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

Grammar school in 1962. Getty
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What I learned about class after my twin brother and I were separated by the 11-plus

When my twin brother went into a secondary modern school, and I went to a grammar, something more than a private rift opened up: we were assigned to different social classes. 

The cultural schism exposed by Brexit in Britain and the election of Donald Trump in the United States has been a long time in the making. It goes deep, and for many it has been not only a bleak social ­phenomenon, but also a profound personal experience.

When my twin brother went into the C stream of a secondary modern school in the 1950s, and I passed the examination for Northampton Grammar School, something more than a private rift opened up: we were assigned to different social classes. Apprenticed to a carpenter at 15, he did national service, while I remained at school until I went up to Cambridge University. By this time, the breach had become irreparable. Our separate lives were emblematic of divisions in Britain which have only recently been officially acknowledged. My brother made a success of his life restoring historic buildings, but many others did not, consigned to failure at 11, or subsequently ejected from employment that they had imagined would last a lifetime – work scornfully dismissed now as “jobs for life”, as though heavy manual labour were an idle sinecure.

 

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Why do we recognise the true nature of the society we live in only when it is on the verge of dissolution? Perhaps its passing shows up its certainties for the brief, shadowy arrangements that they are. Yet while it remains, it is life itself, the only possible way for human beings to be. No society is exempt from the cycle of ascent, momentary stability and decay, and this is as true in Britain of the industrial era as it was of a declining agrarian society in the 18th century.

In An Essay on the Principle of Population (1798), Thomas Malthus, echoing the French physiocrats, declared that manufacturing would never increase the wealth of the nation because food production was its primary economic purpose. The industrial worker “will have added nothing to the gross produce of the land: he has consumed a portion of this gross product, and has left a bit of lace in return; and though he may sell this bit of lace for three times the quantity of provisions he has consumed whilst he was making it . . . he cannot be considered as having added by his labour to any essential part of the riches of the state”.

Rarely can such predictions have been so swiftly disconfirmed. Industry was already sweeping up people in its compulsions, as Oliver Goldsmith had lamented of a wasting rural life in his poem “The Deserted Village” (1770): “Far, far away, thy children leave the land.” Industry effaced the sensibility of country people and remade it in the image of the rigid discipline of manufacturing, mining and mill. A new kind of human being came into existence: the industrial worker, whose disposition, mutinous and refractory, was observed by the rich with suspicion, as they could not assess its potential for disaffection and tumult. Little was known of the “alien” mentality of the people; as little, perhaps, as that revealed to an astonished establishment by the unanticipated result of the EU referendum.

No wonder the working class became a central preoccupation of governments, reformers and politicians. There was controversy from the beginning over the “true” temper of the worker, then predominantly male, engaged in the making of things, useful and necessary to the prosperity of Britain. Did the workers want a fairer share of the wealth of the country? Did they seek to overthrow the established order? What was simmering in their mysterious, impenetrable communities of poverty?

Researchers ventured into darkest England – to places frequently likened to sites of imperial conquest – and returned with lurid tales of squalor and discontent; at the same time, trade unions and friendly and burial societies were growing, the co-operative movement evolved, and eventually a Labour party emerged which at last appeared to be a definitive expression of the psyche of the working class.

Strengthened as the 20th century dawned, but weakened by war and the Depression, Labour gained new vigour after the defeat of Nazism. With the coming of peace in 1945, both the spread of communism and the dissolution of the European empires made it timely, just and prudent for ruling elites to make concessions to the working class. Hence the marriage of unequals between capitalism and welfare, which at the time promised to be a permanent settlement.

What was regarded as the enduring sensibility of the industrial worker was doomed to follow its agricultural predecessor. It, too, became fully defined only when close to disintegration. When E P Thompson published his splendid Making of the English Working Class in 1963, signs of its decomposition were already detectable. Similarly, The Uses of Literacy, Richard Hoggart’s tender depiction of working-class culture (first published 60 years ago this year), was based on his experiences as a child in the 1920s and 1930s. The historians Eric Hobsbawm and Raymond Williams also framed what looked like a definitive version of the ­working class even as workers from the Caribbean and south Asia, recruited for a waning textile industry and transport and health systems, were transforming it.

Similarly, the consolation that the gritty north was the true source of Britain’s wealth, in contrast to a soft, self-indulgent south, left a long afterglow; it persisted long after the factories had collapsed in clouds of brick dust and splinters of glass and the south, with its financial services and advanced technologies, had become the principal generator of wealth.

 

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Social class was always inflected by individual circumstances. There were other elements involved in the separation from my twin. Our mother’s husband was diagnosed with tertiary syphilis in 1939; at the time, this was curable only by prolonged treatment with injections of arsenic and mercury. Our mother, who looked after the butcher’s shop that we lived above, realised that there would be no children in the marriage. A strong and resourceful woman, she met an engineer working on a construction site near the butcher’s shop she ran while her husband drove his lorry, carrying timber, bricks and glass all over the Midlands. He also carried more tender cargoes, with whom he spent nights in the back of the truck under a tarpaulin intended to protect merchandise from the rain. From one of these cargoes he contracted the disease, the sibilant syllables of which struck terror into those touched by it, much as HIV/Aids was to do half a century later.

Our mother became pregnant with my brother and me. Perhaps it was a fear that the two men in her life might gang up on her that impelled her to keep me and my brother apart, distributing roles that would ensure we never learned truly to know one another, even though we lived in the same house, with its frozen atmosphere, numb with secrets, for the first 18 years of our lives. My brother was practical and good-looking, docile and sweet-tempered; I was clever and fat, demanding and devious. Our schooling played a secondary role, but it did succeed in driving us further apart. Class was only one element in the hidden geometry of kinship.

 

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Even in the 1950s, when the effect of ­prosperity on the working class was discussed in The Affluent Society by John Kenneth Galbraith and The Status Seekers by Vance Packard, it was difficult to sustain belief in the existence of a homogeneous class. In 1959, after three consecutive Conservative electoral victories, even the Daily Mirror doubted whether a Labour party had a future.

Writing In Pursuit of the English in 1960, Doris Lessing described her “search” for the working class as “a platonic image, a grail, a quintessence, and by definition, unattainable”. Having been assured in her native Southern Africa that black workers were “not working class in the true sense”, she came to Britain, where, after encounters with the Communist Party (“not typical”), miners and dockworkers (“very specialised” labour) and workers in a new town (“tainted by capitalism”), she was advised that the true working class could be discovered only somewhere like South Africa, where “the black masses are not yet corrupted by industrialism”.

The erosion of identity of the working class, as it existed between the mid-19th century and the end of the Second World War, went largely unrecognised by its defenders and representatives. It was certainly apparent in Blackburn in 1969, when, for my book City Close-Up, I recorded a torrent of racism and prejudice in working-class areas: this was the outrage of people who had never been consulted on the social and economic mutation of their world. Barbara Castle, the energetic and radical MP for the town, suggested I play down race, because “in a few years it will burn itself out”.

 

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Class itself was already in flux as a result of the unprecedented affluence of the time, and class consciousness was dissolving in the mild acid of consumerism. The differences between my twin and me appeared to be influenced by culture rather than class, because he was economically more successful than I was. This faltering of a sense of class was perhaps a symptom of the triumph of market-based relationships over those that are socially determined; and perceptions of the world had shifted in accordance with this reality.

 

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Distance grew between the way people actually were and an embalmed version of the working class which continued to animate the left. In 1977, I published What Went Wrong?, subtitled Working People and the Ideals of the Labour Movement. In the US the subtitle was presciently amended to Why Hasn’t Having More Made People Happier? – in that advanced country, ideals and the labour movement had become unintelligible concepts.

I interviewed hundreds of elderly Labour activists who, looking at a world changed beyond recognition, spoke of their younger selves with the sad detachment with which people usually speak of the dead; their tone bore the melancholy regret of In memoriam notices.

It was clear four decades ago that the northern industrial towns were “wanting in purpose, looking for the meaning they once derived from their role in producing goods”. In the 1970s the feeling was that immigrants from Asia had somehow usurped the people’s way of life: they lived in houses lately vacated by millworkers; they had a strong sense of family and neighbourhood, as well as powerful cultural and religious traditions – all characteristics supposed to “belong” to Lancashire.

During the economic restructuring in the 1980s, I compared (in my book Unemployment) the experience of being out of work in those days with that of the 1930s, with its poignant tales of officials from the ­Unemployment Assistance Board, sitting in the balcony at the Rialto Cinema to see who was in the stalls when they should have been pounding the pavement looking for work; or Means Test men compelling families to sell an upright piano or a wedding ring before they could receive a penny of state charity. In the 1930s, no one doubted work would return; in the 1980s, industrial work was vanishing.

It seemed the working class in Britain had attained quietus after the miners’ strike in 1984. High unemployment was said to be “frictional” as we moved between epochs, a “creative imbalance” that would one day make us all richer and happier, though not quite yet. The working class was eliminated from the very history that, in some versions of prophecy, was to have ensured its ultimate triumph. Had the working classes died and gone to a heaven shaped in the image of expropriated socialist utopias? Had they been drowned in prosperity or assimilated into an expanding middle class? Whatever their fate, they were no longer of any account in the version of society disseminated by the media. This was reinforced by the collapse of the USSR, and there ceased to be any interest in what might be happening to them. Their sometime heroic role had been unceremoniously annulled.

In the absence of the working class, the rich were transformed: employers no longer exploiters of labour, but philanthropic providers of work. Those amassing fortunes became authors of the doctrines of wealth creationism. The working class, far from the gravedigger of capitalism, was merely a transient irritant. The class reached its zenith, faltered and fell back; and the ­liberatory power once attributed to it was appropriated by the warriors of wealth, who assumed the mantle of destiny of those they had displaced.

The working class was fragmented and dispersed, like the migrants who now constituted such a significant segment of it. New generations grew, not as citizens of this or that town, with its place in a national division of labour, but as dependants of a global market. If “globalisation” is to the 21st century what industrialisation was to the 19th, its significance lies in its disarming of people, no longer able to answer basic needs in the places where they live, but compelled to buy in what they need from countries whose names are only a vague echo of forgotten geography lessons. As the market colonises society, we become subjects of a curiously dematerialising topography: Theresa May could not have expressed it better when she said that “if you believe you’re a citizen of the world, you’re a citizen of nowhere” – although this was not her ­intended meaning.

As the (welfare) state shrank, the market dilated, invasive and predatory. Our lives are so penetrated by its “values” that these now appear in our most intimate relationships – we speak of emotional investment and interrogate our deepest attachments, asking what returns we will get; should we cut our losses; what are our best assets; are we in the market for a new relationship; shall we take a gamble; what is to be gained out of profitless attachments; will it pay dividends; what will it yield? Just as “human nature” serves as a cover for the nature of capitalism, so society provides an alibi for market-induced disorders – obesity and pathologies around eating, unquiet addictions to alcohol, drugs, gambling, celebrity, sex, food; all facilitated by what money, in its own right the most addictive substance known to humanity, can buy.

No wonder this age is characterised by nostalgia for coherence and purpose. It focuses on the recent manufacturing era, even if this was shadowed by grim institutions of factory, chapel, pub, workhouse, cinema and cemetery and the oppression of women and children – just as the Industrial Age directed its yearnings towards a past of sunlit field and flower-filled hedgerow, despite the omnipresence then of overseer, magistrate, bailiff and parish pay-table.

 

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Despite a sense of continuous change, the wounds of social class continued to influence even those to whom it no longer appeared as a force in their lives. My twin brother paid for his early membership of the working class with his death 12 years ago from mesothelioma: his early construction work had exposed him to the baleful effects of asbestos.

 

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The disorientation is profound: demolition of the old workplaces also suppressed the way of life and sensibility that accompanied them. Progressives, no less alarmed by these developments than the reactionaries, applauded them, turning to the growing diversity and pluralism of the labour force. They welcomed the shifting composition of the working population, in which women, ethnic minorities and LGBT people were moulded into a fragile coalition for social progress. That such an alliance contained factions and some incompatible objectives (say, respect for same-sex relationships, at odds with many Muslims and evangelical black churches) was not its greatest failing. This lay in the elevation of social equalities over economic equality, which continued to get worse, even for most of those in the groups favoured by progressives. Moreover, “mobility” was interpreted as a one-way street; few considered the downwardly mobile, many of whom proudly acknowledged their working-class roots. Poverty, too, was redefined: no longer concerned with unanswered need, it was now measured against unattainable wealth.

 

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Personal relationships – which for most people are now more powerful than any sense of social influence – also help to conceal patterns of class and what in 1993 Richard Sennett called its “hidden injuries”. Our mother revealed to my brother and me the secret of our paternity only when both men were dead. This also exposed unsuspected inherited features: my brother had acquired from our biological father his love of restoring buildings, while I had the questionable gift of his radicalism. He had been a member of the Communist Party in the 1930s.

 

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The fluid nature of class complicates the re-emergence of a working class in its new, emancipatory alliance with the super-wealthy – Trump and the funders of Brexit. Its sudden resurrection is attended not by the solidarities of belonging, but by those of a graveyard ideology of hatreds thought to have been conquered. This is a gift to demagogues and “strongmen”, as it enables them to perceive once more the “true” nature of a class whose heart still beats to rhythms of imperial nostalgia and aggressive nationalism.

Perhaps, following the precedents of agrarian and industrial cultures, the cult of the market is finally being acknowledged, just as it, too, is on the point of eclipse. Beneath the chaos of a culture where even truth has become a kind of consumer choice, new patterns of resistance are forming: commitment to a more just distribution of the goods of the Earth and respect for a planet ransacked by an omnivorous market; a rejection of robotics displacing humanity; a rediscovery of our capacity to do and make things freely for ourselves and each other.

But the savage regressions of our time may be not just a momentary disturbance, any more than agrarian and industrial society were. The cycle may have to play itself out, in who knows what ugly and distressing scenes, before the time for remorse comes round once more; then, appalled by our destructiveness, we shall repeat the constantly broken resolution: Never Again.

The great Spanish humanist Juan Luis Vives, whose influence helped shape the Elizabethan poor law, wrote, in On Assistance to the Poor (1526): “. . . the poor are cast out of the churches and wander over the land; they do not receive the sacraments and they hear no sermons. We do not know by what law they live, nor what [are] their practices and beliefs.” After five centuries of upheaval and driven change, and in a radically altered context, his words still have a haunting, prophetic relevance.

Jeremy Seabrook’s most recent book is “The Song of the Shirt”, published in India by Navayana and in the UK by Hurst

This article first appeared in the 06 April 2017 issue of the New Statesman, Spring Double Issue

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