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 English Revolt

Brexit, Euroscepticism and the future of the United Kingdom.

English voters have led – some would say forced – the United Kingdom towards exit from the European Union. Was this an English revolt, the result of an ­upsurge over decades of a more assertive, perhaps resentful, sense of English identity? At one level, clearly so. Surveys indicate that individuals who most often describe themselves as “English”, and regions where this is common, were more inclined to vote Leave on 23 June. Some of these are poorer regions where marginalised people think that their voices are more likely to be heard in a national democracy than in an international trading bloc, and for whom patriotism is a source of self-respect. But it would only make sense to regard Leave as essentially an English reaction if discontent with the EU were confined to England, or specifically linked with feelings of Englishness.

In fact, negative opinions about the EU, and especially about its economic policy, are now more widespread in other countries than they are in England. Polls by the Pew Research Centre last month showed that disapproval of the EU was as high in Germany and the Netherlands as in Britain, and higher in France, Greece and Spain. Though aggravated by the 2007-2008 crash and enforced policies of austerity, a decline in support was clear earlier. France’s referendum of May 2005 gave a 55 per cent No to the proposed EU constitution after thorough debate, and a now familiar pattern emerged: enthusiastic Europeanism was confined to the wealthiest suburbs and quarters of Paris, and the only professional groups that strongly voted Yes were big business, the liberal professions and academics.

Going far beyond the atavistic and incoherent English revolt that some think they discern, our referendum result is partly a consequence of transnational political phenomena across the democratic world: the disaffection of citizens from conventional politics, shown by falling turnouts for elections, shrinking party membership and the rise of new, sometimes extreme political movements; as well as the simultaneous detachment of a professional political class from civil society, and its consequent retreat into a closed world of institutions.

The EU embodies these phenomena in uniquely acute form. In several cases its central bodies have opposed – or, if one prefers, have been forced to deny – democratically expressed wishes. In Greece and Italy, the EU has enforced changes of government and policy, and in Denmark, Ireland and the Netherlands it has pressed countries to ignore or reverse popular referendums. Its own representative body, the European Parliament, has gained neither power nor legitimacy. Crucial decisions are taken in secret, making the EU a hiding place for beleaguered politicians as well as a source of lavish financial reward for insiders. In the words of the historian John Gillingham, Europe is now being governed by neither its peoples nor its ideals, but by a bank board. This is not the “superstate” of Eurosceptic mythology. Though it drains power and legitimacy away from national governments, it is incapable of exercising power effectively itself, whether to cope with short-term emergencies such as an inflow of refugees, or to solve chronic failings such as the creation of mass unemployment in southern Europe. The result is paralysis, the inability either to extricate itself from failing institutions or to make them work.

If popular discontent with the EU continues to increase (and it is hard to see how it could not) sooner or later there will be some unmanageable political or social crisis. The response of too many supporters of the EU is to screw the lid down tighter, including now by promising to make life difficult for the United Kingdom, pour décourager les autres. This is the organisation – unpopular, unaccountable, secretive, often corrupt, and economically failing – from which our decision to depart apparently causes people to weep in the streets.

***

Why this decision? Why in Britain? The simplest and perhaps the best answer is that we have had a referendum. If France, Greece, Italy and some other countries had been given the same choice, they might well have made the same decision. But of course they have not been and will not be given such a choice, barring severe political crisis. This is most obviously because countries that have adopted the euro – even those such as Greece, for which the IMF has predicted high unemployment at least until the 2040s – have no clear way out.

I make this obvious point to emphasise that the immediate explanation of what has happened lies not only and not mainly in different feelings about the EU in Britain, but in different political opportunities and levels of fear. The contrasting votes in Scotland and Northern Ireland have particular explanations. Scottish nationalists – like their counterparts in Catalonia – see the EU as an indispensable support for independence. Northern Ireland sees the matter primarily as one affecting its own, still tense domestic politics and its relations with the Republic. In a European perspective, Scotland and Northern Ireland are the outliers, not England and Wales. Indeed, Scotland’s vote makes it stand out as one of the most pro-EU countries in Europe. If ever there is another referendum to see whether Scots prefer the EU to the UK, it will show whether this level of support for the EU is solid.

If England is exceptional, it is not in its disaffection from the EU, nor in the political divisions the referendum vote has exposed (if France, for instance, had such a vote, one could expect blood in the streets). Rather, its exceptional characteristic is its long-standing and settled scepticism about the European project in principle, greater than in any other EU country. Every ­member has a specific history that shapes its attitude to the theoretical idea of European integration. As John Gillingham, one of the most perceptive historians of the EU, describes its beginnings: “to the French [supranationalism was] a flag of convenience, to the Italians it was preferable (by definition) to government by Rome, to the Germans a welcome escape route, and to the Benelux nations a better choice than being dominated by powerful neighbours”.

Subsequently, for the eastern European states, it was a decisive step away from communist dictatorship, and for southern Europe a line drawn under a traumatic history of civil conflict. There is also a widespread belief, powerful though fanciful, that the EU prevents war between the European states. All these are important reasons why there remains considerable support for unification as an aspiration. But all these reasons are weaker, and some of them non-existent, in Britain, and especially in England. The simple reason for this is that Britain’s experience of the 20th century was far less traumatic. Moreover, during that time loyalty to the nation was not tarnished with fascism, but was rather the buttress of freedom and democracy. Conversely, the vision of a European “superstate” is seen less as a guarantee of peace and freedom, and rather as the latest in a five-century succession of would-be continental hegemons.

Given all this, an obvious question is why the United Kingdom ever joined in the European project in the first place. The answer helps to explain the country’s subsequent lack of enthusiasm. Its first response to the creation of the European Economic Community in 1957 was not to join, but to agree to establish a separate European Free Trade Association (Efta) in 1959 with Austria, Denmark, Norway, Portugal, Sweden and Switzerland; over the next three decades the seven founder members were joined by Finland, Iceland and Liechtenstein. This worked efficiently, cheaply and amicably, and, in time, Efta and the EEC would doubtless have created trading arrangements and systems of co-operation. But then the historic mistake was made. Efta was considered too small to provide the diplomatic clout craved by Whitehall at a time of severe post-imperial jitters. A cabinet committee warned in 1960 that “if we try to remain aloof from [the EEC] – bearing in mind that this will be happening simultaneously with the contraction of our overseas possessions – we shall run the risk of losing political influence and of ceasing to be able to exercise any real claim to be a world Power”.

Besides, Washington disliked Efta as a barrier to its aim of a federal Europe, and the Americans put heavy pressure on London to apply to accede to the Treaty of Rome, which it duly did in August 1961. “It is only full membership, with the possibility of controlling and dominating Europe,” wrote an optimistic British cabinet official, “that is really attractive.”

As the former US secretary of state Dean Acheson (one of the early backers of European integration) put it, in a now celebrated comment in December 1962: “Great Britain has lost an empire, and has not yet found a role. The attempt to play a separate power role . . . apart from Europe . . . based on a ‘special relationship’ with the United States [or] on being the head of a ‘Commonwealth’ . . . – this role is about played out.”

Acheson’s words long haunted British policymakers; perhaps they still do. And yet Britain remains one of the half-dozen strongest and most assertive states anywhere in the world, just as it has been for the past three centuries.

To fear of diplomatic marginalisation was added fear of economic decline. A government report in 1953 warned of “relegation of the UK to the second division”. Over the next 30 years there was a chorus of dismay about “the sick man of Europe”. Belief that EEC membership at any price was the only cure for Britain’s perceived economic ills became the orthodoxy in official circles: Britain was “the sinking Titanic”, and “Europe” the lifeboat.

So, on 1 January 1973 Britain formally entered the EEC with Denmark and Ireland. Other Efta members remained outside the Community – Switzerland and Norway for good. Harold Wilson’s 1975 referendum on whether to stay in the EEC in effect turned on Europe’s superior economic performance – which, though no one realised it at the time, had just ended.

This memory of apparent British economic weakness half a century ago still seems to weigh with older Remainers. Yet it was based on a fundamental misconception: that European growth rates were permanently higher than in a supposedly outdated and declining Britain. In reality, faster growth on the mainland in the 1950s and 1960s was due to one-off structural modernisation: the large agricultural workforce shifted into more productive industrial employment. From the mid-1940s to the early 1970s this gave several European countries “windfall growth” at a higher rate than was possible in Britain, which since the 19th century had had no large agricultural sector to convert. By the early 1970s, once that catching up was finished, European growth rates became the same as, or slightly lower than, Britain’s. When measured over the whole half-century from 1950 to 2000, Britain’s economic performance was no different from the ­European norm. By the mid-1980s, growth was faster than in France and Germany, and today Britain’s economic fundamentals remain strong.

Slower European growth lessened the perceived attractiveness of EU integration. In 1992, on Black Wednesday (16 September), hesitant participation in the European Exchange Rate Mechanism led to forced devaluations in Finland, Sweden, Italy, Spain and, finally, Britain. This was a huge political shock, though an economic boost.

Black Wednesday subsequently made it politically difficult for Britain to join the eurozone – allowing us a narrow escape, attributable more to circumstance than to policy, as vocal political and economic lobbies urged joining.

Moreover, Britain’s trade with the rest of the EU was declining as a proportion of its global activity: as Gordon Brown observed in 2005, 80 per cent of the UK’s potential trade lay outside the EU. The EU’s single market proved not very effective at increasing trade between its members even before the crash of 2007-2008, and prolonged austerity thereafter made it stagnant. Consequently, in the 2016 referendum campaign, more emphasis was placed on the dangers of leaving the single market than on the precise benefits of being in it.

But the days when Britain seemed the Titanic and Europe the lifeboat were long gone. On the contrary, Britain, with its fluid and largely unregulated labour market, had become the employer of last resort for the depressed countries of the eurozone. The sustained importation of workers since the 1990s had become, for a large part of Britain’s working class, the thing that most obviously outweighed whatever legal or economic advantages the EU might theoretically offer.

***

What galvanised the vote for Brexit, I think, was a core attachment to national democracy: the only sort of democracy that exists in Europe. That is what “getting our country back” essentially means. Granted, the slogan covers a multitude of concerns and wishes, some of them irreconcilable; but that is what pluralist democracy involves. Britain has long been the country most ­resistant to ceding greater powers to the EU: opinion polls in the lead-up to the referendum showed that only 6 per cent of people in the UK (compared to 34 per cent in France, for instance, and 26 per cent in Germany) favoured increased centralisation – a measure of the feebleness of Euro-federalism in Britain.

In contrast, two-thirds wanted powers returned from the EU to the British government, with a majority even among the relatively Europhile young. This suggests a much greater opposition to EU centralisation than shown by the 52 per cent vote for Brexit. The difference may be accounted for by the huge pressure put on the electorate during the campaign. Indeed, arithmetic suggests that half even of Remain voters oppose greater powers being given to the EU. Yet its supporters regard an increase of EU control over economic and financial decisions – the basics of politics – as indispensable if the EU is to survive, because of the strains inherent in the eurozone system. This stark contradiction between the decentralisation that many of the peoples of Europe – and above all the British – want to see and the greater centralisation that the EU as an institution needs is wilfully ignored by Remain supporters. Those who deplore the British electorate’s excessive attachment to self-government as some sort of impertinence should be clear (not least with themselves) about whether they believe that the age of democracy in Europe is over, and that great decisions should be left to professional politicians, bureaucracies and large corporations.

Some have dismissed the Leave vote as an incoherent and anarchic protest against “the establishment”, or as a xenophobic reaction against immigrants. Some of the media in Britain and abroad have been doing their best to propagate this view. Yet xenophobia has not been a significant feature of British politics since the 1960s, and certainly far less so than in many obedient EU member states, including France, Germany, Greece and the Netherlands. As for the anti-establishment “revolt”, this emerged when parts of the establishment began to put organised pressure on the electorate to vote Remain. Would-be opinion-formers have hardly covered themselves in glory in recent weeks. They have been out of touch and out of sympathy with opinion in the country, unwilling or unable to engage in reasoned debate, and resorting to collective proclamations of institutional authority which proved embarrassingly ineffective.

Worst of all, their main argument – whether they were artists, actors, film-makers, university vice-chancellors or prestigious learned societies – was one of unabashed self interest: the EU is our milch-cow, and hence you must feed it. This was a lamentable trahison des clercs. The reaction to the referendum result by some Remain partisans has been a monumental fit of pique that includes talking up economic crisis (which, as Keynes showed, is often self-fulfilling) and smearing 17 million Leave voters as xenophobes. This is both irresponsible and futile, and paves the way to political marginalisation.

The Queen’s call for “deeper, cooler consideration” is much needed. I recall Victor Hugo’s crushing invective against French elitists who rejected the verdict of democracy, when in 1850 he scorned “your ignorance of the country today, the antipathy that you feel for it and that it feels for you”.

This antipathy has reduced English politics to a temporary shambles. It is too early to say whether there will be some realignment of the fragments: One-Nation Toryism, Conservative neoliberalism, “new” and “old” Labour, the hibernating Liberal Democrats and Greens, the various nationalists and, of course, the unpredictable Ukip. When in the past there were similar crises – such as Labour’s rift over the national government in 1931, the Liberals’ split over Irish home rule in 1886, or the Tory fragmentation over the repeal of the Corn Laws in 1846 – the political balance was permanently changed.

***

Many Europeans fear that a breakdown of the EU could slide into a return to the horrors of the mid-20th century. Most people in Britain do not. The fundamental feature of the referendum campaign was that the majority was not frightened out of voting for Leave, either by political or by economic warnings. This is testimony to a significant change since the last referendum in 1975: most people no longer see Britain as a declining country dependent on the EU.

A Eurobarometer poll in 2013 showed that Britain was the only EU member state in which most citizens felt that they could face the future better outside the Union. Last month’s referendum reflected this view, which was not reversed by reiterated predictions of doom.

In retrospect, joining the Common Market in 1973 has proved an immense historic error. It is surely evident that we would not have been applying to join the EU in 2016 had we, like Norway or Switzerland, remained outside it. Yet the political and possibly economic costs of leaving it now are considerable. Even though discontent with the EU across much of Europe has recently overtaken sentiment in Britain, Britain is unique, in that, ever since the 1970s, its public has been consistently far less ­favourable to the idea of European integration than the electorate in any other country. Hence the various “opt-outs” and the critically important decision to remain outside the euro.

Now, by a great historic irony, we are heading towards the sort of associate status with the EU that we had in the late 1960s as the leading member of Efta, and which we could have kept. Instead, this country was led by its political elite, for reasons of prestige and because of exaggerated fears of national decline and marginalisation, into a vain attempt to be “at the heart of Europe”. It has been a dangerous illusion, born of the postwar declinist obsession, that Britain must “punch above its weight” both by following in the footsteps of the United States and by attaching itself to the EU.

For some, money, blood and control over our own policy were sacrifices worth making for a “seat at the top table”. This dual strategy has collapsed. In future we shall have to decide what is the appropriate and desirable role for Britain to play in the world, and we shall have to decide it for ourselves.

Robert Tombs is Professor of French History at Cambridge University. His most recent book is “The English and Their History” (Penguin)

This article first appeared in the 21 July 2016 issue of the New Statesman, The English Revolt