploded. The women, his relatives, tried to run out, fear and rage written on their faces. But it seemed that the sniper was still nearby, so they were pushed back inside and a family member pulled hard on the metal door to keep them contained.

The women’s voices filled the neigh­bourhood. In the middle of the street, looking horribly alone, Safar’s body lay on the cart. It was not yet safe enough to take him to the cemetery.

There are other fronts in the war to retake Mosul: the federal police and army are moving in from the south and may soon retake what is left of the city’s airport. To the west, the Shia militias of Iraq’s Popular Mobilisation Forces have cut off escape routes to Raqqa in Syria and are on top of the IS stronghold of Tal Afar. In the north, several towns and villages have been taken by the Iraqi army’s 16th Division and the Kurdish peshmerga.

But it is in the east that Mosul proper is being cleared of IS militants. Major al-Abeidi’s convoy was hit again the other day. He sent me pictures of his badly damaged Humvee and complained that he had lost the car and spilled his energy drink.

“We’ll be at the river in weeks,” he said confidently. Until then, eastern Mosul and its people will remain in the maelstrom – surviving not in a city, but on a battlefield.

Quentin Sommerville is the BBC’s Middle East correspondent

This article first appeared in the 24 November 2016 issue of the New Statesman, Blair: out of exile