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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Does the working class need to ask for its Labour Party back?

The more working class voters there were in a constituency in 2017, the more it tended to swing to the Tories.

When Theresa May called the general election nearly two months ago, all the evidence – opinion polls and local election results especially – pointed to the expectation that the Labour Party would be crushed, with many of its MPs losing their seats.

The assumption was that Labour under Jeremy Corbyn would be unable to win over Conservative voters, because he was too left-wing to appeal to those close to the political centre ground.

Some commentators, myself included, took this a little further, arguing that Corbyn was left-wing in a way that would alienate the very people he claimed to speak for, ie working class people, while appealing primarily to virtue-signalling middle class romantics like Corbyn himself, who have no more interest than he does in the business of parliament but love a good rally or social media spat.

The local elections that took place in May appeared to confirm the above expectation and analysis, with hundreds of Labour councillors losing their seats. However, opinion polls began to shift, and while different polling companies’ methodologies led to different estimates of support for the two main parties, all showed Labour on the rise – with YouGov predicting two days before the election that the Conservatives would win a mere 305 out of 650 seats, while Labour would win 266.

Despite a miserable campaign in support of a depressing manifesto, enlivened only by the promised revival of an anachronistic bloodsport beloved of the rural elite – indeed, a campaign so bad that political historian Glen O’Hara joked about having ‘watched and wondered whether Mrs May was a Corbynite sleeper agent’ – the Conservatives actually did slightly better than this prediction, winning their highest share of the vote since 1983 and coming to hold 317 seats to the Labour Party’s 262.

This left them only 55 seats ahead of their historic rival: a gap only very slightly wider than the 48-seat lead that they had after the 2010 general election, when David Cameron defeated the supposedly very unpopular Gordon Brown. The 2017 result would have been impossible without the activists who have stuck with the Labour Party regardless of their feelings about the leader, some of whom are now publicly expressing shame at the part they played in what is widely seen as Corbyn’s triumph.

Does the Labour Party’s unexpectedly narrow defeat refute the diagnosis of Corbynism as a middle class politics that alienates the party’s traditionally working class base, but doesn’t really care? Constituency-by-constituency analysis of the 2017 results by Paula Surridge, of the University of Bristol, suggests that it does not.

The Leave vote

We should perhaps begin with a pattern that was already apparent on election night. Parts of the country that voted strongly to quit the European Union appeared to show a swing away from Labour towards the Conservative Party, while areas that voted strongly for Remain appeared to show a swing in the opposite direction.* 

Surridge’s analysis confirms that this was indeed a trend: the higher the estimated Leave vote, the more the Labour vote share fell between 2010 and 2017, and the more the Conservative vote share rose during the same period. Blue dots represent actual constituencies; the red line represents the trend.

On the face of it, this is baffling. Both the Labour Party and the Conservative Party are officially committed to leaving the EU, and Jeremy Corbyn famously used a three-line whip to force his MPs to support the Tory Brexit bill in February.

The anti-Brexit parties were the Liberal Democrats, the Scottish National Party, and the Greens. There was therefore no sense in which a vote for Labour could have been a vote against leaving the EU. Why, then, should a constituency’s support or opposition to Brexit have made any difference?

This brings us to the paradox that the Labour MP John Mann has called the ‘Bolsover question’: why the second-largest Labour-to-Conservative swing in the country should have occurred in the constituency of Dennis Skinner.

Skinner is not only – as Mann observed – one of Jeremy Corbyn’s staunchest supporters in the Commons, but also  – although Mann did not draw attention to this fact  – one of the Labour Party’s staunchest advocates of Brexit. Why should a constituency that voted for Brexit by 29,730 votes to 12,242 have swung so heavily against a strongly pro-Brexit candidate for a pro-Brexit party?

Here’s a thought: maybe constituencies swung away from Corbyn’s Labour Party for the same sorts of reasons that they voted Leave, and swung towards it for the same sorts of reasons that they voted Remain? Or to put it another way: what if Corbynism appeals to the kinds of people to whom EU membership seems advantageous, and repels the kinds of people to whom it seems an encumbrance, regardless of the fact that Corbyn – as a disciple of Tony Benn  – is resolutely anti-EU?

Let’s take a look at some of the other things that Surridge found.

Educational level

Exit polling after last year’s EU referendum found that the more educated a person was, the more likely they were to have voted Remain. While some Remainers might like to dismiss this as ignorance on the part of Leavers, it can also be interpreted as an expression of anger at being left behind in Britain’s ever-more highly globalised economy.

So we should take note of Surridge’s finding that the higher the percentage of university degree holders in a constituency, the more it would tend to swing towards Labour from 2010 to 2017, and the lower the percentage of degree holders, the more it would tend to swing towards the Conservatives.

Ethnicity

While a bare majority of white voters opted for Leave last year, large majorities of black and Asian voters chose Remain. The reasons for this are complex – but it is notable that Surridge finds that the lower the percentage of white British voters in a constituency, the more it would tend to swing towards Labour, and the higher the percentage of white British voters, the more it would tend to swing towards the Conservatives.

While it is certainly good news for Labour that it is winning votes in more diverse communities, it should think carefully about why this is not happening in less ethnically diverse parts of the country – particularly as these are often economically struggling areas unattractive to immigrants.

Class

Now the biggest question of all. The Labour Party was set up to provide parliamentary representation for working class people, and the far left trumpeted Corbyn’s leadership as a triumph for "working class politics". But opinion polls showed something very different: under Corbyn, working class support for Labour rapidly fell to its lowest point ever.

Moreover, by-election results in the strongly working class constituencies of Stoke-on-Trent Central and Copeland showed swings from Labour to the Conservatives, as indeed they had during the Labour Party’s last flirtation with Bennism in 1983. Did the general election see working class voters change their minds and flock back to Corbyn’s "socialist" party?

My goodness. Surridge’s analysis shows that the more working class voters there are in a constituency, the more it tended to swing Conservative, and the fewer there are, the more it tended to swing Labour. To put some figures on that, she found that for every 10 per cent more working class voters in a constituency, there tended to have been a fall of about 3 per cent in the Labour vote and a rise of about 5 per cent in the Tory vote between 2010 and 2017.

Think about that for a moment. This is Corbyn bringing the party back to its "working class, socialist roots"?

Correlations, 2010-2017 and 2015-2017

I sense an objection: these figures show the swing from 2010 to 2017, and Corbyn’s only been in charge since 2015. Maybe it’s all Ed Miliband’s fault?

Apparently not. Surridge calculated the correlations between all the above variables and the change in the Conservative and Labour vote, both for the period of 2010-2017, and for the period of 2015-2017. And here they are:

While it is true that many correlations are weaker for the period 2015-2017 than for 2010-2017, the positive correlations remain positive and the negative correlations remain negative.

In other words, working class voters, voters not educated to college level, and voters in ethnically homogeneous areas love Corbyn’s Labour Party even less than they loved Miliband’s. Meanwhile middle class voters, those educated to college level or higher, and voters in ethnically diverse areas love it even more.

It should also be noted that the positive correlation between the percentage of working class voters and the change in the Conservative vote, and the negative correlation between the percentage of voters with degrees and the change in the Conservative vote, are both stronger for the period 2015-2017 than they are for 2010-2017, indicating a rapid growth of support for the Conservative Party among the very social groups that Labour traditionally represented.

This should worry Labour politicians with ambitions to be in government, because there is simply no way that a Labour leader can become prime minister without persuading Conservative voters in Tory seats to switch to Labour. Corbyn may have put together an unexpectedly large anti-Tory coalition of voters, but it’s largely concentrated in areas that already vote Labour – and traditional Labour voters are being driven faster than ever into the Tories’ arms.

The triumph of the "socialism fan"

In recent decades, Labour has become the party of anti-racism. It can be proud of the fact that its vote share has risen in ethnically diverse constituencies – although it seems to me that the racism many Labour supporters (and in some cases, activists and even politicians) have shown towards the Jewish community ought to be treated with rather more alarm than it apparently is.

But whatever the positives in this mixed achievement, it should be hard indeed for the party to find cause for celebration in the fact that the Conservatives are so rapidly becoming the party of the "left behind".

In the post-New Labour era – and even more so under Corbyn than under Miliband – Labour has become a party of highly educated middle class people, "socialism fans" especially. I said it before the election, and it remains the case today.

Indeed, the Labour leadership’s understanding of this point seems the most likely explanation for their manifesto pledge to end student fees (a policy that would benefit only higher-earning graduates, since people who do not go to university do not incur student fees, and people who do but end up in lower-paying jobs don’t have to repay their loans) while maintaining the Conservative "benefit cap", which negatively affects low earners, disabled people and the unemployed.

To what extent Labour’s new middle class voters will continue to back the party in the future seems unclear. After all, Corbyn can’t really do anything about their student fees, since he is not prime minister, and while he could do something about Brexit (since Labour, the anti-Brexit parties, and pro-EU Tories such as Ken Clarke now collectively hold a majority of seats in the Commons), he’s promised not to (good Bennite that he is).

Then again, he might publicly change his lifelong position on Europe just as he has publicly changed his lifelong positions on terrorism, nuclear weapons and Nato. He wouldn’t be the first leader to decide that Paris was worth a mass.

Fair play to him, though. In losing the election by only slightly more seats than Gordon Brown, he won the anticipated leadership contest in advance. So if the working class asks for its Labour Party back, he can confidently tell it to get lost.


* Canterbury is a notable exception here, having narrowly voted Leave in 2016 but swung to Labour in 2017. A very small city with two well-known universities, it hosts a very big student population during term time (when the general election took place), a large proportion of whom would typically have been expected to be resident elsewhere during the holidays when the EU referendum took place.

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