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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The war on poaching

More than 1,100 rhinos were killed for their horns in Africa in 2016. Quasi-military conservation units are trying to stop the slaughter.

The Savé Valley Conservancy, 900 square miles of pristine wilderness in the Lowveld of south-eastern Zimbabwe, seems like a paradise.

Drive along its dirt tracks, past flat-topped acacias and vast-trunked baobab trees, and you scatter zebras and warthogs, impalas and wildebeest, kudus and waterbuck. Elephants lumber through the bush, leaving destruction in their wake. Giraffes placidly return your stares. Baboons cavort in the trees. A crowned eagle flies overhead with a rock rabbit in its talons. A pack of exquisitely patterned wild dogs lie on the warm red earth. There are lions and leopards, too, but out of sight.

My guide and I meet Bryce Clemence, the stocky, bearded outdoorsman who heads the conservancy’s Special Species Protection Unit (SSPU), by a muddy waterhole so that he can show us the most special of those species. He and a couple of his armed men lead us a few hundred yards into the bush before silently motioning us to stop. We wait, move on, stop again. Clemence points. Thirty yards away stands a two-tonne rhinoceros, a 15-year-old bull. It cannot see us, for rhinos have poor eyesight. It cannot smell us because we are downwind. But it senses our presence. Its ears revolve like miniature satellite dishes.

As we study this magnificent, primeval beast through our binoculars, one thing quickly becomes apparent. It has no horns. Normally it would have two, weighing seven kilos or more, but they have been removed in an effort to protect it. Rhino horn fetches around $60,000 a kilo in China and other east Asian countries, where it is considered an aphrodisiac and a cure for diverse ailments. This animal’s horns would have been worth more than $400,000 – a fortune in Zimbabwe, where the average household income is $62 a month and unemployment exceeds 90 per cent.

Sadly, not even de-horning works. Poachers will kill de-horned rhinos for any residual horn. In February 2015 they shot a six-month-old calf for just 30 grams of horn, Clemence tells me.

Savé Valley may look idyllic, but it is a front line in a war against rhino-poaching. More than 1,100 of the animals were killed across Africa in 2016, leaving barely 20,000 white rhinos, classified as “near threatened” by the International Union for Conservation of Nature, and 5,000 “critically endangered” black rhinos. What distinguishes Savé Valley is that it has begun to turn the tide, but only because it has access to the sort of funding that most African national parks can only dream of.

Clemence’s quasi-military operation consists of 35 highly trained men, all expert trackers, supremely fit and equipped with semi-automatic rifles and radios. Working in pairs, they do ten-day stints in the bush, monitoring the conservancy’s 168 rhinos from dawn to dark and endlessly searching for human tracks – or “spoor”.

They are supported by a canine unit whose two Belgian Malinois dogs can track at night and over rocks; a substantial network of paid informants in the surrounding communities and beyond; four 4x4 vehicles and 12 motorbikes; and nearly 100 armed scouts employed by the two-dozen private ranches that make up the conservancy.

Even that force is insufficient, Clemence says. The poaching gangs are growing more sophisticated. They now use high-powered hunting rifles with silencers to shoot the rhinos, and AK-47s to ward off the rangers. Sometimes the poachers use AK-47s against rhinos too: in 2014 one was hit 23 times.

They have begun using poison. One poacher was caught after laying oranges and cabbages laced with the pesticide Temik in the path of a rhino – Temik is nicknamed “Two-step” because that is how many steps an animal takes before dying. Another poacher planned to poison a waterhole, but was thwarted by an informer. “Poisoning is disgusting because it’s totally indiscriminate and has the potential to do massive harm,” Clemence says.

He has also caught poachers preparing to use the sedatives ketamine and xylazine. Having darted a rhino, they would then hack off its horns before it woke. They once hacked off the horns of a rhino that had been knocked out by a bullet and it woke with half its head missing. The creature survived for a week before Clemence’s unit found it. Vets had to put it down. “When you catch a poacher you want to beat him to death with a pick handle and very slowly break his bones, but you have to be professional,” says David Goosen, manager of the 230-square-mile Sango ranch, which forms part of the conservancy.

The odds are stacked against the SSPU in other ways, too. The poachers are paid well by the syndicates that run them – perhaps $5,000 each for a kilo of rhino horn. And even if caught, their chances of escaping punishment are high. Thanks to bribery or incompetence, just 3 per cent of prosecutions for rhino poaching in Zimbabwe end in convictions.

“You have to virtually catch them in the field red-handed, and even then they often get away with it,” Goosen says. “As soon as they get to the police station, a well-connected lawyer turns up, which means someone higher up is looking after their interests.” The maximum sentence for intent to kill a rhino is nine years for a first offence – less than for stealing cattle.

The SSPU is prevailing nonetheless. In the first three months of 2012, when Clemence arrived, the conservancy lost 14 rhinos. In 2015 it lost 12, last year three. It has also defeated Zimbabwe’s most notorious rhino-poaching gang.

Tavengwa Mazhongwe learned his craft from his older brother, “Big Sam”, who was killed poaching in 2009. Mazhongwe was responsible for at least 150 rhino killings, including many in Savé Valley. In December 2015 Clemence learned he was planning another attack and put his rangers on alert.

They found the gang’s spoor at 6.30 one morning, and tracked the four armed men in intense heat for nine hours. The gang took great care to cover their tracks, but late in the afternoon the rangers found them resting in a river bed. The rangers opened fire, killing one and seriously wounding a second. Mazhongwe and one other man escaped, but he was arrested near Harare two weeks later and given a record 35-year sentence for multiple offences. A judge had to acquit an officer in Zimbabwe’s Central Intelligence Organisation who drove the gang to the conservancy in a government vehicle because, he complained, the police did not dare investigate govenment officials. The rangers recovered an AK-47, a Mauser rifle with silencer, an axe, rubber gloves, a medical kit, tinned food and a phone-charger pack.

“You’ll never get to where you say ‘we’ve won’, but we have won in the sense that we’ve brought poaching down to a manageable level,” Clemence says. “We’ve taken out some of the most notorious syndicates. Victory will simply be breeding more than we’re losing and having sustainable numbers to pass to the next generation.” He hopes that the conservancy’s rhino population will reach 200 within two years, enabling it to relocate some animals to other parts of Zimbabwe where the battle is going less well.

The SSPU’s success comes down to skill, motivation, organisation and – above all – resources. The unit costs $400,000 a year, and is funded mainly by foreign NGOs such as Britain’s Tusk Trust. It receives practical support from the conservancy’s private ranches, some of whom – given the dearth of tourism – have to generate the necessary funds by permitting limited elephant and lion hunting for $20,000 an animal.

Zimbabwe’s national parks have no such resources. That is why private conservancies have 80 per cent of the country’s rhinos but 1.5 per cent of its land, while the parks have 15 per cent of the land but 20 per cent of the rhinos. Within a few years most of those parks will have no rhinos at all.

Martin Fletcher’s assignment in Zimbabwe was financed by the Pulitzer Center on Crisis Reporting

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