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

MILES COLE FOR NEW STATESMAN
Show Hide image

Meet the Three Brexiteers: the men who could change how we exit the EU

What is really going on between Boris Johnson, David Davis and Liam Fox over Britain’s exit from the EU?

For newspapers with only the Olympics to write about during August, the squabbling “Three Brexiteers” – the senior ministers supposedly tasked with executing the will of the British people to remove us from the European Union – came as a gift. The men concerned are David Davis, the new Secretary of State for Exiting the European Union; Boris Johnson, who is what our passports used to call Her Majesty’s Principal Secretary of State for Foreign and Commonwealth Affairs; and Liam Fox, the Secretary of State for International Trade. This odd trio amused the press for several reasons, mostly bogus: that they share responsibility for securing Brexit (untrue); that they all hate each other (untrue); that Fox has parked his tanks on Johnson’s lawn to the extent of demanding that some of the powers of the Foreign Office be transferred to his department (apparently true); and that they must take it in turns to use Chevening, hitherto the foreign secretary’s grace-and-favour, 115-room pile in Kent (certainly true, though none rushed to avail himself of the privilege). Inevitably, the whole question is far more layered and complex than the silly-season column fillers even began to suggest.

The dynamic between the three men is not straightforward. Davis and Fox are hardcore Brexiteers of long standing. In this year’s referendum campaign Davis was more closely associated with the unofficial Leave.eu group and its sister organisation Grassroots Out, and shared platforms with (among others) Nigel Farage and the Labour MP Kate Hoey. Fox, who announced just before Christmas 2015 that he would support Leave, appeared on various platforms and was more closely associated with the mainstream Vote Leave campaign, which was little more than a Tory front operation.

Davis was runner-up to David Cameron in the Tories’ 2005 leadership election, Fox an also-ran. There was little empathy between the two men during that race. Fox is immersed in US politics and has a wide range of senior contacts in the Republican Party, in and out of Congress, and in those days was seen as something of a neocon. Davis is a more conventional Tory, but with that 19th-century Liberal strain in his ­political make-up that also distinguished Margaret Thatcher (he calls himself a “Thatcherite”). He and Fox share many economic ideas as well as a dislike of the EU, but their ideas about foreign policy and, particularly, the degree of reverence with which the US world-view should be treated, differ sharply.

In June 2008 Davis resigned as shadow home secretary and from the Commons, triggering a by-election, in which he stood, to draw attention to the erosion of civil liberties in Britain. David Cameron, who found Davis wearing, saw this as a stunt and took the opportunity not to readmit him to the shadow cabinet after his re-election a month later. It was claimed Cameron offered Davis a place in the coalition cabinet in 2010 to appease the right, but Davis – disliking a range of the coalition’s policies –
preferred the back benches. His friends believed his leadership ambitions had not been quelled and that he would build up his constituency in the party better by not being in government with the Liberal Democrats. No offer of a job in cabinet came after June 2015, which seems to have hardened Davis further against the Cameron line on Europe; but Davis, not the most popular man in the parliamentary party, chose not to offer himself as a potential leader after Cameron’s auto-defenestration this summer.

Fox, however, did, even though there was equally scant evidence of his popularity. Finishing bottom of the first ballot, he then shrewdly put himself behind Theresa May, with whom he is said to have cordial relations, rather than one of the Brexiteer candidates. This helped ensure his return to cabinet. He had served in 2010-11 as defence secretary, departing in odd circumstances. It was disclosed that Adam Werritty, 17 years Fox’s junior and best man at his wedding, had been passing himself off as an adviser to Fox, but wasn’t on the official payroll and had no security clearance. Werritty reportedly attended 40 of 70 recorded engagements that Fox made as defence secretary, had been Fox’s business partner in his Atlantic Bridge charity, and had accompanied him on numerous official trips.

Though no harm had been done to British interests, Fox conceded that he had made an error of judgement and resigned. For him, too, the road back was long: he turned down the offer of a minister of state’s job at the Foreign Office in July 2014 in order to retain the freedom to criticise government (and particularly economic) policy. He became ever less warm to Cameron, who offered him nothing after the 2015 Tory victory. His Euroscepticism is of long duration, and it hardened in his absence from government.

***

Boris Johnson has no such pedigree, which begins to explain the suspicion in which Davis and Fox are said to hold him. It was shortly before the end of his second term as mayor of London, and the day after Michael Gove’s spectacular announcement that he would be voting to leave the EU, that Johnson decided which way to jump. Few in his party believed his choice to embrace Leave was made after anything other than a calculation about how best to further his rampant ambition to lead the Conservative Party and become prime minister. He had spent many years as a columnist being rude about Europe, but there is a world of difference between that and advocating complete withdrawal. Until Gove blew the whistle on Johnson as a potentially inadequate prime minister – to the relief of scores of Tory MPs who nonetheless do nothing to defend Gove against accusations of disloyalty – the plan seemed to be working perfectly.

Theresa May’s appointment of Johnson was cunning. Although pundits include him in the trio conducting Brexit, his role seems limited to maintaining friendships with those we are divorcing. An early engagement was a Bastille Day party in London, at which the French audience booed him. May’s establishment of the Brexit Department under Davis means the Foreign Office follows rather than leads on this most crucial question of foreign policy. She is no fool, and knows that among Johnson’s attested failings is his inability (apparently because of idleness) to acquaint himself with detail. The accomplishment of our departure from Europe is greatly about detail and the Prime Minister knew he could not master it.

Davis had been a successful minister for Europe in the 1990s, had worked in the private sector for years – he was an executive with Tate & Lyle – and, as a genuine Leaver, had the motivation as well as the experience to see that the job was done. However, making Johnson Foreign Secretary allowed May to appease that section of the party, mainly at the grass roots, that believes he is a great statesman. Yet word from Downing Street is that as well as Europe being parcelled off to Davis, the really important issues of foreign policy – notably relations with the US, China and Russia – will be handled from No 10, the Foreign Office again following rather than leading. This confirms a trend begun by Tony Blair nearly 20 years ago. So the powers Johnson will have are unlikely to make him the Anthony Eden de nos jours.

Davis surfaced for an anodyne speech in Ulster on 1 September confirming his desire to avoid tariffs when trading with the EU, but has kept a low profile since his appointment for, it seems, two reasons. First, his task is considerable, and while his department and the expert negotiators it requires are being assembled it was wiser to avoid saying anything, despite the growing restlessness of some of his allies on the right. His statement to the Commons on Monday was no more revelatory, serving to confirm what little we knew but to emphasise that it is not likely we will stay in the single market – the obvious conclusion to draw from May’s insistence that free movement of people is over. Even if the government has decided to leave by means of repealing the European Communities Act 1972, which many Tory Brexiteers think probable, there is nothing Davis can say about detail until the government decides exactly how to pursue that strategy – and that may be weeks yet.

Second, he knows Remainers outnumber Brexiteers in cabinet. He is deeply concerned to bring support with him, and knows he will do that best by keeping May close. Ministers who wouldn’t have a career in politics but for her will be careful to follow her lead. In July and August, May made it clear that she favoured caution, and caution was what her secretary of state provided. So, when she said (again) at last week’s special cabinet meeting at Chequers that Brexit means Brexit – that those Remainers in denial should recognise the inevitability of our leaving – and that immigration controls were inevitable, it seemed that she and Davis were united on the key questions, and the hardliners in their party could rest easy.

The tensions among the trio of ministers were really between just two of them, Johnson and Fox, and Fox appears responsible. Probably presuming on what he considered his good relationship with May, he asked during August that the Foreign Office should lose its role in trading relationships. May immediately voiced annoyance at what some of her colleagues and officials branded a “turf war”. Her anger may have been provoked in part by her failure to see the clash coming – she created overlaps between departments in her restructuring of Whitehall that a little more thought would have avoided – but also by her sense that a public which voted for Brexit would expect her ministers to be getting on with it, not jockeying for position and making the political class even more despised than it already was.

Fox asked to have “economic diplomacy” moved to his department in a “rational restructuring”. He had a point. He has no responsibility for securing Brexit – that lies squarely in Davis’s department – but until it is accomplished he cannot usurp the EU and make definitive trading arrangements with other nations. He can, however, hold preparatory talks with his American friends and others (he has just visited India). That does create an overlap of economic diplomacy, so one presumes the arguments between Fox and Johnson have only just begun. Fox claimed his acquisition of these powers was “crucial to the delivery of objectives I have been set by the Prime Minister”.

May slapped him down, to the amusement of Johnson partisans, but Johnson had to second some officials to Fox’s department. Fox found himself briefed against by a Foreign Office mandarin who called him “nutty and obsessive” and likened him to “Donald Rumsfeld on steroids”. This did not restrain Fox, who told a US radio show in July that his department would be taking over “a wing” of the Foreign Office, a reflection of the importance of its duties. He added: “We are effectively taking all of the elements that were UK trade and investment out of what was the Business Department. We’re taking defence and security exports from what was the Ministry of Defence where I used to be secretary of state. We’re taking UK export finance out of the Treasury, and we’re creating a totally new trade negotiation department all within itself.” Fox has also been given the venerable title of President of the Board of Trade, and has not been idle. Besides his mission to India, his department is about to open three new offices in the US – in Minneapolis, Raleigh and San Diego – to add to the existing 11.

After Fox’s spat with Johnson the two ministers, and Davis, who seemed merely an innocent bystander, held a “clear the air” meeting at the Cabinet Office on 24 August. In so far as differences between the three matter, the main one was over immigration: Davis and Fox wanted border controls with Europe reinstated, whatever the effect on the single market, but Johnson didn’t. Given May’s statement after the Chequers meeting, Johnson seems to have lost.

***

The initiative is now very much with Davis. Some backbench colleagues are telling him, in effect, there doesn’t need to be a negotiation: John Redwood has made this point seriatim on his blog, and vocally during a BBC Radio 4 documentary presented by Gus O’Donnell, the former cabinet secretary, at the end of August. Brexiteers have accused O’Donnell, and other former officials who have joined the debate, of talking up the difficulties of leaving. What the hardliners want is for Davis to announce the repeal of the European Communities Act, by which we joined what is now the EU. Given the EU’s net trade surplus with the UK – £70bn a year – the hardline view is that the EU has much more to lose than we do from denying us access to the single market.

As one of Davis’s friends told me: “There are 47 countries that have access to the single market without having to concede free movement of people. America, Russia and China have Most Favoured Nation status with the EU. Given all the money the EU makes from us, is it really in their interests to offer us a worse deal than any of those 50 countries?” This line is playing well in the Brexit Department. Davis is also being told that whatever the rhetoric of other nations – notably the doomed regime in France – ­Europe relies too much on doing business on favourable terms in the City of London to deny “passporting” rights (the ability to do business across the EU while based in the UK) to British financial institutions.

Backbenchers anxious for the process to start are telling Davis to say to the EU that it can either allow Britain access to the single market, without insisting on free movement, in return for tariff-free operation here; or the two parties can trade on World Trade Organisation terms, with tariffs, which will harm the EU more than it will harm the UK. The lack of hostile response from Germany, the biggest importer of British exports in Europe, gives the Brexiteers cause for hope that things may not be so acrimonious, and the reality far from the gloom of George Osborne’s Project Fear.

For the moment, the three ministers are not squabbling: but then it is a mistake to see them as interdependent. May will have to sort out the overlaps between Johnson and Fox’s departments: but Davis knows what he has to do, and what his remit is to do it. What remains to be decided is whether this will be a so-called hard Brexit (coming out on our terms) or “soft” (coming out on Europe’s). The rhetoric so far suggests the former; unless Davis forfeits May’s support, that is how it will stay. May must also remember that if she does feel she must stop backing Davis, she will not only have to find someone else to do his job, but deal with backbenchers who remain to be convinced that she will see the job through. In the end, as chief executive, fulfilling the will of the British people will be her responsibility.

Simon Heffer is a columnist for the Daily and Sunday Telegraphs

Simon Heffer is a journalist, author and political commentator, who has worked for long stretches at the Daily Telegraph and the Daily Mail. He has written biographies of Thomas Carlyle, Ralph Vaughan Williams and Enoch Powell, and reviews and writes on politics for the New Statesman

This article first appeared in the 08 September 2016 issue of the New Statesman, The Three Brexiteers