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

LOUISA GOULIAMAKI/AFP/GETTY IMAGES
Show Hide image

How Vladimir Putin lost Ukraine

Putin’s war cost Russia its centuries-long shared identity with its neighbour. Now, Kyiv risks betraying the spirit of the Maidan revolution.

When the Russian inquest finally comes, the answer will be clear. It was President Vladimir Putin who lost Ukraine – after a millennium of shared east Slav identity. When the Ukrainian inquest into who lost the ­Euromaidan’s “Revolution of Dignity” finally comes, the answer, on the present evidence, will also be clear. It was an elite core of politicians and oligarchs who first worked a miracle in fighting Russia’s military Goliath to a stalemate – only to revert to kleptocratic business as usual when the acute threat eased.

Ukrainians’ consolidation of a distinct national identity after centuries of being regarded as a fuzzy subset of the dominant Russians – and after a quarter-century of independence – began in February 2014. It sounds banal to say that when one nation attacks a neighbour, especially if the two have regarded each other as brothers for a thousand years, the victims feel aggrieved and pull together against the attacker. But this is what happened when Putin launched his undeclared war on Ukraine, sent hooded “little green men” to take over Crimea’s regional parliament by intimidation, and then annexed the peninsula. The mutation of this early tactical success into strategic failure is best traced by reviewing the players and the dynamics as Ukraine held off Russia and crystallised its singular new identity.

On the Russian side only one actor matters: Putin. When the old Soviet Union split apart in 1991, its kleptocracy was replicated in its two biggest east Slav successor states. By 2015 Russia ranked a joint 119th out of 167 countries on Transparency International’s Corruption Perceptions Index. Ukraine was 130th. A Wild East capitalism prevailed, in which emergent oligarchs carved up the state’s wealth through murky privatisation deals. But there was one main political difference between the two countries. Putin quickly restored the primacy of politicians over Russian tycoons after he became president. In Ukraine, oligarchs were able to use their new wealth to dominate politics.

When Putin suddenly broke out from Europe’s seven-decade peace order in February 2014, Western policymakers asked the diminished number of Kremlinologists in their midst why he was acting this way. Some, such as Dmitry Gorenburg, an associate at Harvard’s Davis Centre for Russian and Eurasian Studies and a military analyst, pointed to fear as the Russian president’s root instinct. Putin has shown little interest in economics; he has not worried about looming inflation or capital flight, or Russia’s distorting reliance on oil and gas revenues. What he was afraid of, it seemed, was unchecked democratic contagion: as transmitted from Poles in the 1980s to restive East Germans and then Czechs in 1989, to Ukrainians in the mid-2000s, and even on to Muscovites in 2011/12 before Putin managed to stop their street protests.

This analysis is plausible. In 1989, as a young officer of the Soviet Committee for State Security, Putin was serving with the KGB’s Dresden outpost. He saw the Berlin Wall fall – overnight, under the press of East Berliners who mistakenly thought it had been officially opened. He later faulted the then Soviet Communist Party chief, Mikhail Gorbachev, for failing to intervene militarily when the wall crumbled, or when protesters stormed the Stasi headquarters across the street from his office to halt the incineration of incriminating files by East Germany’s adjunct of the KGB. He watched Moscow’s 20 top divisions, which encircled Berlin for half a century after the glorious Soviet victory over Hitler in 1945, retreat ingloriously a thousand miles to the east.

Putin further witnessed the swift break­away of Moscow’s external empire, in the stampede of the freed central Europeans, from Estonia to Romania, to join the European Union and Nato, and the 1991 break-up of Moscow’s internal Soviet empire. He called the collapse of the Soviet Union the “greatest geopolitical catastrophe” of the 20th century. And as late as 2008 – 17 years after more than 92 per cent of Ukrainian citizens, including the 21 per cent ethnic Russian minority, had voted for independence – he told President George W Bush, “You have to understand, George, that Ukraine is not even a country.”

***

Most agonising of all, in his first term as Russia’s president in the 21st century, Putin had to listen to American triumphalism about the series of pro-democracy “colour revolutions” in the streets of ex-communist Serbia in 2000, Georgia in 2003 and Ukraine in 2004. For him, as a career secret policeman, these revolutions represented no broad social yearning for “dignity”, as the Polish Solidarity leader Lech Walesa first phrased it. Rather, it was an inexplicable victory by American CIA manipulations – in what was Moscow’s own sphere of influence, by right – over the manipulations of Russia’s FSB, successor to the Soviet KGB.

The uprising that aroused the most angst in the Kremlin was the Orange Revolution on Kyiv’s main square, or maidan, where protesters demanded and won a repeat of the 2004 election after blatant vote-rigging in favour of the then prime minister, Viktor Yanukovych, the pro-Russian heir apparent to the Ukrainian presidency. It was bad enough for Moscow when the west Slavs in Poland and Czechoslovakia instantly ditched their Slavic identity for a European one in the 1990s: Poland uprooted systemic corruption, built robust democratic and judicial institutions, and went from having a poverty rate that matched Ukraine’s to a per capita GDP three times the size of its neighbour’s today. It was devastating when the Little Russians, too, began to do so, rejecting Yanukovych and Russia’s network of control in the rerun of the vote in 2004.

In the event, Putin need not have worried. The Orange Revolution self-destructed in the fratricide between its two top leaders, who forfeited leadership to Yanukovych in the reasonably fair 2010 election.

On the Ukrainian side of the 2014 Euromaidan revolution, four figures stand out. The two chief rivals are the Ukrainian president, Petro Poroshenko (worth $979m, and number six on Novoye Vremya magazine’s 2015 list of the richest Ukrainians), and the then governor of Dnipropet­rovsk in central Ukraine, Ihor Kolomoyskyi (number two on the list, at $1.9bn).

Poroshenko was a second-tier oligarch who had served briefly as foreign minister in the Orange Revolution government and as minister for trade and economic development under Yanukovych in 2012. He helped fund the pro-Europe, anti-corruption protest against Yanukovych’s authoritarian rule from the movement’s spontaneous inception in November 2013, and his TV news outlet Channel 5 gave full coverage to the three-month agora and its estimated one million participants.

After Yanukovych finally sent his special police to suppress the protest by killing dozens of the demonstrators in late February, the Ukrainian president’s own Party of Regions deserted him. He absconded to Russia overnight with an estimated personal fortune of $12bn, amassed in four years in office. Parliament, by a majority that suddenly included the Party of Regions, appointed an interim president and government and set presidential elections for May 2014. The “Chocolate King”, as Poroshenko was nicknamed for his confectionery empire, was duly elected president of the new Ukraine with a 54 per cent majority.

Kolomoyskyi, who also holds Israeli and Cypriot citizenship, was called back to Ukraine from his Swiss residence by the improvised government just as Russia was annexing Crimea. He was appointed governor of his own regional stronghold of Dnipropetrovsk with a mandate to mount a defence against the Russia-stoked secession brewing in neighbouring eastern Ukraine. Kolomoyskyi was famed for his hostile takeovers of rival banks as well as oil, media and other firms. He quickly raised and underwrote several militias among the 40 to 50 volunteer battalions that sprang up to fight against westward spread of the start-up separatist Donetsk (DPR) and Luhansk (LPR) People’s Republics. These battalions were instrumental in holding the line against separatist/Russian forces and giving the Ukrainian state time to rebuild the army that Yanukovych had bled of its budget.

Two oligarchs who did not cast their lot in with post-Euromaidan Ukraine were Rinat Akhmetov (at $4.5bn still the richest Ukrainian, even after losing more than half of his wealth over the past year) and Dmytro Firtash, whose net worth has fallen to $1bn. Both had been leading supporters of Yanukovych and his party, and since his departure they have hedged their bets between Kyiv and Moscow. Their recent losses have resulted partly from a redistribution of their wealth to other oligarchs.

Akhmetov, the son of a coal miner who rose to become the “godfather” of the Donetsk clan – and the owner of Shakhtar Donetsk football club – has his coal and iron base in the war-ravaged Don Basin (Donbas) and relies on Moscow’s goodwill there. Firtash, who under President Yanukovych controlled the lucrative distribution of Russian gas through Ukrainian pipelines to Europe, is also dependent on Russia. In spring 2014, he asked the Russian oligarch Vasily Anisimov to pay a record Austrian bail of €125m ($141m) in cash to get him out of jail. Under the bail terms, Firtash is barred from leaving Austria as he awaits the final legal decision on a US extradition request on charges of international bribery. Yet from Vienna he still wields his political clout, funds several Ukrainian parties across the political spectrum and, it is widely reported, brokered a division of power between Poroshenko and Vitaly Klitschko in the run-up to the May 2014 presidential election, in which Klitschko stood down as a candidate. (The former world heavyweight boxing champion is now mayor of Kyiv.)

***

Putin no doubt saw his annexation of Crimea – and his follow-on campaign to reconquer Catherine the Great’s “Novorossiya”, comprising the eastern 40 per cent of today’s Ukraine – as compensation for the abrupt downfall of his acolyte Yanukovych, and thus the end of Russia’s rightful suzerainty over all of Ukraine. Europeans, Americans and Ukrainians, on the contrary, saw the first formal takeover of a neighbour’s land in Europe since the Second World War as Putin’s return to a 19th-century concept of “might makes right”, as well as a violation of international law and treaties Moscow had signed to respect Ukrainian borders.

The West was cautious in reacting. It baulked at getting sucked into another intervention in a theatre of complicated logistics and little geopolitical interest. It knew as well as Putin did that Moscow enjoys escalation dominance in its home region by virtue of geography, its claim to a vital interest in Ukraine that the West lacks, and the Russian president’s willpower in a world of European peace and US exhaustion. It had no desire to put Putin’s repeated brandishing of his nuclear weapons to the test over a second-order confrontation. The West therefore responded by imposing financial rather than military sanctions, which Putin prematurely scorned as a pinprick.

In addition, Putin misread Ukraine’s military resilience. Easy success in Crimea – and strong domestic approval of his boasts that he was restoring Russia’s greatness in the world – emboldened him to probe further in eastern Ukraine. Ukraine’s ragtag army had put up no resistance in Crimea, for three reasons. First, years of embezzlement of defence budgets had left it with only 6,000 combat-ready soldiers and with two-decade-old weapons. Second, it was subverted by the many Ukrainian officers who were loyal to Moscow rather than Kyiv. Finally, there was Ukrainians’ sheer disbelief – despite Stalin’s mass starvation of Ukrainian peasants in the 1930s – that Russians would actually shoot at their proclaimed younger brothers.

Putin expected an equally cost-free operation in the Donbas. He seemed to believe his own propaganda that disgruntled Russian-speaking citizens of eastern Ukraine were Russians manqués and would rush to rebel against Kyiv, if only the charge were led by a few Russian commandos. Eastern Ukraine was, after all, the part of the country in which identity was most blurred; easterners paid little attention to differences between Ukrainians and Russians in everyday life, and most had cousins in both Russia and western Ukraine. In a way, the region was the ideal test of Putin’s construct of a unifying goal to fill the vacuum left after futurist communist ideology evaporated. The campaign was first presented as Putin’s dream of a Eurasian Union, but that was dropped once it became clear that Ukraine would not be a part of it. Thereafter it was repackaged as gathering in fellow ethnics left outside the “Russian world” by the Soviet collapse, and then as retaking the tsarist Novorossiya.

At first, the Russian-backed secessionists took quick control over roughly two-thirds of the Donetsk and Luhansk oblasts, or provinces. Putin, however, overestimated the warrior zeal of the easterners and the usual gripes of any province about the meagre payouts it gets from central government. In the early days, the local people warmed to the promises of higher pensions made by the separatists. And grandmothers visibly enjoyed acting as civilian shields by surrounding local administration buildings that were occupied by separatists and preventing Ukrainian soldiers from reclaiming the offices. But as the novelty wore off and the hardship of war increased, Moscow and the secessionists it sponsored increasingly had to rely on a motley band of mercenaries and Donbas criminal gangs that did well in firefights only when they were assisted by Russian “volunteers” and armed with the heavy weapons the Russians were shuttling across the border.

In purely military terms, Putin probably could have escalated in the spring of 2014 from the kind of limited, disguised and therefore deniable warfare that the West calls “hybrid”, replacing the hooded “little green men” with regular Russian soldiers in marked uniforms in an all-out invasion of the Novorossiya oblasts. That was certainly the Russian president’s threat in massing 80,000 troops on the northern, eastern and southern borders of Ukraine and exercising them on high alert.

As late as September 2014 Putin boasted to President Poroshenko that if he so desired, “Russian troops could be in Kyiv within two days – and also in Riga, Vilnius, Tallinn, Warsaw, or Bucharest.” But he did not invade when Ukraine’s provisional government was still shaky – and still reeling under the Russian show of force.

Three reasons for Putin’s decision not to order an invasion in spring 2014 might be inferred. The first was a tactical reduction of his bellicosity at a time when the European Union was still debating financial sanctions on Russia for annexing Crimea. The second was the weakness of the novice Ukrainian government, which could foreseeably have collapsed and left Kyiv with a political vacuum the Russians could fill without firing a shot. The third was perhaps a premonition in the Russian army that it was being overstretched and that an occupation of its neighbour, given Ukraine’s strong military tradition, might turn into a quagmire of messy guerrilla warfare.

Putin’s military threats to Ukraine were counterproductive and stoked Ukrainian anger. In May 2014 a Pew survey found that 77 per cent of Ukrainians, including 70 per cent of those living in eastern Ukraine outside the Donbas war zone, thought that their country should remain united instead of breaking up. And in early July, even before the shooting down of the Malaysian Airlines MH17 civilian jet by a Russian-made Buk missile fired from insurgent territory, Pew reported that 60 per cent of Ukrainians had a general negative view of Russia. It was a sharp reversal from 2011, when 84 per cent of Ukrainians had viewed Russia positively.

The Euromaidan spirit drew in ever more Ukrainians who had been politically passive. Volunteers flocked to enlist in the army, in the revived National Guard and in the private militias raised and paid for by Kolomoyskyi and other oligarchs. Civilian volunteers cooked and delivered food to recruits. Techies designed and built their own surveillance drones from scratch to observe border areas that Ukraine no longer controlled.

Ukrainian veterans who had once formed the backbone of the Soviet army’s rough equivalent of Western non-commissioned officers, together with local Afgantsy – veterans of the Soviet army’s doomed expedition in Afghanistan in the 1980s – gave the rookies accelerated basic training. Weapons factories in Ukraine that had once supplied the Soviet army managed to repair 20-year-old tanks and build new ones even as the battles raged. And morale was vastly better on the side of Ukrainian defenders against a threat to their very existence than it was among opportunistic rebel mercenaries and criminal gangs. By mid-August 2014, Ukrainian troops had recaptured most of the rebel territory and reduced the Donetsk and Luhansk People’s Republics to two small pockets.

That was too much for Putin. At the end of August, he signalled his red line in the sand: he would not let his proxies be defeated. He sent elite airborne troops into the Donbas to mount a counteroffensive alongside separatist/Russian ground forces armed with Russian heavy weapons. Within days, they broke the Ukrainian siege and restored the secessionists’ control of about half of the territory that the DPR and LPR had ruled at their height.

President Poroshenko understood the message and immediately proposed a truce, and the German chancellor, Angela Merkel, brokered the Minsk ceasefire of 5 September. The shaky agreement at least reduced the scale of violence for five months, until the separatist/Russian forces made a fresh effort to break through strengthened Ukrainian lines in January and February of 2015 – and failed. A further shaky “Minsk-2” truce followed. But on 1 September 2015 the heavy guns abruptly fell silent and, for the most part, remained silent. For the first time in a year, overjoyed babushkas in the separatist Donbas enclave could walk across the front lines to reach Ukrainian-held towns seven kilometres away and buy salo (pork rind), butter and eggs at far cheaper prices. They returned to tell journalists that their greatest wish was simply for the fighting to stop.

***

At the end of September Putin opened a front in Syria, and reportedly redeployed some special forces from Ukraine to the new battlefield. Ukraine dropped off Russian TV bulletins. The war there had
caused 8,000 deaths and forced 2.4 million people from their homes. It was clear that Putin was belatedly acknowledging that the war also had strategic costs for Russia.

He had first lost all of Ukraine, with the exception of Crimea, to the Euromaidan that he despised. He had failed to salvage Novorossiya for Russia. He had failed, too, to maintain the shelled and charred Donbas region in any form he wanted to annex or subsidise – and keeping it as a zone of frozen conflict for future mischief-making wasn’t much of a consolation prize. He had provoked the West into resuscitating Nato and imposing sanctions that damaged the Russian economy. He had alarmed Belarus, Kazakhstan and Turkmenistan into distancing themselves somewhat from Moscow.

Moreover, the Russian war in Ukraine raised the spectre of the failed Soviet invasion of Afghanistan that killed 15,000 Soviet soldiers in the 1980s and gave birth to the Russian Committee of Soldiers’ Mothers, which tries to ferret out facts about their dead sons. Last May, after many inquiries by the committee about Russian casualties in Ukraine, the Duma passed legislation banning the spread of information about Russian casualties across the border. In this context, it seemed unlikely that Putin would risk incurring a rise in Russian deaths by resuming heavy fighting in Ukraine.

This appraisal, however, takes the pressure off the Ukrainian oligarchs to grow beyond the robber-baron stage and become patriotic philanthropists. On the present evidence, they no longer sense much urgency with regard to implementing reform legislation, installing the rule of law, building democratic institutions and rooting out kleptocracy as opposed to exploiting it.

Putin has surely lost Ukraine. The Ukrainian oligarchs have not yet surely lost their own country. But how ironic it will be if he manages to melt their urgency into complacency by easing the pressure on Ukraine, thus paving the way for that final loss of the Revolution of Dignity. It would give the last laugh to Georgy Arbatov, the Kremlin’s leading Americanist who prophesied as the Cold War ended: “We are going to do to you the worst thing we possibly could – we are going to take your enemy away.”

Elizabeth Pond is based in Berlin and is the author of several books about Germany, Europe and the Balkans. They include “Beyond the Wall: Germany’s Road to Unification” (Brookings Institution)

This article first appeared in the 05 February 2015 issue of the New Statesman, Putin's war