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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Donald Trump and the age of rage

What the rise of Trump tells us about our failing politics.

I met Donald Trump at a party in midtown Manhattan hosted by Dominick Dunne, the novelist and Vanity Fair journalist. It was October 1999 and the party was being held to celebrate the launch of Dunne’s new book, The Way We Lived Then, which is about old Hollywood (the title is a nod to Anthony Trollope).

Trump wasn’t there to talk to people, of course, but to be photographed, an ambition at which he fully succeeded, significantly helped by the presence of his striking new girlfriend, Melania Knauss (now his third wife). Trump’s urgent need to be noticed manifested itself as a kind of weird social radiance. What is interesting, from my point of view, is that I’ve forgotten the other guests at that party, many of equal ­celebrity, far greater achievement and much more ­interest. Trump registers with people, including, to my surprise, with me.

Those strands of Trump’s personality have served his presidential ambitions well. He leaves an impression, his central point of difference from the amorphous Beltway professionals whom he ridicules. “Ghastly” or “vulgar” aren’t really criticisms in Trump’s world-view; “forgettable”, however, is the bottom of the moral scale. This instantly creates asymmetries for his opponents: it is difficult to inflict reputational damage on a politician who neither needs nor craves respectability.

But personal magnetism – I cannot bring myself to type “charisma” – does not explain the Trump phenomenon. He is the most spectacular beneficiary of something far wider and more international: the perception that politics as we know it is failing. Running against Washington is as old as Washington, but never has it looked quite like this.

How do you like anti-politics now? For it is anti-politics – the contempt for the “establishment” and the convenient flight from serious debate about how it could better exercise power – that has taken Donald Trump to within striking distance of a shot at the White House. And as the search for the right person or plan to stop him becomes frantic (the responsibility is America’s, the concern is global), we should ask the wider questions. What if intelligent people – pundits and voters alike – had stood up more bravely for the political mainstream, pointing out the necessity of compromise, pragmatism and disappointment? Strands of the Republican Party now regret the visceral attacks they sanctioned against President Obama. The party unleashed a demotic rage that subsequently turned against its own establishment. The analogy applies far beyond the Republican Party: is anti-politics a parlour game that has got out of control?

Ironically, the ascent of the establishment as a focus of hatred and political anger has coincided with the decline of the establishment as an instrument of power. Think of the weakness of the establishment currently governing the Republicans in America. It has proved notably useless at doing all the things establishments are supposed to do: manipulate power behind the scenes, undermine mavericks and keep the show on the road.

This failure seems especially out of character for the Republicans. Even allowing for the insanity of its Tea Party strands, you would have expected the GOP – if its “establishment” was what we imagined it to be – to have snuffed out this Trump nonsense, probably during a grouse shoot in South Carolina, or over a few holes of golf at Augusta National in Georgia. Isn’t power what these people do? No longer, it seems, except in our imagination. So why are we so sure that the establishment, which can’t even cough up a decent candidate, is the power pulling the strings? I am beginning to wonder if the establishment’s new role, far from the exercise of unchecked power, is to provide a convenient palliative sideshow. So long as we insist that the establishment is messing up the world, then we won’t have to face up to tangible and worsening political problems and our reluctance to debate them seriously.

***

Donald Trump is both the em­bodiment of political failure and the result of political failure – or perceived political failure. He represents political failure because he has accelerated the descent of political discourse: “They’re rapists, build walls, ban Muslims.” He is the result of political failure because he taps in to a deep, subliminal anger: the conviction that “the system” has betrayed and abandoned the people.

Why do so many people feel this way, to the extent that even Trump (and other preposterous candidates) become palatable? Despite widespread political correctness, there is one group that it is perfectly legitimate to despise: politicians. When I worked for a newspaper, I was surprised one day to hear a reporter, usually so fair and mild-mannered, describe her hatred and contempt for politicians – “the worst people, just disgusting”. This is the kind of comment you hear from normally civilised and balanced people, who usually don’t know any politicians personally, but feel quite certain of the truth of their conviction.

In Britain, the parliamentary expenses scandal, though indefensible, was not the cause of this contempt, but rather its consequence. Given the strength of the underlying hatred, an appropriate story was always going to come along that allowed our contempt to be channelled into ridicule. I’ve seen news stories operate along the same lines in professional sport. When a manager or team has become unpopular with the fans, an event or “error” will act as a lightning rod for general ill-feeling. Usually the tipping point is quite routine; people get away with much worse when their stock is high.

Why are politicians and the “establishment” so despised? The new populism is partly a delayed consequence of the end of deference, in part fuelled by the emergence, especially on social media, of a strong, hard-edged and almost daily picture of “the will of the people”. Maybe this is what real democracy looks like?

Economics is also central to the “age of rage”. In the loosest terms – except among the very poorest – even “late capitalism” has continued to raise absolute living standards, albeit increasingly slowly. But few people judge their wealth according to absolute living standards. Wealth is perceived as relative to something else: relative to the past, relative to others (especially those inside “the establishment”) and, crucially, relative to individuals’ own expectations.

By those criteria, most people feel much poorer. The political class itself is the target of these economic frustrations, exacerbated by the financial crisis, even though politics is far from a complete explanation.

Second, there is a sense that politics has “failed” at ground level. This has two deep causes, which, taken together, create a significant credibility gap. First, as politics has been professionalised, its practitioners have become better at knowing what to say to get elected. Whatever their other failings, none of us can doubt that politicians spend more time than ever working out what the electorate wants, and devote greater energy towards trying to suggest that they know how to deliver it.

Having professionalised electoral messaging, politicians simultaneously professionalised avoiding controversy once in power. The degeneration of the political interview into unlistenable banalities is only one side of the coin. The flipside is the gaffe-hungry media, encouraged by an anti-politics sentiment in the electorate. The “gotcha” culture of debate doesn’t make politicians accountable, it makes them evasive.

The continual threat of being “caught out” saying the wrong thing – or saying ­anything – coexists with the perpetual expectation that politicians will be saying something at all times. We have drifted towards the assumption that politicians will speak in public non-stop, yet without taking any risks: the definition of a boring conversation. Trump’s ghastly voice seems fresh to so many people because he isn’t schooled in this tradition.

Professional political strategy clings to the notion that any vacuum creates space for an opposition advance. I think they’re wrong, and that it is impossible for politicians to have interesting and important things to say on the hour, every day. My view, in contrast, is that politicians devalue their own words by printing too many of them. But would they do it if the electorate didn’t expect it?

***

The ultra-professionalisation of politics has coincided with a huge crunch on the state’s capacity to expand. A simplistic history of politics in the second half of the 20th century would show parties winning power by handing out an ever-expanding range of goodies. Today, however, that ­arrangement is pincered from three sides: an ageing population, burgeoning expectations, and the weight of existing commitments to taxpayers, such as pensions. So, the central challenge facing overstretched liberal democracies is obvious: people want more services and benefits than they want to pay for. (Evidence that voters prefer not to focus on this contradiction lies in the remarkable success of Bernie Sanders, who promises more of everything without explaining how to pay for it. Both the Trump and the Sanders campaigns channel political disenchantment, but they exploit the feeling in opposite ways.)

For governments, however, a credibility deficit accumulates over the long term. And even quite effective administrations, as a result, leave the impression of significant underachievement. In other words, just when politicians have professionalised the art of saying the “right” thing, they have found it harder than ever to get things done in office. As with living standards, it is this deficit – the gap between political promises and governmental performance – that is causing problems, not the performance alone. Are today’s governments really worse than some of those gone? If so, when exactly were these exceptional governments of the past? These questions, intriguing as they are, do not figure in how people think.

How can the political class narrow the credibility gap? The tempting answer is to suggest providing the kind of sparkling, error-free government that has never existed and never will exist. The other problem, revising improbable expectations, at least might be achieved. In the ultra-professional era, political parties have suffered from a kind of prisoner’s dilemma: if, despite the long-term problem of credibility, they don’t play the media-friendly game of promises and button-pushing, someone else will.

After all, what does the alternative look like? “You can’t have this, lower your expectations, things are going to be hard”: it’s easy to see why politicians don’t relish saying these things, even when they’re true. The whole process that has led to today’s political disenchantment is all too rational: rational politicians coming up with rational avoidance strategies for problems that may not be soluble. Haven’t we, the electorate, played a part in that process, too?

Domestic frustrations are compounded by threats emanating from abroad. Hyper-terrorism, globalisation and migration on an unprecedented scale are huge problems and challenges with no obvious solutions. Donald Trump has exploited fears on both counts with crass answers. How much harder it is to turn complex approaches to the two problems into easy soundbites.

When I was living in New York in the late 1990s, the Clintons seemed to represent a great deal of what was wrong with politics. Ethically they hovered somewhere between dodgy and outright corrupt. Their personal relationship seemed an extension of political lobbying, more an alliance than a marriage; politically they told us how much they cared, rather than showing it. Bill had the partially redeeming quality of charm. Hillary had a talking-clock voice and predictable opinions – her 1996 book, It Takes a Village, was beyond parody – without Bill’s knowing wink.

And now? If she is up against Trump in November, I will happily stuff envelopes and campaign for her. Whatever it takes. The nature of my U-turn says everything about Trump: nothing about Hillary, whose reputation has become even more tarnished and whose political voice is more jaded. If she must be the future, we can be in no doubt about the impoverishment of the choice.

There is a view that a win for Hillary, and the restoration of competent (but cynical) middle-ground politics, will show the hollowness of anti-politics as a movement – a frenzy that won’t survive the cold rationality of the ballot box. This opinion holds that it is parties that have gone nuts, not the people. “This is not the revolt of the public against the party leadership,” argued Philip Collins in the Times. “It is the revolt of the party activists against the public.”

Yet the view that a Hillary win will see predictable centrism safely restored feels wide of the mark. I doubt a simple reprisal of Clinton-Blairism (which Daniel Finkelstein defined as the idea that it is “possible to do everything without upsetting anybody”) can get us out of this hole. Trump taps in to something frightening. If it’s defeated this time, it will still come back, even if the man will not. Until the deficit of political credibility is reduced, the demotic potential of the populist “outsider” will remain.

And next time I’m pretty sure it will be someone nastier than Donald Trump. The need is to find a better Hillary Clinton. That will only get harder if intelligent people go on paying lip-service to anti-politics. There are always establishments. The important question is how good they are.

Ed Smith is a contributing writer for the New Statesman

Ed Smith is a journalist and author, most recently of Luck. He is a former professional cricketer and played for both Middlesex and England.

This article first appeared in the 14 April 2016 issue of the New Statesman, The making of a monster