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 love affairs of Stan Laurel: "If I had to do it over again things would be different"

A romantic who craved stability, the English comedian Stan Laurel led a Hollywood love life as chaotic as his films’ plots

The comedian Stan Laurel was, even by the standards of his time, a prodigious correspondent. The Stan Laurel Correspondence Archive Project contains more than 1,500 artefacts, and these are only the documents that have so far been traced, as many of his early missives appear to have been lost. He was, quite literally, a man of letters.

His punctiliousness about correspondence can be ascribed, at least in part, to his natural good manners, but letters were also a means of filling his long retirement. He outlived his screen partner Oliver Hardy – “Babe” to his friends – by almost eight years but refused all offers of work during that time. Instead, heartbreakingly, he wrote sketches and routines for the duo that would never be performed. It was, perhaps, a way for Laurel to speak with Babe again, if only in his head, until he followed him into the dark on 23 February 1965.

Though Laurel and Hardy have never been forgotten, they are currently undergoing an energetic revival. Stan and Ollie, a film dramatisation of their later years, starring Steve Coogan as Stan Laurel and John C Reilly as Oliver Hardy, is scheduled for release in 2018. Talking Pictures TV is to start showing the duo’s long features from September. Sixty years since Oliver Hardy’s death on 7 August 1957, the duo will soon be rediscovered by a new generation.

They were such different men and such unlikely partners. Laurel was born Arthur Stanley Jefferson in 1890, in Ulverston, then part of Lancashire, the son of AJ, a theatre manager, and Margaret, an actress. He made his stage debut at the age of 16 and never again considered an alternative profession, eventually leaving for the United States to act on the vaudeville circuit before finally ending up in the nascent Hollywood. Norvell Hardy, meanwhile, came from Harlem, Georgia, the son of a slave overseer who died in the year of his son’s birth, 1892, and whose first name, Oliver, Norvell took as his own.

Hardy, who had worked as a singer and as a projectionist, became a jobbing actor, often being cast as the “heavy”because of his bulk. Laurel, by contrast, was groomed for stardom, but it repeatedly slipped through his fingers. Unlike Chaplin’s Tramp, or the boater-and-glasses-wearing Harold Lloyd, he had no persona. Only when Hal Roach paired him with Hardy did he finally find a mask that fitted, and thus a professional marriage slowly grew into a friendship that would endure until Babe’s death.

Laurel was the creative engine of the partnership, creating storylines and gags, intimately involving himself in the directing and editing of each film, but Hardy was the better, subtler actor. Laurel was a creature of the stage, trained to act for the back rows; Hardy, by contrast, had watched countless films from his projectionist’s perch and knew that the smallest of gestures – the raising of an eyebrow, a glance flicked in the audience’s direction – would be writ large on the screen. Laurel recognised this and tailored his scripts to his partner’s strengths.

Thus – and unusually for such partnerships – they never argued with each other about either screen time or money, despite the notorious parsimony of their producer Hal Roach, who paid them what he could get away with and would not let them negotiate their contracts together in order to weaken their bargaining position. Indeed, apart from one contretemps about the degree of dishevelment permitted to Babe’s hair, it seems that Laurel and Hardy never argued very much at all.

And then Babe died, leaving his partner bereft. What was a man to do but remember and write? So Laurel, always a prodigious correspondent, spent much of his retirement communicating with friends and fans by post. It helped that he had a curious and abiding affection for stationery. During one of the many interviews he conducted with John McCabe, his first serious biographer, Laurel revealed a wish to own a stationery store. Even he didn’t seem sure exactly why, but he admitted that he was quite content to while away entire afternoons in examining grades of paper.

Since letters were Laurel’s primary source of contact with the world, much of his writing is quite mundane. He deals with repeated inquiries about the state of his health – “I’m now feeling pretty good,” he informs a Scottish fan called Peter Elrick on 8 June 1960. “I suffered a slight stroke in ’55, fortunately I made a good recovery & am able to get around quite well again, of course I shall never be in a condition to work any more.” He notes the passing of actors he has known (to Jimmy Wiseman on 29 January 1959: “That was a terrible thing about [Carl] ‘Alfalfa’ Switzer wasn’t it? All over a few dollars’ debt he had to lose his life. I knew him very well as a kid in Our Gang films…”), answers queries about his films and his late partner (to Richard Handova on 21 March 1964: “Regarding the tattoo on Mr Hardy’s right arm – yes, that was an actual marking made when he was a kid – he always regretted having this done”) and often writes simply for the pleasure of having written, thus using up some stationery and enabling him to shop for more (“Just a few more stamps – hope you’re feeling well – nothing much to tell you, everything is as usual here,” represents the entirety of a letter to Irene Heffernan on 10 March 1964).

In researching my novel about Stan Laurel, I read a lot of his correspondence. I had to stop after a while, because the archive can overwhelm one with detail. For example, I might have found a way to include Oliver Hardy’s tattoo, which I didn’t know about until I read the letter just now. But of all the Laurel letters that I have read, one in particular stands out. It was written to his second wife, Ruth, on 1 July 1937, as their relationship was disintegrating. It is so striking that I quote it here in its entirety:

Dear Ruth,

When Lois divorced me it unbalanced me mentally & I made up my mind that I couldn’t be happy any more. I met & married you in that frame of mind, & the longer it went on, the stronger it became. That’s why I left you with the insane idea Lois would take me back.

After I left you, I found out definitely that she wouldn’t. I then realised the terrible mistake I had made & was too proud to admit it, so then I tried to find a new interest to forget it all, & truthfully Ruth I never have. I have drank just to keep up my spirits & I know I can’t last doing that, & am straining every effort to get back to normal.

You’ve been swell through it all, except the few rash things you did. I don’t blame you for not being in love with me, but my state of mind overrules my true feeling. If I had to do it over again things would be a lot different, but not in this town or this business. My marital happiness means more than all the millions.

Why has this letter stayed with me? I think it’s because of the penultimate sentence: “If I had to do it over again things would be a lot different, but not in this town or this business.” Hollywood brought Laurel a career, acclaim and a personal and professional relationship by which he came to be defined, but all at a price.

Stan Laurel was a complicated man, and complicated men lead complicated lives. In Laurel’s case, many of these complexities related to women. His comic performances and lack of vanity on screen often disguise his handsomeness, and monochrome film cannot communicate the blueness of his eyes. Women fell for him, and fell hard. He amassed more ex-wives than is wise for any gentleman (three in total, one of whom, Ruth, he married twice), to which number may be added a common-law wife and at least one long-standing mistress.

Had Laurel remained in Britain, serving an apprenticeship to his father before assuming control of one of the family’s theatres, women might not have been such a temptation for him. At the very least, he would have been constrained by a combination of finances and anonymity. Instead, he left for the United States and changed his name. In 1917, he met Mae Dahlberg, an older Australian actress who claimed to be a widow, despite the existence elsewhere of a husband who was very much alive and well. Laurel and Mae worked the vaudeville circuit together and shared a bed, but Mae – who lacked the talent to match her ambition – was eventually paid to disappear, as much to facilitate Laurel’s wedding to a younger, prettier actress named Lois Neilson as to ensure the furtherance of his career.

Yet it wasn’t long into this marriage before Laurel commenced an affair with the French actress Alyce Ardell, one that would persist for two decades, spanning three further nuptials. Ardell was Laurel’s pressure valve: as marriage after marriage fell apart, he would turn to her, although he seemed unwilling, or unable, to connect this adultery with the disintegration of his formal relationships.

The end of his first marriage was not the result of Laurel’s unfaithfulness alone. His second child with Lois, whom they named Stanley, died in May 1930 after just nine days of life. For a relationship that was already in trouble, it may have represented the final, fatal blow. Nevertheless, he always regretted leaving Lois. “I don’t think I could ever love again like I loved Lois,” he writes to Ruth on Christmas Eve in 1936. “I tried to get over it, but I can’t. I’m unhappy even after all you’ve done to try to make me happy, so why chase rainbows?”

But chasing rainbows was Stan Laurel’s default mode. He admitted advertising his intention to marry Ruth in the hope that Lois might take him back. Even after he and Ruth wed for the first time, he wrote letters to Lois seeking reconciliation. It set a pattern for the years to come: dissatisfaction in marriage; a retreat to Alyce Ardell’s bed; divorce; another marriage, including a year-long involvement with a notorious Russian gold-digger named Vera Ivanova Shuvalova, known by her stage name of Illiana (in the course of which Laurel, under the influence of alcohol, dug a hole in his garden with the stated intention of burying her in it), and finally contentment with another Russian, a widow named Ida Kitaeva Raphael, that lasted until his death.

These marital tribulations unfolded in full view of the media, with humiliating details laid bare. In 1946, he was forced to reveal in open court that alimony and child support payments left him with just $200 at the end of every month, and he had only $2,000 left in his bank account. In the course of divorce proceedings involving Illiana, his two previous wives were also briefly in attendance, leading the press to dub Lois, Ruth and Illiana “triple-threat husband hazards”. It might have been more accurate to term Stan Laurel a wife hazard, but despite all his failings, Lois and Ruth, at least, remained hugely fond of him.

“When he has something, he doesn’t want it,” Ruth told a Californian court in 1946, during their second set of divorce proceedings, “but when he hasn’t got it, he wants it. But he’s still a swell fellow.”

Laurel’s weakness was women, but he was not promiscuous. I think it is possible that he was always looking for a structure to his existence and believed that contentment in marriage might provide it, but his comedy was predicated on a conviction that all things tended towards chaos, in art as in life.

Thanks to the perfect complement of Oliver Hardy, Laurel was perhaps the greatest screen comedian of his generation – greater even than Chaplin, I would argue, because there is a purity to Laurel’s work that is lacking in Chaplin’s. Chaplin – to whom Laurel once acted as an understudy and with whom he stayed in contact over the years – wanted to be recognised as a great artist and succeeded, but at the cost of becoming less and less funny, of leaving the comedian behind. Stan Laurel sought only to make his audience laugh, and out of that ambition he created his art.

“he: A Novel” by John Connolly is published by Hodder & Stoughton on 24 August

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