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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The age of lies: how politicians hide behind statistics

Perhaps it is time to combine our Trump-era, heightened sensitivity to untruths with a new broadcasting technique or two.

The small slabs of crude election soundbites, with extra ornamentation in the form of half-true and meaningless headline statistics, clunk across the airwaves, and we grimace. The dead prose reaches us umpteen times a day – “an economy that works for all”, “the many and not the few”, “work is the way out of poverty”, “more being spent on our schools than ever before”, “the NHS is treating more patients than ever ­before”, “fastest growth rate in Europe”, “the national interest”, “the most ­important election in my lifetime” – and yes, let’s hear it for “strong and stable leadership”.

On 30 April, Andrew Marr tried a little witty and civilised pre-emptive mocking to stop Theresa May using soundbites in his interview with her, but it did not work because it could not work. Embarrassment about clichés and almost idiotic numbers is not what democratic politicians worry about at election time. Many of us may pine for the old American game-show device – where, for failing to amuse and divert the audience, contestants are removed from the fray by a man hammering a gong – but that is not on offer and, in election mode, the politicians will do as they have long learned to do. They will listen to the Lynton Crosbys and Seumas Milnes of this world and plough on – and on.

The soundbites are largely vacuous and we are more noisily sardonic about them than three decades ago (hooray for media literacy) but they aren’t worse than normal. There is no point expecting the debate to run on the lines of Gladstone’s Midlothian campaign 140 years ago, when he charged around Britain giving five-hour speeches – richly informed by Liberal philosophy – which did the trick for him and his party.

The clichés are, naturally, often interchangeable. Everybody running for high political office could quite contentedly utter any or all of the above phrases, though I concede it doesn’t require an inspired analyst of modern British politics to know what Theresa May is trying to do with her leadership riff – nor Jeremy Corbyn with his “rule for the many and not the few”, a phrase that has been used religiously since the adoption of universal suffrage. Only Jacob Rees-Mogg would put it to one side.

I spent almost 30 years at the BBC – working with a cadre of (mostly) hugely talented and impartial presenters and editors trying to find ways of injecting a bit more surprise or rigour into political interviews. (Surprise and rigour are often not the same thing.) I recall David Dimbleby reducing Alastair Campbell to semi-public fury in 1997 by excavating Tony Blair’s early political career and finding, neither surprisingly nor, in my view, particularly reprehensibly, that he had said Michael Foot-like things in a Michael Foot-like era. Oddly, nobody had thought to do this after he had been elected leader three years earlier, so Dimbleby’s approach to Blair had an element of ­surprise. And then there was John Humphrys’s relentless needling of Gordon Brown for his comic refusal after the 2008 financial crash to use the word “cuts” to describe what might have to happen to reduce the budget deficit, or even to agree with his own chancellor, Alistair Darling, that the global economic outlook was very bad. Brown had an on-air mega-curdle.

We know the score – the politicians find the rhetorical and statistical position that provides the best short-term defensive crouch, while the interviewer at least wants to make sure that the audience knows the question posed is relevant, fair and, if need be, that it has been dodged. Time presses on both participants – but the impact of the compression is unequal. The interviewee usually has the upper hand. In her early period Margaret Thatcher, who was a good deal more nervous than her subsequent reputation for clarity and authority would suggest, might well have been the all-time queen of interview delay tactics. However, most interviewees know that once they have found an answer to a question the first thing to do is to pad it out in case the next question is a little more difficult.

I am not outraged by any of this; nor do I believe these encounters should be dismissed as sterile, or that we should be contemptuous of the skills involved on either side of the exchange. The sort of one-sided triumph enjoyed by LBC’s Nick Ferrari with Diane Abbott is rare, and her numerical amnesia over policing made a whole argument go kerplunk – but even in more orthodox interviews you can often detect at the very least a broad weakness in a broad argument.

To my ear Corbyn sounds perpetually unsteady on defence policy (see his Marr interview in the first week of the campaign) and public finances, and neither May nor David Cameron before her manages much fluency on the impact of cuts on the working poor once they have uttered that threadbare soundbite about work being the route out of poverty. Would that it were so simple.

Our willingness to dismiss as boring these interviews, the staple of daily current affairs programmes, is overdone. And we have been a little graceless about the extent to which senior UK politicians do – or did – engage in at least some forms of public debate. Anyone who follows the US media will know how rare it has always been for senior members of the administration and White House staff to expose themselves to the sort of scrutiny still supplied by the Sunday political shows, Radio 4 current affairs programmes, Newsnight or Channel 4 News.

For decades, senior politicians in the UK turned up in the studios – often with scarcely concealed irritation – but they went through with it. In part because it was expected and in part out of self-interest. Good interview performances could lead to rapid promotion. Iain Duncan Smith was (you may be surprised by this) particularly effective in his early years at advocating his causes, and his party’s, in front of a microphone. But the studios did for him when he became Tory leader. As it turned out, his failings were more obvious when confronted by a skilled interviewer than in the House of Commons. His nervous coughing finally caught up with him one morning on the Today programme, and that was that.

Duncan Smith and Abbott are far from alone in seeing their currency plummet as a result of losing the plot in an interview. Harriet Harman, normally a highly fluent and agile politician, was sacked as social security secretary in 1998 after a grim outing, at least for her, with John Humphrys – caused not by his abrasiveness nor by any Abbott-like forgetfulness, but by her almost tangible unhappiness with a New Labour policy she was defending.

Even now, on BBC Question Time, some heavyweights will turn up only to be mauled by the voters on topics a long way away from the heart of their portfolio. Yes, they get copious notes from party researchers and have endless rehearsals to minimise the chance of saying anything too intellectually lively: but they should nevertheless get credit for risking it in the first place.

However, outside election time this tradition of broadcasting interrogation and debate, not much more than 50 years old, is under stealthy attack. The presenting team on Today is seriously good, but it is hard not to notice that the heavy hitters turn up less often for their ten minutes of duelling; similarly with Newsnight and Channel 4 News.

The Prime Minister’s Olympian approach to this sort of public engagement aggravates what was already a problem. The broadcasters may be losing ground. In this election there will be no head-to-head leaders’ debates featuring Labour and the Conservatives, and there is no great uproar about it. As it happens, I don’t believe that their absence is a disaster – not least because the format of individual leaders confronting an engaged Question Time audience one at a time (a “tradition” that began in 1997) provides far more substance and revelation than the 2010 or 2015 leaders’ debates did.

In the meantime, what can be done to the interview to improve the quality of public debate? Forcing out the clichés is not a realistic goal. Yet perhaps it is time to combine our Trump-era, heightened sensitivity to untruths with a new broadcasting technique or two. The BBC Trust (which I was part of for two years until it ceased to exist in April) commissioned its final independent editorial report on the BBC’s use of statistics from a panel of experts chaired by the former UK chief statistician Jil Matheson.

It is a superb piece of work. Above all it pleads with the BBC to do more to put statistics in context. The work was largely complete before the EU referendum so it did not pass judgement about either the veracity of the Brexiteers’ “extra £350m for the NHS” claim or the BBC’s coverage of that claim. I listened and watched a lot and, contrary to the views of many leading members of the Remain campaign, the BBC seemed to me to have consistently signalled to the audience the risible nature of the figure, if not as rudely as many would have liked.

Yet there is a different perspective on that cause célèbre. Only very rarely did the BBC on air (or anyone else, for that matter) compare the sums involved with total UK public expenditure: a net annual payment to the EU of about £8.5bn, compared to public expenditure of about £785bn. This £8.5bn is not a trivial sum – and it is likely to sound gargantuan to an unskilled worker on low wages in Hartlepool – but it hardly threatens the nation’s existence. We will have to think about that number all over again when the EU divorce bill gets paid.

In the past few years there has been a welcome growth online of fact-checking websites that get to grips with some of the half-sense or nonsense uttered – sometimes deliberately – in public debate. Among the broadcasters, Channel 4 News got in first with “FactCheck” and deserves great credit for having done so. The BBC has Reality Check; there are also the non-aligned Full Fact and others. And the Institute for Fiscal Studies (IFS) sits as a mega-authority when it pronounces on individual economic statistics. (It was a particularly dispiriting episode when the IFS took a pounding during the EU campaign.)

The good newspapers and the broadcasters have correspondents who can – and do – understand the context in which statistical argument takes place. They know the difference between a big number and a not-so-big number, the difference between an aggregate spending figure and spending per head of population, the difference in importance between a one-month figure and a trend – and a trend that does not change much over time.

This is all good, and better than it used to be. But perhaps more of this rigour can be woven into what is still the dominant form of political accountability in broadcasting: the interview.

So let us try a thought experiment. Imagine (though we don’t really have to imagine) that the Health Secretary, Jeremy Hunt, comes into a studio to say, surprise, surprise, that more is being spent in real terms on the NHS than ever before. Imagine that he is told there will be no questions on anything else until he can answer, let’s say, two obvious supplementary questions: in the course of the past 60 years how often has his assertion not been true? (Answer, says the IFS: four times, one of which was 2011/12.) And what has been the growth in per capita NHS spend, in real terms, since 2009/10, compared to the previous 15 years or so? (Answer: 0.6 per cent, as opposed to 5.4 per cent.) Answering these would show that his boast is one that almost all of his predecessors could have made, and also that the Conservative-led coalition was less generous to the health service than the preceding Labour government. It would be absolutely fair for Jeremy Hunt to respond vigorously about the need to cut the deficit or even to make points about who was in government when the crash happened – but he could not be allowed to get away with statistical near-rubbish.

Similarly, the mantra on English education (“Our schools are getting more money than ever before”) is a waste of air. It’s not that the cuts are “vicious” – just that the assertion when put in context is gibberish. The economy is growing and the school population is growing, fast. So if we were not spending more in total, and in real terms, then the cuts would be vicious. And yet, per head, there will be less in real terms for pupils. Period.

The front-line interviewers I know best are very skilled journalists and they often do try to get a jab in when the numerical nonsense gets going – but they have to move on, whether to other urgent matters or to seek a news headline from the interview, and there is not enough jeopardy for the press officer or spin doctor who wrote the politician’s brief to desist from writing the same stuff next time around.

There may be other ways of levelling up matters. The interview could proceed as normal; but at the end of it up could pop, say, Tim Harford (of the brilliant statistics programme More or Less on Radio 4) to put in the necessary corrections. It would have to be done within a few minutes or else the impact would dissipate. From time to time, Harford or his equivalent does appear after a political interviewee has spouted statistically illiterate twaddle – but not often enough, and usually this happens long after the attempted mugging of intelligent debate. Too little, too late.

It would be obligatory to ensure that this type of treatment, particularly at election time, was meted out to all the parties – but outside the election it is the government of the day and its news departments that are going to have to face most of the music. Fair enough.

My suggestion is not put forward because I am advocating a particular party’s reading of the state of the nation (or nations). There is no monopoly on vice. We should not forget Labour’s “triple counting” of health service spending after 1997 even if Blair/Brown subsequently, in benign economic circumstances, did indeed put their foot on the health-spending accelerator.

Rather, when the election dust settles and the media seminar post-mortems crank up yet again – about the level of turnout, political ennui, the particular disengagement of the young, the coverage of the leaders, the role of opinion polls and other staples – we need to keep working on how to improve the quality of public debate. It is not all awful, and a stylised contempt for what is good is itself corrupting of democracy. But the numbers nonsense needs fixing. 

Mark Damazer is Master of St Peter’s College, Oxford, and was the controller of BBC Radio 4 from 2004 to 2010

This article first appeared in the 18 May 2017 issue of the New Statesman, Age of Lies

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