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

Mike Niles/PEAS
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How to keep a girl in school for 56p

In Uganda, a strip of fabric can help lift families out of poverty.

“Every school holiday, we lose ten to 15 girls. They elope or conceive.” I’m sitting in an orange-brick house, mint-green and pink paint flaking off the walls. This is the front line of an ambitious social experiment: trying to lift families out of poverty by convincing them to educate their daughters.

My guide is Paul Lyavaala, the head of school at Kityerera High in Mayuge, eastern Uganda. The son of a local dignitary, he studied in the capital, Kampala, but returned home to run this institution, which has 605 students, 58 per cent of them female. Before the British charity PEAS opened Kityerera, students faced a ten-kilometre walk to the nearest secondary school.

Most of the school’s pupils come from homes like this one, just ten minutes’ walk from the gates. There are few possessions in the front room here – a grain silo, a vivid poster of the country’s president, Yoweri Museveni, unironically photoshopped into various Rambo-style poses – but there are handmade doilies on the table.

The homeowner, Yusuf, never went to school; he depends on agricultural labour, digging in a nearby field for himself in the morning and for others in the afternoon. One of his eight children comes to meet us, introducing herself as Phionah. She is 18 and hopes to train as a nurse. The country sorely needs girls like her – there is one nurse for every 11,000 people – but the training costs two million Ugandan shillings (£445), and her family does not have the money.

Further down the road, Paul greets another family: a father and his two wives. Two months earlier, the second wife’s teenage daughter Precious had a baby, Moses. Many schools wouldn’t have allowed her to return but Kityerera has, and she comes home every lunchtime to breastfeed. “When they found out she was pregnant, they were afraid she would be ashamed and feel small,” Paul says, translating for us. “They were extremely happy the school let her come back and gave her free time to breastfeed.”

Precious is lucky, he tells us afterwards. The family believes in witchcraft, and a few years ago might have thrown her and the baby out for bringing bad luck and attracting the disapproval of neighbours. Earlier, on the short drive to the village, we had passed a mound of rocks by the road. “They caught a thief yesterday; he stole a motorbike,” Paul had observed, with no visible emotion. A pause. “Mob justice.”

Yusuf and Phionah. Photo: Mike Niles/PEAS

Uganda is a beautiful country: iron-red soil and lush green grass. It defies easy characterisation. Middle-aged men hold hands unselfconsciously in public, but in 2013 the parliament debated a bill that would have made homosexuality punishable by death. Poverty rates have fallen dramatically in the past two decades, but 37.8 per cent of the people still live on less than £1 a day. Yet in Kampala you can (if you have the money) eat a takeaway chicken with ginger and spring onion that tastes like Chinatown’s finest. The recent arrival of Chinese investment money is obvious – the highway running from Entebbe Airport to the capital is plastered with signs in Mandarin next to half-built roundabouts.

 I arrive a month after the presidential election, which brought about the unsurprising re-election of Museveni. The victory was helped by his chief rival, Kizza Besigye, being under house arrest. That said, the appeal of continuity under a strongman – Muse­veni has been in charge since 1986 – is more understandable when you look at some of the countries that share a border with Uganda: Rwanda to the south, the Democratic Republic of Congo to the west, Kenya to the east and South Sudan to the north.

I’m here as the guest of PEAS, a charity supported by the New Statesman which runs 28 schools in Uganda and two in Zambia. In recent years, most development money has been focused on primary education, pushed by the second Millennium Devel­opment Goal, which states that every child in the world should complete five or six years of schooling. In 1997 Uganda began to make primary education available to all, and it now spends 900 billion shillings (£200m) a year supporting the policy, though Museveni’s government is troubled by rising dropout rates.

At secondary level, those are hugely magnified. Even schools supported by charities need to charge fees to become sustainable in the long term, and the cost, plus books and uniform (between 25,000 and 35,000 shillings, or £5.50-£7.70), is too much for many parents. Children are also often needed at home to do seasonal work, or they get married young, or families decide there is no point educating their daughters – hence Paul Lyavaala’s gloom about the numbers of pupils who disappear from the rolls over the summer holiday.

***

Travelling through rural Uganda, I get used to double-takes and occasional cries of “Mzungu!” (a Bantu word, first used for European explorers, that is now applied to any white person). Yet the class sitting in front of me at Kityerera High could not be more polite. There’s a formality to schooling in Uganda that jars with my recent trips to state schools in London. The uniforms – orange dresses, and white shirts with grey trousers – are immaculately washed and pressed even though the school offers little in the way of laundry facilities. This school has a “senior woman teacher”, Lilian ­Wamai, and a “senior man teacher”, Moses Kibita. There is one laptop, which belongs to the headmaster, Albert Ondonyi.

The school has gathered pupils to talk to me about their lives and aspirations. Jonathan, 17, loves music but wants to be an aeronautical engineer. Eighteen-year-old Felistus is the third of six children and one of the few boys to join the “Girls’ Club”. The children’s names – Isaac, Zakaria, Fatumah, Aloysius – reflect the country’s religious ­diversity, with a population that is 44 per cent Catholic, 39 per cent Anglican and 10 per cent Muslim.

PEAS puts extra effort into female education, with the support of money made available by the UN and NGOs. (The boys at ­Kityerera tell me they are annoyed that their dormitory, unlike the girls’ one, doesn’t have solar-powered lights.) All the research suggests that better-educated women are healthier, are more able to work for money, marry later and have healthier children. “Educate a girl, education a nation,” reads a sign stuck into the grass.

Sitting in a cool classroom, we talk about the Girls’ Club, an after-school group the school has established to try to retain more female pupils. Here, they do what we might call PSHE (personal, social, health and economic education) and learn skills such as basket-weaving. The boys help by collecting the raw materials, such as papyrus reeds or palm leaves, from nearby swamps. At the local market, a small basket might sell for 2,000 Ugandan shillings (44p) and a large one for 10,000 (£2.20). The profits help ­pupils buy extras they need.

There is one particular extra I’m interested in because it can make a huge difference to girls’ chances of making it to the end of secondary education: sanitary towels. At the school canteen, a pack of disposable pads costs 2,500 shillings (56p), putting them out of reach for many pupils. The girls have to use rags, or whatever else they can find. Some parents keep them at home and they lose a week of lessons every month.

As girl after girl tells me how much she worries about standing up in class to find blood all over her orange dress, I remember how much the same thought preoccupied me as a teenager. At my school, we compulsively shared stories of the apocryphal girl who had started her first period during a choir recital and had fled the assembly hall, eternally shamed as a scarlet stain spread across her uniform.

Mixed up with embarrassment here in Uganda is a fundamental issue of hygiene: managing a period without running water or sanitary bins can be messy and smelly. It might be only an eggcup of blood, but often it feels like a deluge. Across the developing world, and in refugee camps, a lack of safe, clean, single-sex toilet facilities exposes women to violence and disease.

For that reason, the girls and boys of Kit­yerera are well coached in telling Western visitors about menstruation; I’ve never had a 15-year-old boy talk to me about periods before, never mind half a dozen of them. Two years ago, the girls in Kityerera were ­issued with AFRIpads, made by a local company. Reusable, washable sanitary pads clip into a fabric holder that can be slotted inside knickers. There is only one problem: they are supposed to be used for not much longer than a year. So the girls want more.

PEAS is trying to identify more of these small-scale ideas that can have larger benefits. At another school, this one in Malongo, near Lake Victoria, five hours’ drive from Kampala, Annie Theresa Akech from the board of governors tells me how important it is to let parents pay in instalments. (Subsistence farmers and fisherfolk can rarely produce a lump sum.) Yet the schools do charge fees, because the aim is for all of them to become self-sustaining within a year and to be run and staffed by local people. Solar panels provide electricity, which in turn ­allows for the installation of computer labs. None of the PEAS schools uses corporal punishment, in contrast to a nearby primary school we visit, where a long, swishing cane keeps the children in line.

In this context, sanitary pads – and the craftwork on offer at Girls’ Clubs that makes it possible for pupils to buy them – are liberating. They offer equality, helping girls get as much out of school as their brothers do. They free girls from the extra burden of worrying that they will be shamed in front of their classmates. They give girls in Uganda what they need: a chance.

Helen Lewis stayed with PEAS at its house in Kampala. You can donate to the charity here: peas.org.uk

Helen Lewis is deputy editor of the New Statesman. She has presented BBC Radio 4’s Week in Westminster and is a regular panellist on BBC1’s Sunday Politics.

This article first appeared in the 11 August 2016 issue of the New Statesman, From the Somme to lraq