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

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Why Isis seeks a battle with Western nations - and why it can't be ignored

Islamic State believes it must eventually confront and then defeat the West. To get there, it seeks to polarise Muslim and non-Muslim communities alike.

It was precisely the type of attack that had long been feared: a co-ordinated and brutal act of urban warfare that brought Paris to a standstill for more than three hours on an otherwise typical Friday night. Six of the nine attackers had spent time fighting for Islamic State in Syria. Indeed, it was the third act of international terrorism perpetrated by IS in a fortnight, a campaign that started with the bombing of a Russian Metrojet flight over Sinai in Egypt, followed by a double suicide bombing in Beirut that killed 41 people – the deadliest attack in the Lebanese capital since the civil war there ended in 1990.

There are several significant operational observations to be made about what transpired in Paris. The attackers wore suicide belts in which the active ingredient was TATP, a highly unstable explosive based on acetone and hydrogen peroxide. TATP was also used in July 2005 when the London transport network was attacked. Known as the “mother of Satan” because of its volatility, it is usually manufactured at home and it is prone to accidental detonation – or, indeed, sometimes fails to detonate at all.

When two weeks after the July 2005 attacks four bombers attempted to replicate the carnage, their bombs failed to explode precisely because they had not been manufactured properly. The same was true for Richard Reid, the “Shoe Bomber”, and Umar Farouk Abdulmutallab, the “Underwear Bomber”, who smuggled TATP explosives on to American aircraft in 2001 and 2009, respectively.

Perhaps the most worrying aspect of the Paris attacks is that every device proved to be viable – a reality born of the permissive environment in Syria and Iraq. A new generation of terrorists is now able to learn and rehearse the skills required to build devices that detonate successfully. The skills come with experience, and the newly ungoverned spaces of the Levant provide an ideal training ground.

Yet, for all the viability of the TATP devices used in Paris, the greatest loss of life came from assault rifles. This demonstrates how relatively unsophisticated tactics can still achieve mass casualties for terrorists determined to kill as many people as possible. The threat is particularly acute in mainland Europe, where automatic weapons move easily across the Continent, typically originating from criminal gangs in eastern Europe. Smuggling them into Britain is harder because the Channel limits the number of potential entry points.

The added protection resulting from Britain being an island is often overlooked. Just as guns are able to move more freely across the Continent, so, too, can people. This was brought into sharp relief when Imran Khawaja, a British man from west London who joined Islamic State in January 2014, attempted to re-enter the UK.

Khawaja had been particularly cunning. He hoped to slip back into Britain by evading the authorities after faking his own death in Syria, a plan his compatriots facilitated by eulogising and glorifying him. He then made his way across Europe by land, passing through several European countries before being arrested on arrival at Dover. None of this is to suggest that Britain does not face a very serious threat from Islamic State terrorism (it does), but the risks here are diminished compared to the threat facing countries in mainland Europe.


Trying to understand the strategic rationale behind Islamic State’s attacks outside Syria and Iraq is daunting. A degree of conjecture is required, although information gleaned from its communiqués, statements, and behaviour can go some way towards
informing a judgement.

It may seem obvious to observe that IS sees itself primarily as a state, yet this is worth restating, because other jihadist groups have made claims to statehood while continuing to act as terrorists or insurgents, tacitly recognising the nonsense of their own position. Not so Islamic State. It truly believes it has achieved the Sunni ideal of a caliphate and it acts accordingly.

This was the thinking that led the group to break from al-Qaeda, rebuffing Ayman al-Zawahiri’s position as the group’s emir. From Islamic State’s perspective, countries are not subservient to individuals. The significance of this self-belief became apparent last summer when the US began dropping aid parcels to stranded Yazidis who were otherwise starving and dying from exposure in the Sinjar Mountains of Iraq. The US also committed itself to protecting Erbil in northern Iraq by bombing IS fighters who were moving on the city, not least because US diplomats were based there and President Obama could not afford a repeat of the 2012 Benghazi debacle in Libya.

Islamic State responded by beheading its first Western hostage, the American journalist James Foley. Although the video of this was billed as a “Message to America”, it was directed specifically at Obama rather than the American people. In a speech evidently written for him, Foley told viewers that the US government was to blame for his execution because of its “complacency and criminality”.

When Mohammed Emwazi – “Jihadi John” – appeared in Isis videos as executioner-in-chief, he went some way towards explaining those accusations. “You are no longer fighting an insurgency. We are an Islamic army and a state,” he said. “Any attempt, by you, Obama, to deny the Muslims their rights of living safely under the Islamic caliphate will result in the bloodshed of your people.” To that extent, Islamic State has pursued a campaign of retribution over the past 12 months against those it regards as belligerent enemies: the United States, Britain, France, Russia and its regional arch-rival Hezbollah, the Lebanese-based and Iranian-backed Shia militia.

There is an unspoken corollary to this approach, too: that Islamic State wants to make the cost of acting against it so unbearably high that its opponents are intimidated into acquiescence. For all its nihilistic sadism, IS is a rational actor. The group controls a large landmass, enjoys autonomy and makes claims to a revived caliphate. That is a project it wants to continue expanding and consolidating by being left alone to overrun the Middle East, a process that involves massacring minorities, including the Shias, Christians, Yazidis and Kurds.
If the West intervenes in this it must be prepared to face the prospect of mass-casualty terrorism at home.

Some will invariably argue that this is precisely what we should do. Leave them to it: Islamic State may be distasteful, but the cost of acting against it is too high. Besides, we cannot police the world, and what concern is it of ours if Arab societies implode in this way?

This view overlooks a broader (and inevitable) strategic imperative that can never be divorced from Islamic State. The group’s millenarianism and commitment to eschatological beliefs are such that it wants to be left alone – for now.

IS ultimately believes it must confront and then defeat the West in a comprehensive battle between haqq and batil: truth and falsehood. That became clear enough when Abdul-Rahman Kassig (originally Peter Kassig) became the fifth Western hostage to be executed by IS in November last year. The video of his killing was different from those that preceded it and started with the execution of 21 soldiers from the Syrian Arab Army who were fighting on behalf of President Bashar al-Assad.

A short speech by Mohammed Emwazi – again, directed at Obama – noted that the execution was taking place in Dabiq, a town in north-western Syria. The significance of this is not to be underestimated. Dabiq is noted as being the venue of a final showdown between the armies of Islam and those of “Rome”, a reference to the superpower of the day.

“To Obama, the dog of Rome, today we’re slaughtering the soldiers of Bashar and tomorrow we’ll be slaughtering your soldiers,” Emwazi said. “We will break this final and last crusade . . . and here we are burying the first of your crusader army [Kassig] in Dabiq.”

Kassig was branded a “crusader” because he had served in the US armed forces.

That final encounter is not necessarily reliant on Western intervention. Emwazi explained that Islamic State would also use Dabiq as a springboard to “slaughter your people on your streets”. Thus, for Islamic State, a confrontation with the West is inevitable. It would rather be left to consolidate its position for now, but there is no eventuality in which we could expect to escape its sabre-rattling indefinitely.

The religious significance attached to sites such as Dabiq plays a huge role in motivating the fighters of IS. While the world looks on with horrified bewilderment at its rampages, the power of its eschatological reasoning provides some insight.

Writing shortly after Russia entered the conflict, a relatively well-known Dutch fighter called Yilmaz (also known as Chechclear) invoked the importance of end-times prophecies. “Read the many hadith [sayings of the Prophet Muhammad] regarding Bilad al Sham [Greater Syria/the Levant] and the battles that are going to be fought on these grounds,” he said. “Is it not slowly unfolding before our eyes?”

Herein lies the power of Islamic State’s reasoning – its fighters, and the movement as a whole, draw huge succour from the religious importance of the sites around which they are fighting. It serves to convince them of the righteousness of their cause and the nobility of their endeavours.

Faced with a campaign of Western aerial bombardment (albeit one that is limited and unambitious), Islamic State has decided to bait its enemies into fighting it on the ground. To that end, towards the end of the Kassig execution video, Emwazi advises Obama that Islamic State is “eagerly waiting for the rest of your armies [sic] to arrive”.


One final point should be noted about the possible strategic aims of the Paris attacks of 13 November. Islamic State has been dispirited by the mass migration of Syrian refugees into Europe. Instead, it has appealed to them to migrate eastwards, towards the caliphate, rather than into disbelieving Western nations.

In an attempt to dissuade refugees from heading to Europe, IS released a series of videos featuring Western foreign fighters – including some from France – who told viewers how much they despised their home countries. Their message was one of persecution, of Muslims under siege, and of a hostile, unwelcoming Western world.

By way of contrast, they attempted to display the benefits of living in the so-called caliphate, with stilted images of the good life that would make even North Korean officials blush: schoolchildren in class, doctors in hospitals, market stalls filled with fresh produce.

Smuggling fighters into France who had posed as refugees is likely to have been a deliberate and calculating move, designed to exploit fears among some about the potential security risk posed by accepting Syrian refugees. Islamic State likens refugees seeking a future in Europe to the fracturing of Islam into various encampments following the death of the Prophet Muhammad in 632AD. Most of these sects arose from divisions over who should succeed the Prophet in leadership of the Muslim community, but some went into open apostasy.

Viewing events in this way, Islamic State argues that any Muslim not backing its project is guilty of heresy. For refugees to be running from it in such large numbers is particularly humiliating: the group even ran an advert that juxtaposed an image of a camouflaged military jacket alongside that of a life vest. A caption read, “How would you rather meet Allah?”

An article published this year in Islamic State’s English-language magazine Dabiq made this very point. It noted that: “Now, with the presence of the Islamic State, the opportunity to perform hijrah [migration] from darul-kufr [the land of disbelief] to darul-Islam [the land of Islam] and wage jihad against the Crusaders . . . is available to every Muslim as well as the chance to live under the shade of the Shariah alone.”

Islamic State recognises that it cannot kill all of the refugees, but by exploiting European fears about their arrival and presence, they can at least make their lives more difficult and force them into rethinking their choice. All of this falls into a strategy where IS wants to eradicate what it calls the “grayzone” of coexistence. Its aim is to divide the world along binary lines – Muslim and non-Muslim; Islam and non-Islam; black and white – with absolutely no room for any shades of grey.

“The Muslims in the West will quickly find themselves between one of two choices, they either apostatise and adopt the kufri [infidel] religion propagated by Bush, Obama, Blair, Cameron, Sarkozy and Hollande in the name of Islam so as to live amongst the kuffar [disbelievers] without hardship, or they [migrate] to the Islamic State,” says an editorial in Dabiq magazine. “The option to stand on the sidelines as a mere observer is being lost.”


Atrocities such as the Paris attacks are designed to put a strain on the “grayzone”, thereby polarising Muslim and non-Muslim communities alike. Indeed, this is precisely what Islamic State said it hoped to achieve after the Malian-French radical Amedy Coulibaly declared, in a video released two days after his death, that he had participated in the Charlie Hebdo attacks on IS’s behalf. “The time had come for another event – magnified by the presence of the Caliphate on the global stage – to further bring division to the world and destroy the grayzone everywhere,” Dabiq said.

Beyond the tendency of all totalitarian movements to move towards absolutism in their quest for dominance, Islamic State also believes that by polarising and dividing the world it will hasten the return of the messiah. Once again, eschatology reveals itself as an important motivating principle.

This is both a blessing and a curse for Islamic State. Certainly, it is what underwrites its remarkable self-assurance and certainty and at the same time fuels its barbarism. Yet it may also prove to be its unravelling. IS has now attacked Russian and French civilians within a fortnight, killing hundreds. The wider world is finally realising that Islamic State is a threat it cannot afford to ignore.

Shiraz Maher is a contributing writer for the New Statesman and a senior research fellow at the International Centre for the Study of Radicalisation at King’s College London

Shiraz Maher is a contributing writer for the New Statesman and a senior research fellow at King’s College London’s International Centre for the Study of Radicalisation.

This article first appeared in the 19 November 2015 issue of the New Statesman, The age of terror