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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Jupiter in the Élysée: how long can Emmanuel Macron's good luck last?

Before entering politics, he studied Machiavelli and the art of gaining and holding power. But is the young French president a lion or a fox?

“A prince, being compelled knowingly to adopt the beast, ought to choose the fox and the lion; because the lion cannot defend himself against snares, and the fox cannot defend himself against wolves. Therefore, it is necessary to be a fox to discover the snares and a lion to terrify the wolves.”

This was Niccolò Machiavelli’s advice to young rulers in the notorious handbook that he wrote for them, The Prince, in the early 16th century. The ruler needs to be a strong lion to scare off the wolves but also a cunning fox to recognise the traps that the lion might fall into. We are very far here from the simplistic idea that “the ends justify the means”, a phrase that does not appear in the book – a Machiavellianism that was caricatured later to blacken his name.

As a young philosophy student at Paris Nanterre University, Emmanuel Macron would have known the difference, and the “lion and fox” analogy has been doing the rounds among political commentators in France as a way of characterising his rule.

Macron wrote his undergraduate dissertation on Machiavelli, exploring his ideas about politics and the representation of history in his work. This was before he went to the Paris Institute of Political Studies – better known as Sciences Po – where many aspiring French politicians go, and to the École nationale d’administration, France’s elite finishing school and its equivalent to Oxford’s politics, philosophy and economics course.

The story of his subsequent vertiginous rise to the top is well known: after spending some time as an inspector of finances in the French ministry of economy and serving as the deputy rapporteur for the commission to improve French economic growth, headed by Jacques Attali, he broke with the French high civil service to become an investment banker at Rothschild & Cie, making himself a tidy sum. François Hollande called him back to politics in 2012, making him his deputy secretary-general at the Élysée before naming him as minister of the economy, industry and digital affairs in 2014. Upon leaving government and breaking with the Parti Socialiste (PS), Macron founded his own political movement – En Marche! – in 2016, with which he swept to the presidency to become France’s youngest leader since Napoleon, at the age of 39.

Like Machiavelli before him, who served as a senior civil servant and diplomat in the Republic of Florence, Macron has the experience of high civil service and political position. But unlike Machiavelli, who was removed from his job when the Medici family returned to power in 1512, Macron has attained his country’s highest political office. He is exactly the type of “new prince” for whom Machiavelli was writing: someone who has only recently come to power, who is lacking an established structure and must stabilise his position in order to rule. To the new prince, Machiavelli’s advice was to be both a strong lion, ready to remove one’s enemies forcefully if need be, and a sly fox, to avoid the traps that the lion might not see.

Macron has described his presidency as “Jupiterian”, after the Roman sky and lightning god, the king of the other gods: he will be an aloof but strong leader, thundering orders from on high. This suggests that Macron has decided to be a lion. But has the young prince who declared that he wanted a renaissance of France forgotten the Florentine’s advice about also being a fox?

***

Macron outfoxed his PS rivals in his rise to power. Sensing that Hollande’s record unpopularity – it fell as low as 4 per cent – would be a death sentence for anyone associated with him, he fled the government’s sinking ship after only two years as economy minister. He was right: Hollande never recovered, becoming the first incumbent French president of the Fifth Republic not to seek a second mandate. Macron also avoided the trap of the PS primaries, which was to account for his main centre-left rival, the former prime minister Manuel Valls. Valls fell victim to the anger within the PS rank and file over the reform of the labour market, perceived as betraying the left-wing values of the party – a reform first piloted by Macron and pushed through parliament by decree by Valls.

Macron the fox avoided paying the price of the political fallout that engulfed the labour market reforms that he had instigated and succeeded in detaching himself from Hollande’s toxic legacy. Within the party, the principal beneficiary was Benoît Hamon, who had rebelled against the government’s policy of austerity, and he won the PS primaries. But that victory was short-lived. Hamon was quickly overtaken by the far-left firebrand Jean-Luc Mélenchon, who appeared to be the more credible left-wing anti-Hollande candidate. As a result, a large space opened on the centre left for Macron, who wanted to occupy the centre ground – a space that would not have existed with Valls as the PS candidate.

His positioning of himself as being beyond left and right was also astute. First, it presented Macron as being the credible, centrist alternative to Marine Le Pen of the Front National (FN) – if one didn’t support Mélenchon and oppose one extreme with another. It also sowed confusion in the traditional left- and right-wing parties: those closer to Hollande and Valls, not recognising themselves in the more leftist and ecological programme of Hamon, turned to Macron; and so, too, did the supporters of the failed centre-right candidate Alain Juppé, who, not recognising themselves in François Fillon’s economically Thatcherite and Catholic, socially conservative platform, found themselves drawn to Macron.

Presenting a new opposition between progressives and conservatives – mirroring Le Pen’s “patriots v globalists” rhetoric – Macron captured the French zeitgeist. He played to two audiences usually kept separate by the play of political parties. And when the centrist candidate François Bayrou offered to form an alliance, Macron the fox jumped at the opportunity. That gave him a 5 per cent boost in the polling, after which he never looked back.

While Macron the fox was using all of his cunning on the political plane, Macron the lion was consolidating his authority within his En Marche! movement, which carries his initials. Portrayed as a political start-up, with an informal, horizontal organisational structure – “helpers” (not employees) used the informal tu to address “Manu” – it is, like most unicorns, highly centralised around its boss, Macron, who makes all of the key decisions. It was he who hand-picked the 428 candidates who ran under his banner for the legislative elections. Whereas the PS and the Republicans hold internal elections to designate candidates, La République En Marche! (as Macron’s party was renamed after his presidential election) is the most centralised political party in France.

Macron the lion also showed his claws in the second-round debate with Marine Le Pen – a debate that Jacques Chirac had refused to have with Le Pen’s father, Jean-Marie, when the then FN leader made it through to the second round of the presidential contest in 2002. He forcefully confronted her, and the debate was the turning point of the second round. After it, Macron’s ratings jumped 7 per cent to the 66 per cent he was elected on.

In the subsequent legislative election, La République En Marche! won by itself a majority of seats, something rare in the Fifth Republic, which is normally led by a coalition of right-wing or left-wing parties. Macron can now rule without his centrist allies the Mouvement Démocrate (MoDem), whom he ruthlessly eviscerated from his government, throwing out its hapless leader, François Bayrou, whose initial support had provided him the boost without which he would never have made it into power.

***

Macron’s capture of the presidency and the national assembly has brought about accusations of a one-party state. It is true that Macron the lion holds the reins of the two most powerful institutions of France, but he has no control over the local branches of government. Moreover, the assembly is one of the most diverse that the Fifth Republic has ever had: there is a record number of female deputies (223, up from the previous legislature’s 155), ethnic minorities are better represented, and the two extremes – whether Mélenchon’s La France Insoumise or Le Pen’s FN – are present.

With many of his deputies being political novices, however, Macron the lion will be able to dictate how he wants things at the assembly to proceed. That both Mélenchon and Le Pen (for the first time in the assembly) have elected positions will suit him: beneath their shooting matches, his party will go about implementing the reforms he has promised. His appointment of a moderate right-winger close to Juppé, Édouard Philippe, as prime minister continues to sow discord within the established political parties, leading to factions of both the PS and the Republicans to declare themselves Macron-compatible, or willing to be “constructive”. As such, there is no strong constituted opposition in the assembly, the role falling to Mélenchon’s 17 deputies. Macron the lion is implementing Macron the fox’s policy of divide and rule.

Macron has a radical view of how the assembly should work, one he laid out in his manifesto. Instead of the usual back and forth between the left and right, he wants the assembly, whose deputies he will reduce by a third, to transform itself into an evaluative body. Its role will be to judge the policies announced by the government, revise and amend them where necessary, then vote them into law. What Macron wants to do is to transform the assembly into an expert body of assessors, which explains why he brought so many deputies from civil society into his party.

In an essay entitled “The Labyrinths of Politics”, written in 2011 for the magazine Esprit, Macron presented his vision of how politics should be conducted. He had joined the editorial board of Esprit after serving as the philosopher Paul Ricœur’s editorial assistant in the late 1990s and wrote several reviews and articles over the next ten years. In “The Labyrinths”, he criticised the “hiatus” between political debate and policy implementation: once a political decision had been made, there was a disconnect between that decision and its implementation.

To solve this problem, Macron the lion proposed to clarify the role that each institution was to play, so that public policy might be able to overcome its immobility and become efficient again. He argued that the ideology of the left and right had to be replaced with proposals for competing visions of society.

In his US-style State of the Union address to the joint houses of parliament at the Palace of Versailles, Macron the lion reiterated this vision. The point of the exercise was to determine the responsibilities of each of the institutions: he, as president, would offer a grand vision of society; his prime minister would elaborate its details; the parliament and senate would evaluate it before voting it into law. The top-down nature of the approach is confirmed by his desire to pass one of his most contentious measures, the reform of the labour market, by decree, which would mean that parliament could vote only to approve it. He has also publicly brought into line anyone who might deviate from this procedure – not least his prime minister, whom he corrected over the timing of fiscal reform, and his army chief of staff, General Pierre de Villiers, who was forced to resign after criticising the reduction of the military budget. He reminded both that he was their boss.

***

Macron the lion’s consolidation of his power on the domestic front continues apace. He has promised to end the state of emergency that has been in existence since the November 2015 terrorist attacks in Paris, but by bringing many of these measures into common law, thereby substantially increasing the power of the state.

That Versailles, the seat of the French “Sun King”, Louis XIV, should play such a prominent role in Macron the lion’s establishment of his power should come as no surprise – he has pursued what some have described as a “monarchical” style of governance. In an interview in 2015, when he was still minister for the economy, Macron explained that since the beheading of King Louis XVI during the French Revolution, political power in France has felt empty, incomplete. This thesis of democracy as an “empty space” was developed by the political philosopher Claude Lefort, though Macron does not seem to have been influenced by him. Since the king’s death, on Macron’s account, great leaders such as Napoleon or Charles de Gaulle have been able to occupy that space, whereas others, such as Hollande, have failed. Macron the lion king has every intention to fill it, for his presidency to be a true republican monarchy.

It was at Versailles that Macron the lion welcomed Vladimir Putin for his first state visit and gave him a public dressing-down over the role that the Russian media had played in the French elections, peddling conspiracy theories about him (there were suggestions that he was living a secret life as a gay man). The choice of location was astute. Because of his KGB training, Putin values being able to understand the international partners he has to deal with. By bringing him to Versailles, Macron sent a signal to Putin that France, too, could play the type of 19th-century power politics that Russia indulges in. Moreover, that the invitation took place during a celebration of Peter the Great was intended to remind Putin of Russia’s Western vocation.

By bringing Putin to Versailles, Macron also announced to the world that he was returning to what he calls the “Gaullist-Mitterrandian” line of foreign policy. This means Paris being a natural ally of Washington, but willing to follow its own independent objectives and also serving as an intermediary between Washington and Moscow. With his now infamous white-knuckled handshake with Donald Trump, Macron the lion showed (literally) that he had the strength to hold his own against one of France’s oldest friends.

Macron the lion committed one mistake, however, after the Trump handshake, which was to explain why he did it: authority needs no explanation. And it backfired. In the US president’s rationale for leaving the Paris climate change agreement, he cited Macron’s handshake. To make amends, Macron invited Trump to attend the Bastille Day military parade in Paris to mark the centenary of US entry into the First World War, which Trump seemed to enjoy. Any good lion would appreciate the display of military power – Trump is no fox – but it allowed Macron to pass a foxlike message to his American counterpart: that there is a link between global warming, which encourages the migration of those people from the Muslim countries whom he wants to ban from entering the US, and terrorism. Trump said he would think about it.

Machiavelli’s criterion for success for a young prince is duration: the new prince must be able to stabilise his power and rule over a long period. This is how Machiavelli would judge Macron. Will Macron succeed, or will the streets thwart his reforms? He has at least five years ahead of him, but will he be re-elected? Would that be success in Machiavelli’s eyes? Will Macron even run for a second presidential term?

Essential for success is what Machiavelli calls “Fortuna” – that is, luck. Macron has been remarkably lucky so far. Had it not been for the “Penelopegate” fake jobs scandal, it would be Fillon we would be discussing today as French president. And Macron has also come to power in a period when Europe is renewing itself with growth, which will help his target of reducing unemployment to 7 per cent, down from the almost 10 per cent that it stands at.

***

For Machiavelli, Fortuna is a woman and she favours the brave. In particular, she favours young, brave men – characteristics that Macron has. To make the best out of Fortuna, one needs virtù, that elusive value of having good judgement. It is virtù that transforms fortune into an opportunity, and Macron has showed good virtù so far, from escaping Hollande’s sinking PS ship to creating his own party, forming a coalition with François Bayrou and engaging in a televised debate with Marine Le Pen.

Fortuna is, however, fickle. So what will happen when Macron’s luck runs out? Will his virtù desert him, too? Machiavelli’s advice to maintain a strong state is to keep the people contented and the grandi on side. His choice of Édouard Philippe, who was a little-known mayor of Le Havre, as prime minister was inspired, as Philippe owes his position to Macron. He has kept the support of the grandi of both parties by bringing them into government. But he has also alienated his old ally Bayrou, and his public humiliation of the army chief of staff has been criticised.

What the prince should fear are conspiracies from within and conspiracies from without. On the international stage, Macron has developed his independent line but crucial to his success in Europe will be his continuing good relations with Angela Merkel. His recent nationalisation of the French shipyards at Saint-Nazaire in Brittany has infuriated his Italian partners, and he has sent his economy minister to Rome to make amends.

At the domestic level, Machiavelli’s counsel is to avoid being hated at all costs. As a liberal (still a dirty word in France) and a former employee of a Rothschild bank, seen as close to employers and wanting to reform the labour market, making it easier to hire and fire, Macron is already hated by a section of the population. He must ensure that this section does not become too large. To do so, he must show himself to be a courageous, firm and decisive leader.

His real test at the domestic level will come in September, when the inevitable street protests against his labour reforms will take place in Paris. Reform of the labour market has been one of his top priorities, so if Macron were to vacillate, he would lose authority. In the choice between being loved and being feared, Machiavelli recommends fear.

Macron’s popularity is high, with approval ratings reaching 64 per cent in June. These have inevitably dropped – at the time of writing, they were down to 54 per cent – but his popularity is also his best protection against internal conspiracies. He will have to be wary of the ambitions of Prime Minister Philippe, whom he has already called back into line on several occasions. But if his popularity remains high, he will be safe.

Macron’s drop in the polls comes, in part, as a result of cuts to housing benefits and a delay in tax cuts, so he must be sure to keep the people content. One of the president’s projects is the “moralising of public life” – to end some of the nepotistic practices of politics (employing one’s family members, for example) that seem to hark back to the ancien régime. Completing that reform of the political class will keep the people who want change on his side.

In the next five years, Macron will have to use all of his lion strength and fox cunning to establish his rule and make it last into the next presidency.

Hugo Drochon is an historian of late nineteenth and twentieth century political thought, with interests in continental political thought, democratic theory, liberalism and political realism. His book Nietzsche’s Great Politics came out with Princeton University Press in 2016. 

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