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

MILES COLE FOR NEW STATESMAN
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The Tory civil war

Even if David Cameron clears the fence marked Brexit, he will find a very deep ditch on the other side.

We all know families who fight and argue in the privacy of their own homes but put on a flawless display in public. So it was, for a few days at least, with the Conservative Party when the campaign for the EU referendum began. Both sides were keen to keep it that way, in the long-term interests of their party. Last month, one MP dressed down Norman Smith, the BBC political reporter, for going on the airwaves and talking about “the Tory civil war”. At that stage, he was perhaps right to do so.

Tempers are, however, beginning to fray. Members of White’s, the St James’s Street club and a foremost lair of the Tory grandee, were recently alarmed to see two of that species, Nicholas Soames MP and David
Heathcoat-Amory, an MP until 2010 and a former Europe minister, going at it hammer and tongs about the European question during the lunch hour. Anyone familiar with Soames’s entertaining Twitter feed, which is currently devoted mainly to savaging fellow Tories in Vote Leave, will know that he is no stranger to technicolor vituperation.

It was, according to the account doing the rounds, a ferocious argument, though no blows were struck. “Nicholas and David have known each other since school,” a friend of both men told me. “They have more in common than separates them. It just shows how fraught things are.” That is certainly true. I well remember Soames, a lifelong pro-European, expressing his genuine dismay that Heathcoat-Amory was defeated in 2010 because a Ukip candidate, standing ironically against a devoutly Eurosceptic Tory, split the vote in his Wells constituency and let in a Lib Dem.

Another MP, using an appropriate public school metaphor for a gentlemen’s club packed with Old Etonians, likened them to boys who are friends but who, once on opposite sides of the sports field, let all hell loose at each other. One does not doubt that Soames’s and Heathcoat-Amory’s regard for each other will survive the referendum. Whether the same can be said for the two sides of the Conservative Party – unequal sides at that – come 24 June is quite a different matter.

The way David Cameron has conducted his wing of the Remain campaign in recent weeks has horrified many Tory MPs, even some who are or were notionally on his side. “The personal attacks and crude propaganda have really upset the party and I don’t think he understands how badly this has gone down in the constituencies,” a Remainer told me.

The personal attacks are certainly out in force. Downing Street has started to brief the media about those in particular disfavour. The Sunday Times reported on 15 May that Priti Patel, the employment minister, had behaved “appallingly” (her crime seemed to have been pointing out the government’s failure to supply enough school places to cope with the recent influx of eastern European immigrants). It also claimed that Cameron was especially angry with Michael Gove – which, since Gove has behaved with politeness and a complete lack of hysteria towards the Prime Minister, suggests that the latter must have a very thin skin indeed. Gove does annoy Cameron and his friends, not because of bad behaviour but because his detailed and measured analysis of what is wrong with the EU is hard to rebut, in contrast to more emotive outbursts by the likes of Boris Johnson that can be swatted aside.

Meanwhile, Cameron has sought to ridicule Bernard Jenkin, one of the most vocal Leavers among MPs, for making a perfectly reasonable observation about the dilution of trade union legislation in return for the unions’ support of Remain. The snide side of the Prime Minister’s character, depressingly familiar to those who deal with him in private, is becoming more and more unchecked as tensions in the campaign rise. There have also been briefings against
Penny Mordaunt, the armed forces minister, and, of course, Johnson. One attempt to terrify the country was to have the Sunday Times splash that, Brexit or not, Johnson would be the next leader and, therefore, prime minister. Downing Street seems not to realise that such an outcome is, for reasons few can fathom, one the general public seems to want.

***

The Tory party has long been a coalition. Most diehard Leavers had no social or personal relations with their colleagues in Remain anyway, so that has not changed. Any breakdown in civilities among others at the moment is, for the most part, temporary. Many take the view of Jacob Rees-Mogg that the result must be binding whatever it is and the party must move on. Equally, many don’t, and if the outcome is a narrow victory for Remain it will be the worst possible result for the Prime Minister.

Those trying to maintain peace in the parliamentary party – and it is important to note that a few dozen MPs have never really been interested in Europe and are showing little interest now – believe that things could have been worse. Veterans say the atmosphere is better than it was during the Major government, in the arguments over the ratification of the Maastricht Treaty and Britain’s inglorious departure from the Exchange Rate Mechanism. That, too, is probably true, when one recalls that nine MPs had the whip withdrawn, John Major described some of his cabinet colleagues as “bastards” and he felt constrained to call a leadership contest to prove his mandate to lead the Tories. However, the vote is still a month away and there is scope for things
to worsen.

With the government and the Whitehall machine distracted by the referendum, other aspects of Conservative rule are causing irritation within the party. There is a sense that the whips and Downing Street have given up trying to take MPs with them on other issues, or to explain why changes of policy are being made. There is little doubt about the fragility of the economy, or that it could go south even if the UK remains in the EU – and George Osborne is felt to be doing too little to demonstrate the proverbial firm hand on the tiller, or to inspire confidence among his colleagues.

The recent U-turn on academy schools has caused particular rage among MPs who had gone to great lengths to explain and defend the previous policy to their constituents. Now they find themselves having to do the opposite and, as one of the less self-regarding said to me, “No pompous Tory MP likes being made to look stupid.” There is a widespread belief even among the more feminist MPs – and, believe it or not, the Tories have them of both genders – that Nicky Morgan has proved she is nothing more than a token presence in the cabinet.

Speculation about what would happen in the event of Brexit – and none of the 20 or so MPs I spoke to in preparing this piece, whatever their allegiances, would rule it out – is now starting to grip the Conservatives and is causing tempers to rise. Nobody seems to want Cameron’s immediate departure if the vote goes against him. There is talk of a “managed, orderly withdrawal” to see the party and the country through the initial shock of the change, with a contest getting under way formally at the Tory conference in October and the process – a vote of the parliamentary party, followed by a plebiscite of the membership to decide between the two most popular candidates – over by early December.

Johnson’s high-profile Brexit campaign is, in effect, the start of his bid for the leadership and why Cameron is so agitated about him. Johnson, as I wrote here in March, has not made the best impression on his fellow MPs since returning to the House last May and it is far from assured that he will be one of the final two candidates. There is also an uncomfortable recognition that he achieved little for London as mayor, other than traffic chaos and a series of vanity projects. “We’d like to do a Checkpoint Charlie-style swap, halfway across Westminster Bridge, with Sadiq Khan,” a Remainer told me.

However, Tory activists forcefully tell their MPs that Johnson is a “winner” who merits support in a leadership vote. Some younger MPs, yet to learn the difference between being a representative and being a delegate, are nervous of disagreeing. Three of them – Nigel Adams, Ben Wallace (a junior Northern Ireland minister and former soldier) and Jake Berry – are running a campaign for Johnson, organising lavish drinks parties for colleagues so the candidate can press the flesh. This irritates older MPs, who see it as a provocative manifestation of ambition and vulgarity that the party could do without.

A prominent Brexiter is almost certain to be in the last two in the leadership contest, be it later this year or in 2019-20, whatever the outcome of the referendum. Whether that is Johnson depends on if he self-destructs during this campaign – his reference to Hitler in his Sunday Telegraph interview on 15 May suggests that is quite possible, given the opportunities ahead. What might entertain the general public – and his unrestrained remarks, such as about President Obama’s Kenyan heritage, probably do –
increasingly angers his colleagues.

It may then be up to Michael Gove to offer himself, something that is said to be unlikely at the moment but that may become less so if things go badly for Johnson. Whatever Cameron thinks of his Justice Secretary, his colleagues have nothing but praise for the way in which he has conducted himself. It is widely thought that, in the event of a Remain victory, Cameron will promote Gove, possibly even to deputy prime minister, as a very public healing of wounds, in an attempt to unify his fractured party.

The favourite to end up in the last two with a Brexiter if there is an early leadership contest is Theresa May, described by one who knows her well as “cold, unfriendly, charmless, not as clever as she thinks she is, lacking imagination, unable to think outside the railway lines and intellectually dishonest”. However, he said that were the choice to be between her and Johnson, “I would, of course, vote for her.”

The wider party probably would not. It is accepted that if Johnson reached the last two, the party in the country would elect him leader. His fate, therefore, lies in the hands of his parliamentary colleagues, whenever the contest comes.

An MP who is a constitutional authority told me of his belief that even if Johnson became leader he would struggle to form a government, because a hard core of pro-Europeans might refuse to support him. Others, knowing the ambitions of their brethren, doubt that but the thought was recently echoed by the former MP Matthew Parris, probably the most articulate columnist writing in support of Cameron, who said on BBC radio that if there were a vote for Brexit he and others like him would leave the party.

***

A victory for Remain might end Johnson’s prime ministerial ambitions and the prospect of such a realignment. But unless that victory is substantial – at least as large as the 55-45 vote in the Scottish referendum – Cameron will struggle: and even that margin of victory in Scotland has not squashed demands for another vote.

The Prime Minister has failed to grasp how many of his MPs are against the EU. A former cabinet minister, not known for hyperbole, told me that “more than 200” of the party’s 330 MPs would vote for Brexit in the privacy of the polling booths. The proportion of Leave activists is even higher. Some MPs still maintain that they can find hardly anyone in their shrunken constituency bases who wants to stay in.

What we are witnessing is the expression of the resentments and tribal hatreds of many years, in a party that has never recovered from the splits after Margaret Thatcher’s 1988 Bruges speech and the Maastricht arguments, or indeed from the conduct of the debate over the UK’s entry into the then EEC during the passage of the European Communities Bill in 1972.

A former minister, a pro-European, said: “Dave is going to have to bring in the people he has alienated but even then it is going to be hard for him to do more than limp on for a couple of years.” Another said the government now, with its small majority, deals with the Tory party on a “issue by issue” basis, seeking just to get over the next hurdle. Even if Cameron clears the Becher’s Brook-style fence marked “Brexit”, he may find a very deep ditch on the other side.

Simon Heffer is a columnist for the Daily and Sunday Telegraph

Simon Heffer is a journalist, author and political commentator, who has worked for long stretches at the Daily Telegraph and the Daily Mail. He has written biographies of Thomas Carlyle, Ralph Vaughan Williams and Enoch Powell, and reviews and writes on politics for the New Statesman

This article first appeared in the 19 May 2016 issue of the New Statesman, The Great Huckster