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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Seasons change, Gilmores stay the same

Gilmore Girls is fundamentally about two things: inheritance and community. The four seasons are crucial in exploring those themes.

If you’re out on the road, feeling lonely and so cold / All you have to do is call my name / And I’ll be there. The Gilmore Girls theme, a special version of Carole King’s “Where You Lead” featuring extra vocals from her daughter, plays each episode over images of autumnal New England foliage, and always reminded me of another song on Tapestry, “You’ve Got a Friend”. Winter, spring, summer or fall / All you have to do is call / And I’ll be there.

“Winter”, “Spring”, “Summer” and “Fall” are the episodes that make up Gilmore Girls: A Year in the Life, Netflix’s revival of the Noughties TV series. Fans won’t be at all surprised to see Netflix lean on the four seasons to organise the new show, a fundamental principle of the original series. This integral structure remains even as they dispense with other structures of the previous seven seasons, instead of the original 22-episode year, there are just four episodes used to narrate the Gilmores’ 2016, and each one has ballooned from 45 minutes to 90. And that familiar opening? Gone.

MISS PATTY: And flutter, flutter, flutter, flutter, flutter… and leaves! Where are my leaves? I got pumpkins, I got Pilgrims, I got no leaves.

Until 2016, every episode of Gilmore Girls included the same opening credits, with shots of red and gold leaves, a Connecticut town in the throes of autumn. So, those leafy fall shots would appear at least once an episode, even though the show’s picture-perfect town, Stars Hollow, would spend each series transitioning in and out of each of the four seasons. Of course, Stars Hollow is not a real place under the influence of real changes in the weather: it’s filmed on the perpetually sunny Warner Brothers lot in Los Angeles. And New England is so inextricably associated with autumn splendour, Stars Hollow so relentlessly idyllic, you might have expected the makes of Gilmore Girls to suspend Stars Hollow in a perennial fall, with Rory and Lorelai clutching hot coffees as they tread autumn leaves underfoot all year round. (It might make thematic sense, too: Gilmore Girls’ narrative of a precocious 16-year-old, brimming with brains and potential, slowly failing to achieve her own impossible goals fits both with the season’s connotations of academic beginnings and promise, and with its longer-standing cultural affiliation with maturity, pensive reflection and wistfulness.)

DARREN: Stars Hollow is charming. The last time we drove through there, there was a pumpkin patch.
LORELAI: Sounds like us.
DARREN: In March.
LORELAI: Oh, that would be the year the pumpkins arrived late.

The idea of Stars Hollow in perpetual autumn even comes up in a few episodes. Pumpkins arrive in March, autumnal events continue until the very end of November. Fall decorations are seemingly mandatory for local businesses.  But while every Gilmore Girls viewer can immediately conjure an image of Stars Hollow in fall, so too will they have an equally memorable selection of images of the town in winter, spring, and summer. No season goes unmarked. In fact, in the hyperreal utopia of Stars Hollow, seasons are exaggerated and picturesque: an overabundance of harvest vegetables, fluffy snow, budding blossoms, or falling leaves.

LORELAI: Grass is just not this green — not outside of Pleasantville, it isn’t.
CHRISTOPHER: So, what exactly are you saying?
LORELAI: I’m suggesting they brought in sod.
CHRISTOPHER: You suspect sod.
LORELAI: Yes, or spray paint. Maybe they spray-painted the grass when they spray-painted these trees, ‘cause, I mean, there’s autumnal foliage and then there’s autumnal foliage. It’s over the top, people.

But the seasonal obsession is more than just a way to emphasise the perfection of Stars Hollow. It’s an organising principle for the show’s structure, action and themes.

***

When Kelly Bishop (the actor who plays the most senior Gilmore girl, Emily) received the script for Gilmore Girls, she was stunned by the sheer weight of it. “I kept flicking it over, and looking at the thickness of it,” she told EW. “It was too thick to be a sitcom.” Gilmore Girls, consisting of hour-long episodes that make little sense out of order, but with its emphasis on witty dialogue over dramatic plotlines, hovers in a strange space between sitcom and drama.

Sitcoms are, by definition, situational — they often rely on characters thrown together in a confined space, be it the family living room, friends flatsharing or colleagues in a shitty office space. Comedy is often drawn from the familiarity of the specific surroundings: as a result, fans of The Simpsons or Friends or The Office could accurately draw floor-plans of the shows’ unchanging sets. So, too, could you draw a map of Stars Hollow, if you’ve seen enough episodes (trust me, I’ve done it). The action of a sitcom is often suspended in time and space: episodes end back where they began, the next opening as though nothing of note has happened since. Dramas, though, tend to thrive on progression of both character and plot; casts moving inexorably forward through time and space.

LORELAI: God, the town looks beautiful.
LUKE: Same as always.
LORELAI: No, it’s always different this time of year. It’s magical.
LUKE: If you say so, sure. Oh look, there’s the magical plumbing supply store where I bought a magical float for my toilet last week.
LORELAI: You disappoint me.
LUKE: Oh look. There’s the magical Luke’s Diner, right underneath the apartment that Jess magically lit by leaving every stinkin’ light on.

So, for Gilmore Girls to straddle both these genres, Stars Hollow must hold most of the show’s action and the majority of its ensemble cast, while still allowing the passing year to make its mark on the town. The seasons allow this. Much of this work is done in the background, as the set design changes from episode to episode, but characters are also constantly remarking on the changes in the town with each passing month, as Lorelai does when snow envelops the square.

The result is not just a keen sense of place, but of a place moving through time.

***

TAYLOR: Every other store in town has fall decorations.
LUKE: Hoorah for the mob mentality.
TAYLOR: We’re talking a few streamers and a paper turkey. How’s it gonna hurt to have a paper turkey?
LUKE: No turkey, no squash, no pumpkins. Nothing colored orange.
TAYLOR: OK, you don’t like orange. That’s fine. Autumn has many varied hues to toy with. This is the Autumn Festival. Your shop is right across the street from the Horn of Plenty! You’re smack dab in the middle of everything. You have to decorate.
LUKE: I don’t have to do anything but serve food.
TAYLOR: We’re talking about the spirit of fall!
LUKE: You know where you can stick the spirit of fall?

Gilmore Girls, with its principle cast of family members, and its sprawling ensemble cast of Stars Hollow residents, is fundamentally about two things: inheritance and community. The four seasons similarly become an important device for exploring those themes.

Small rural communities have long organised themselves around the seasons. Stars Hollow is no different — except in the ridiculous extent of its embrace of all things seasonal. Each season of Gilmore Girls is organised around the constant onslaught of annual festivals: the End of Summer Madness Festival that, well, ends summer, the Teen Hayride, the 24-Hour Dance Marathon the Autumn Festival complete with Cornucopia Can Drive and Horn of Plenty, November’s Old Muddy River Bridge Knitathon, the commemorations of the Battle of Stars Hollow, the Winter Carnival, the Snowman-Building Contest, the Christmas Procession, January’s Founders’ Firelight Festival, the Bid-on-a-Basket festival, Groundhog Day, St Patrick’s Day, the Purim festival, a whole host of springtime weddings and engagement parties, the springtime Movie Night in the Square, the annual Easter Egg Hunt, the Hay Bale Maze at the Spring Fling Festival, and the Festival of Living Pictures are just selection of the events honoured in Stars Hollow.

LORELAI: Oh, hey! Turn out the lights.
LUKE: For what? It’s not the real procession, it’s just the rehearsal.
LORELAI: So, it’s pretty.
LUKE: And why do they need to rehearse it? It’s the same thing every year.
LORELAI: Come on Luke, please. It’s hard to imagine living somewhere else isn’t it?

These aren’t just background quirks, lending us an increased sense of familiarity with the town as we’re told over and over that these events unfold in the same, strange way every single year. They’re linchpins which hold key plot events in place. Both Jess and Dean tell Rory they love her, with less than positive consequences, during the supposedly romantic Founder’s Firelight Festivals. Rory’s romantic relationship with Jess speeds up when he bids on her basket at the Bid-on-a-Basket festival, which is also where Sookie and Jackson become engaged. Her relationship with Dean ends (the second time) in spectacular fashion at the Dance Marathon. Luke begins his romantic relationship with Lorelai when dancing with her amidst springtime decorations in the town square at Liz and TJ’s wedding. The list goes on.

The result is that the lives of our main characters, the lives of the smaller Stars Hollow characters, and small-town seasonal events are all inextricably linked to the same calendar. Particularly in the early seasons, every significant relationship, for both Rory and Lorelai, becomes rooted in the community of Stars Hollow. Public acts of citizenship and private expressions of love overlap. To live in Stars Hollow is to live every aspect of your life communally, communing with others, and with nature itself.

LORELAI: Do you know that the best things in my life have happened when it snowed?
RORY: Why, yes, I do.
LORELAI: My best birthday.
RORY: Your first kiss.
LORELAI: Your first steps. They all happened when it snowed.

***

The seasonal structure of the show also brings with it a sense of inevitability, as, in the midst of these reliable annual ceremonies, Gilmore Girls explores ideas of inheritance across the generations. In the grand houses of Emily and Richard’s world (and Lorelai, Christopher and Logan’s youths) inheritance both metaphorical and literal is an encouraged part of family life: but it feels forced and uncomfortable, restricting individuality in favour of decorum and reputation. In Stars Hollow, inheritance functions in a different, but no less crucial, way: more subtle and natural, as constant and eternal as the circles of life. For children who grow up with their parents in Stars Hollow, inheritance seems predestined, even if it didn’t seem so to the characters it affects.  

Many characters are surprised by what they inherit from their parents: Luke never expected to care so much for his father’s old hardware store, Lane is shocked to discover that after years of aching to break out of her mother’s conservative ideals, she’s not comfortable with having sex before marriage. Jess never thought he would pick up a book on intimacy from his uncle Luke, let alone read it sincerely, nor to learn so much valuable advice from him about communication in relationships.

LUKE: You do not want to grow up to be like your mom.
RORY: Sorry, too late.

Of course, that sense of inescapable legacies is taken to extremes in Rory and Lorelai’s relationship: in the very first episode, Lorelai exclaims to her daughter, “After all, you’re me!” While Rory at 16  is, in some ways, a vision of everything Lorelai at 16 was not (responsible, excited by her education, chaste, keeping a constant, serious eye on her future), as the series unfolds, that changes, as Rory becomes more impulsive, reckless and romantic. Viewers are relentlessly confronted by parallels between Rory and Lorelai’s romantic choices: Christopher is to Lorelai as Logan is to Rory, Luke is to Lorelai as Jess is to Rory. Seasons change, Gilmores stay the same.

LORELAI: He kind of looks like Christopher.
LUKE: The grocery kid?
LORELAI: Yeah. He looks like Christopher.
LUKE: And Christopher is Rory’s dad?
LORELAI: The hair, the build, something about the eyes. He reminds me of Christopher.
LUKE: Well that’s not too surprising.
LORELAI: You’re going to quote Freud to me? ’Cause I’ll push you in front of a moving car. This talk was going so well.
LUKE: You and Rory are a lot alike. It’s not surprising you would have similar tastes in men.

It is an inexorable, unavoidable logic, then, that sees Gilmore Girls: A Year in the Life, a show with more interest in the unfolding seasons and the passage of time than ever, that sees Rory finally become her mother. The show’s much-anticipated final four words (“Mom,” “Yeah?” “I’m pregnant”) see Rory at 32, the same age as her mother when the series began, in a similar position to her mother at 16: single, pregnant, unfocused in her career. Some found it frustratingly obvious and pessimistic, others found it optimistic and apt. I’d sum it up in the same way Lorelai comments on her repeating circumstances with her own mother: with a grimly ironic toast “to the circle of life”.

But however you feel about the ending, Gilmore Girls has pulled off one impressive feat. As Lorelai and Rory sit together in the bandstand, and the show cuts to black, it doesn’t feel like the show has ended at all. The fictional landscape of Stars Hollow has a life that extends beyond the screen, as inevitable as the seasons themselves.

Anna Leszkiewicz is a pop culture writer at the New Statesman.