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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What would a Trump presidency mean for the rest of the world?

It would be wrong to hope that either domestic or international checks and balances will constrain Trump abroad. Geopolitically, the result would be unpredictable – at best.

The conventional wisdom about Donald Trump runs something like this. Trump is a buffoon. His solutions to world problems are not policies at all, but merely a set of contrarian reflexes. They will soon be ­exposed in the next televised presidential debate against his rival Hillary Clinton, who put in a strong performance during the first round. He is, critics say, a mere pied piper whose “deplorable” followers suffer from false consciousness about their true economic interest. Trump’s election would be a disaster, the argument runs, but his policies will soon prove impracticable.

The conventional view is wrong. Although his personal behaviour is often clownish or boorish, and he has shown astonishing ignorance of some important international issues, Trump has a perfectly coherent world-view and strategy which are rooted in certain established American traditions, even if these are now largely defunct. Most of his followers know exactly what they are voting for and they are right to believe that he will deliver, or at least attempt to do so. As for the idea that a Trump presidency would be a disaster, that is completely wide of the mark. It is actually much worse than most people think. President Trump has the potential to be an unmitigated catastrophe – if not for the United States, then certainly for the rest of the world.

Far from taking a leap in the dark, Trump supporters know that they will be voting for a clearly defined package of domestic and foreign-political measures. With Trump, in ways that are not really true of his predecessors, or of Hillary Clinton, the two spheres cannot be usefully separated. He stands for the protection of American jobs at home, and therefore for a restrictive trade policy abroad. He wants to get tough on terrorism by having recourse to torture, in both the United States and the rest of the world. He wants to increase military spending. He wants to “put America first” and increase investment in schools and infrastructure in the United States, and therefore eschews “nation-building” abroad.

We should not assume that this is just rhetoric. First, because Trump has been saying all this, or much of it, for years in his writings and in off-the cuff statements. He is no mere opportunist. Second, because we know from scholarly analysis of recent campaigns, such as the one carried out by the former White House adviser and political scientist Steven Schrage, that presidential policies often quite closely track those advanced during the campaign. Third, because Trump emerges from the confluence of two long-dormant but now resurgent American political traditions: the blunt, early-19th-century appeal of Andrew Jackson to the “common man” and the protectionist isolationism that produced the Smoot-Hawley tariffs and the Charles Lindbergh of the 1930s.

When contemplating Trump, critics often focus on his domestic consequences. They foresee an empowering of white supremacist discourses and a surge in hate crimes, especially against Muslims. These are reasonable fears, but the threat Trump poses to politics within the United States is probably overstated. There will certainly be an increase in racial tension and other forms of unpleasantness, but American society is resilient, diverse and fundamentally decent, even if some of it is currently trying to prove the opposite. The US is not seriously at risk of lapsing into the kind of populist authoritarianism we see in many other parts of the world. Moreover, the nature of the American constitution is such that Trump will be very constrained in what he can do at home: by Congress, by the courts and various other checks and balances.

There are far fewer impediments, however, to presidential power in foreign policy. As so much of Trump’s domestic programme depends on what he does abroad, the rest of the world will be much more exposed to a Trump presidency than the Americans themselves.

Trump’s impact on the world will initially be a matter of style. He has shown himself to be misogynistic, vindictive, xenophobic and unafraid to trample on the feelings of veterans or the bereaved. This would be neither here nor there – tastes differ, after all – were it not that Trump’s personality will translate internationally into an instinctive rapport with other “outspoken” leaders such as Vladimir Putin in Russia, Recep Tayyip Erdogan in Turkey or Rodrigo Duterte in the Philippines. In the event of disagreement between them and Trump, we might expect a degree of vituperation on both sides in ways that are not compatible with the long-established dignity of the presidency of the United States.

Style will soon become substance. At best, a Trump presidency will lead to the “Berlusconification” of international politics, which will become extended reality-TV events, at least in so far as they relate to the United States. More seriously, his antics will empower and encourage a coarsening of the discourse between states and about world problems. Here, the contrast with Presidents George W Bush and especially Barack Obama, whatever one thinks of their policies, could not be sharper.

Trump’s style will matter in international politics for another reason. First, despite all his rhetoric about deal-making, where his business experience is considerable – and he has sometimes shown a capacity to compromise – he seems to have a very limited and belligerent idea of what constitutes a successful diplomatic negotiation. Rejecting notions of “win-win”, Trump views a political “deal” as the imposition of his will on the other side. “In the end,” he writes of one successful transaction in his bestselling book The Art of the Deal, “we won by wearing everyone else down.” It is therefore no surprise that he cleaves to an essentially mercantilist view of world trade in which, say, Japan’s gain is America’s loss. Given his severe anger management issues, the great danger is that a clever adversary will get under his skin, provoke outbursts, and either make a laughing stock of the greatest power on Earth or precipitate a confrontation.

Second, Trump favours a particularly intuitive style of decision-making. He has gone on record as saying that people “are surprised by how quickly I make big decisions, but I’ve learned to trust my instincts and not to overthink things”. Of course, it is true that international politics often requires leaders to make speedy decisions, yet it is deeply worrying to think what Trump’s instincts will lead to when he has the proverbial finger on the button. This problem has already been commented on by a phalanx of Republican national security experts, none of whom thinks he should be entrusted with the nuclear codes.

No reliance should be placed here on the restraining force of his advisers, or of the bureaucracy in the US state and defence departments. Trump has already signalled that he will not listen. When asked a few months ago to identify those he consulted most often on foreign affairs, he replied: “I’m speaking with myself, number one, because I have a very good brain and I’ve said a lot of things.” The foreign policy “team” he has produced during the campaign is the weakest and most obscure that anybody has encountered in living memory.



The essence of Donald Trump’s vision for the world is the revival of American national greatness. He wants to “make America great again”. “Americanism, not globalism, will be our credo,” he says. His slogan “America First” is an unashamed borrowing from the isolationist platform of the 1920s and 1930s.

By contrast with every single Democratic and Republican president since the Second World War, including George Bush, Jr, Trump rejects the international liberal order. In office, this will be reflected in his opposition to global human rights initiatives, whether that be the banning of torture, or collective action to help Syrian refugees (whom he sees not as victims but as an Islamist national security threat). He will ride roughshod over human rights sensitivities when building his wall with Mexico. On the environment, Trump is likely to abrogate the Paris accord on greenhouse-gas emissions and to press ahead with work on the disputed Keystone oil pipeline between Canada and the US, as well as other projects.

He may well also play fast and loose with the national debt, having suggested that he may not repay it or the interest in full. “I’ve borrowed knowing that you can pay back with discounts,” he explains, adding that “I would borrow knowing that if the economy crashed you could make a deal”. But he may find that his ability to bounce back no fewer than four times from business bankruptcy may not be a transferable skill.

The other area in which Trump plans to tear up the international rulebook, and here the parallels with his opposition to gun control are evident, is the field of nuclear non-proliferation. He has repeatedly welcomed the idea of a Saudi, or South Korean, or Japanese nuclear bomb. The thinking is that this will achieve a balance of terror, which will keep the peace better than costly American intervention.

Cumulatively, all this will cause considerable disruption. It will unravel many of the webs of international society carefully woven over the past six decades or so. It may well make the Korean Peninsula or the Gulf even more unsafe. It will certainly make life unpleasant for Mexico. And it will lead to the end of the United States acting as the world’s policeman. The US will step up the number of global snatch-squads in the war on terror, certainly, but will cease to exercise a general superintendence over the defence of democracy and human rights. No Iraqs, perhaps, but also no interventions in Bosnia or Kosovo. The worst, however, is yet to come.

At the heart of Trump’s revolt against the liberal order, undoubtedly, is economics. Reviving the national economy is essential to his vision of making America great again. Central to that project is a revision of the terms of trade. Trump is convinced that the US is getting a raw deal, not only from its enemies, but also – and most importantly – from its friends. He might well overturn the North American Free Trade Agreement, will probably disavow the Trans-Pacific Partnership, and is most unlikely to go through with the Transatlantic Trade and Investment Partnership, assuming it is not killed off first on the other side of the Atlantic. He would not be above leaving the World Trade Organisation altogether. Above all, Trump will take on China, which he accuses – with considerable justice – of currency manipulation and sharp practices. At the very least, he will instruct the US ­department of commerce to take cases against China and he may well embark on a full-scale trade war.

If Trump’s grand strategy will begin with economics and trade, it will not end there. His measures will unleash their own, essentially geopolitical dynamic. At the moment, the Chinese are contemplating the prospect of a Trump presidency with remarkable insouciance. They seem to regard him as one of their own, a man who will not bother them with human rights sermons, and with whom they can do business. In some ways they are right: he is one of them. That, however, is the problem. Trump shares their ­zero-sum view of the world, and he explicitly intends to prevail at their expense.




Nobody has ever looked inside the “black box” of an all-out trade confrontation between China and the United States. Even if one thinks – as this author does – that some form of reckoning with China is necessary, Trump is surely the man temperamentally least suited to lead it. His strategy may revive American manufacturing, but modern supply chains are such that China is inextricably stitched into the US industrial ecosystem in ways that could defy safe unravelling. Yet one thing is clear: China, which holds a huge chunk of the US federal debt, will bitterly resist any attempt to repudiate it. Moreover, if unplugged from the US market, particularly at a time of falling European demand, China will face vast economic dislocation and consequent internal unrest. One way or the other, the reaction to any such measures by the Americans will be violent, with a countdown to conflict comparable only to the one triggered by Franklin D Roosevelt’s decision in 1941 to freeze all Japanese assets in the US and impose an oil embargo on Japan.

Another arena where Trump will give the kaleidoscope an almighty kick is Europe. His hostility to the European Union – the principal instrument of the continental order hitherto strongly supported by the United States – is well documented. This will add yet another problem to the long list already confronting Brussels and the national governments. As if that weren’t bad enough, Trump will encourage the European “deplorables”: Alternative für Deutschland in Germany, Jobbik in Hungary and the French Front National. His xenophobia and authoritarian personality will chime with them; his protectionism may even resonate on the European left. He will therefore be much less isolated in Europe than many like to think.

Worse still, the example of a wall with Mexico may well inspire similar endeavours in Europe – in the Balkans and the Mediterranean (where some barrier is necessary to defend the external boundary of the Schengen passportless travel zone), but also in central Europe and perhaps even within the core of the EU, thus destroying free movement of people on mainland Europe. The period from 1989 to 2016 may become known as “the interwall era”. The walls will go up across Europe and we may not see them brought down again in our lifetime.

But the deadliest threat to European security is Trump’s attitude to Nato. He has repeatedly questioned whether the United States should continue to protect Europe, most of which fails to pay its agreed contribution to the common defence. Here – unlike in the cases of South Korea and Japan, which largely pay their way on defence – he has a point. It is negated, however, by his undisguised admiration for Putin, the single greatest threat to the stability of the European order. One of Trump’s top military ­advisers, Michael T Flynn, a retired general, is a Russia enthusiast. One of his most trusted former confidants, Paul Manafort, served as a long-term political consultant to the disgraced ex-president of Ukraine and Russian stooge Viktor Yanukovych. One of his few named foreign policy advisers, Carter Page, also has close links to Russia.

Everything points to a President Trump lifting sanctions on Putin before time and recognising Russia’s annexation of Crimea. He is also highly likely to undermine the value of Nato’s Article 5 guarantee of collective defence, which will place the Baltic and Black Sea states and Poland in the firing line. Yet he seems oblivious to this danger, largely because he does not take Russia seriously in economic terms. It is one of the many failings of his foreign policy, and a surprising one, given his general belligerence, that he
does not take other factors, such as ideology or raw military power, much into account.

Geopolitically, the results of all this are entirely unpredictable and could lead to a different global strategic balance. In effect, Europe will be left on its own to stand against Russia and defend Western values worldwide. Putin may be emboldened to take risks, in Ukraine, in eastern and northern Europe, and elsewhere. On the other hand, he may prefer to explore a strategic partnership with Trump. That will surely begin with a joint effort to support the Assad regime in Syria, and probably develop into an alliance against China. In that case, we will be in a genuinely tripolar or even quadripolar world, in which the relationship between the Russo-American alliance, the British-European confederation and the other Eastern dictatorship, China, will be one of unstable equidistance.




Finally, it would be wrong to hope that either domestic or international checks and balances will constrain Trump abroad. The executive will be bound to obey most of his orders in theory and probably all of them in practice. It is true that the military, the CIA and law-enforcement officers might, as the former National Security Agency and CIA director Michael Hayden has suggested, refuse to follow an “illegal” order. It is also possible that Congress might hold up international trade measures in so far as they relate to treaties. The EU may even be so appalled that it rallies in the face of Trump.

Yet this is wishful thinking. Crucial questions, such as whether to deliver on a Nato Article 5 guarantee in Europe, are matters to be decided by the executive alone, and for good reason. Moreover, Trump will have much of the United States behind him in making his initial foreign policy moves. Demand that the Europeans “pay up” for their own defence? Why not? Beat up on China’s protectionism? What’s not to like? As for Isis, even Homeland’s Peter Quinn thinks that the solution is to “pound Raqqa into a parking lot”. It would take superhuman moral and political courage to stop Trump early on. And with Europe, the idea that it will show resolve in the face of an external threat is, sadly, a sign of the triumph of hope over experience. Many Europeans, in fact, will cheer him on. At home and abroad, Trump will the harvest low-hanging fruit first, and then invest the capital gained in riskier enterprises. When he does really overstep the mark, it will be too late.

There is a very thin silver lining in all of this, at least for Britain: Trump is a known enthusiast for the United Kingdom. He has come out strongly against Scottish independence. He will almost certainly favour London over Brussels in trade matters. Above all, with him in the White House, Theresa May will be the only grown-up left among the major military powers of the West. The EU will almost certainly try to compensate for the loss of an interlocutor in Washington by moving closer to London. Britain will probably also benefit from an outflow of American “creatives” after a Trump victory – at least, of those for whom Canada isn’t far away enough. Britain may well also attract talent from around the world that would otherwise have gone to Silicon Valley or other centres of innovation in the United States.

In short, President Trump is likely to deliver a severe shock to both the US and the rest of the world. Although at home there are clear limits to what he can achieve, there are far fewer constraints abroad. There is little doubt, therefore, that the Americans, and probably the British, will survive Trump. The question is: will the rest of us?

Brendan Simms is an NS contributing writer. His latest book is “Britain’s Europe: a Thousand Years of Conflict and Co-operation” (Allen Lane)

This article first appeared in the 06 October 2016 issue of the New Statesman, Trump's triumph