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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Britain's badger malaise: have the mistrust and misdirection gone too far to cure?

The expansion of the badger cull is dividing rural England and revealing a worrying lack of research enterprise on the part of the government.

Infra-red cameras that fit on top of drones, and devices that can track the signal from police radios: if the new tactics used by anti badger-cull activists appear almost military, that’s because they are.

A leading activist in the protest group Stop the Cull, Jay Tiernan, previously served in the British Army’s Royal Corp of Signals and has helped propel the movement’s technological upgrade.

But don’t mistake this army-like organisation for aggression. Jay left the armed forces when he could no longer reconcile himself to killing for a living – or even to eat: “I convinced myself to go vegetarian and became philosophical to the point where I believed that all life should be treated equal,” he says. He later stepped down from the fox-hunt saboteur movement because he found the risk of becoming caught up in a brawl too great: “I didn’t want to have to be worrying about that.”

In contrast, disrupting a badger cull carries less risk of person-on-person confrontation. Law-abiding protesters look out for badger traps near their local walks, Jay says, and inform others who are willing to go out and destroy them. More-involved activists also attempt to track down the groups of trained marksmen who gather to shoot the badgers. By simply revealing their presence, the activists can force the marksmen to leave the area for safety reasons, he explains.

Yet despite the emphasis on non-direct confrontation, the costs to the state of policing badger culls are still substantial. In 2016 the police costs in Somerset alone reached more than £700,000 – equivalent to £3,277 for every badger killed. Jay himself received a suspended sentence for breaching an injunction designed to keep him away from those involved in the culls.

Many farmers hold that killing badgers is a necessary part of the Government’s wider 25-year strategy for eradicating bovine tuberculosis in cattle. How else could isolated herds be contracting the infection other than via the disease-carrying badger, they ask?

But campaigners and scientists dispute this logic, pointing to the detection of the disease in everything from soil, to sheep and cats. Professor Rosie Woodroffe from the Zoological Society of London has told the Guardian that the benefits of culling remain “uncertain”. While according to Lord Krebs, who worked on a massive pilot cull between 1997 and 2007, the present government trial was not set up as a legitimate experiment, has not monitored badger numbers properly, and has no independent oversight.

The result is spiralling antagonism, both online and in the fields. Over the last week I’ve listened on the phone as one anti-cull campaigner broke down in tears: “If we can’t live with our wildlife in a country as wealthy and educated as this, what hope is there for the rest of the world?” she said. She also asked to remain anonymous for fear of retribution from cull supporters – a fellow campaigner once had an “eviscerated” badger nailed to her gate, she told me.

On the other hand, I’ve spoken to farmers whose distress at losing their livestock shouldn’t be under-estimated. David Barton challenges anyone to not be moved by the video of his diseased cows being shot on his farm in Gloucestershire: “I’m getting out of beef because I can’t emotionally carry on doing this,” he says in the National Farmers Union-sponsored film. There are also claims that the anti-cull protestors resort to intimidation too – like this Tory MP, who in 2013 accused anti-cull “scroungers” of leaving a dead badger on his doorstep.

So why has the debate reached such deadlock? And with the cull set to be extended to 11 new areas this autumn, raising the possibility of up to 33,347 badger deaths, is this mutual mistrust set to become endemic?

Political history plays a part here. In 2013, Patrick Barkham, argued in the Guardian that there were symbolic reasons why it was beneficial for David Cameron’s government to show solidarity with rural communities over the cull. And after Theresa May’s campaign U-turn on scrapping a fox hunting vote, there is little chance she will want to undo that work.

The welfare debate also has aspects which undermine hope of reconciliation. Jay Tiernan is vegan, for example, and is heavily opposed to many aspects of mainstream cattle farming in the UK. He doesn’t “hate” farmers for this, he explains, because hate is unproductive – in fact he admires the hard work they put in. But this doesn’t extend to sympathy for their situation. “I used to be a soldier and would have killed for money, so who am I to judge,” he says, “but I don’t have sympathy for them: they should get another job.”

Some vegan views are problematic for farmers. It not only reduces their market, but can also be seen as a moral judgement on their whole profession. It all adds to a feeling of being ganged up on by activists and left-wing politicians.

When Green Party co-leader Jonathan Bartley called for the government to “fully roll out a humane vaccinations programme for both badgers and cows”, farmer David Barton found the statement “irresponsible and stupid” – considering there is at present no such cattle vaccine available to farmers. While farmer Philip Latham tells me the idea he dislikes badgers couldn't be further from the truth – he even has a hide on his farm from when he spent hours watching them as a boy.

Yet perhaps most problematic of all is the heightened focus on badgers, rather than on other ways the disease spreads. The government's latest report concludes that the unadjusted incidence rate ratios “revealed no statistically significant differences” between cull and non-cull areas – and says that more monitoring and analysis is necessary. But with pro-cull sympathisers often citing research that showed culling reduced TB in cattle by up to 16 percent, and anti-cull sympathisers citing the cover letter to the same report, which said culling could “make no meaningful contribution to cattle TB control”, there is little to suggest that new analysis won’t fall into the same black hole.

The result? A public ever less trusting of the value of evidence. “The data that has just come out has divided farmers and scientists,” says David Barton. "As ever they can do what they want with it and make it work for them.”

Surely a more productive solution is improved support for research into other aspects of disease control, such as improving cattle testing as I wrote about here? Even the National Farmers Union says it “would like to improve cattle testing and believe that the best way to do that would be through research on better diagnostics".

More research will cost more money, but so will killing badgers. And as Brexit approaches, we must improve confidence in our disease control – or risk digging our farming industry its own very big hole.

India Bourke is an environment writer and editorial assistant at the New Statesman.

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