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

CHARLIE FORGHAM-BAILEY FOR NEW STATESMAN
Show Hide image

This 85-year-old wants to climb Everest (again). Is it time to rethink old age?

Consider this. In 1914, the chance of a child living to 100 was 1 per cent. My son has a 50 per cent chance of making it to 104.

In 1952, the Swiss doctor and Alpinist Edouard Wyss-Dunant established the concept of the “death zone”, the altitude above which human beings are unable to acclimatise because of the lack of oxygen. The mark is generally set at 8,000 metres, a height exceeded by only 14 mountains, all of them in the Himalayan or Karakoram ranges in Asia. Of these, at that time, only Annapurna had been scaled, conquered in 1950. But by the end of the decade just two of the ­eight-thousanders were still up for grabs: Shishapangma in Tibet and Nepal’s Dhaulagiri, at 8,167 metres the world’s highest unclimbed peak.

Known as the “White Mountain”, and notorious for avalanches and fierce winds, Dhaulagiri had defeated seven previous expeditions before a Swiss-led attempt in 1960. The party included 13 climbers, with an average age of 30, and a handful of Nepalese sherpa guides. As was customary, the government also insisted they take along a liaison officer, in this case a 28-year-old former soldier called Min Bahadur Sherchan.

Climbing teams usually regarded the liaison officers as a hindrance, “happiest when there is little to do and much to earn”, as the expedition leader Max Eiselin noted in his book about the summit attempt.

But Sherchan, who learned English while serving with the Gurkhas in the ­British army, was different. “He was co-operative and precise and his strong Mongolian features suggested a capable mountaineer; he very quickly became one of us,” Eiselin wrote.

To avoid wasting energy hauling supplies up the mountain on foot, Eiselin brought from Switzerland a light aircraft capable of landing in the snow and taking off on very short runways. But after several successful deliveries, and with the team preparing for its assault on the summit, the plane went missing, presumed crashed.

Sherchan and a porter were sent down the mountain to try to find the wreckage, which they did, before descending to a village in the valley where they could notify the foreign ministry. Instead of staying there, they decided to head back up, equipped only with an ice axe and a ski stick.

With no climbing experience, no footprints to guide them or rope to arrest their falls, the pair spent three days and nights crossing treacherous ice fields and crevasse-streaked glaciers, striding ahead “past all the lurking dangers, like lost children full of the joy of life going unwittingly to their doom”, Eiselin wrote. “All they had was their great strength, good and warm clothing, and an almost frivolous trust in their God.”

Late on the fourth night of their march, in thick mist and -35° Celsius cold, the two men ascended the mountain’s north-east col and stumbled upon the expedition tents at 5,700 metres.

“It was easy for me. I was stronger than the sherpas,” Sherchan, who is now 85, recalls one morning in late February while sitting in the narrow storeroom of a supermarket in Aldershot, Hampshire.

As a non-climbing member of Eiselin’s team, he was not given the opportunity to accompany the six men who completed Dhaulagiri’s first ascent on 13 May 1960. But he did go on to become a celebrated mountaineer in his own right.

It took him 48 years. In 2008, aged 76, Sherchan climbed into the death zone for the first time, becoming the oldest person to scale Mount Everest. Now, nine years on, he is heading back for another attempt.

Standing up in the storeroom aisle, surrounded by packets of rice and bottles of cooking oil, the 85-year-old flexes his right arm. “Feel it,” he says, smiling. His bicep is as firm as a new tennis ball.

 

***

 

There’s a scene early on in Charlie and the Chocolate Factory where the boy’s four grandparents are lying in the same bed, “shrivelled as prunes, and as bony as skele­tons”. Like all extremely old people, they are delicate and weak, Roald Dahl reminds readers. This would have rung true when the book appeared in 1964 and also when my parents read it to me about 15 years later. Even for the most vital old people, a game of bowls was the limit of their exertions. What did seem fantastical to me were the ages of Charlie Bucket’s grandparents – all of them over 90, with Grandpa Joe 96 and a half. As a child, I knew nobody that old.

Today, as I read the book to my six-year-old son, it seems as though Dahl was merely ahead of his time regarding demographics. For much of the past 200 years, advances in tackling infant mortality and chronic diseases of the middle-aged, as well as improved nutrition, income and public health systems, have added two years to life expectancy every decade. As Lynda Gratton and Andrew Scott note in their fascinating book, The 100-Year Life, published last year, we are now “in the midst of a extraordinary transition” in longevity.

Consider this. In 1914, the chance of a child living to 100 was 1 per cent. My son has a 50 per cent chance of making it to 104. Even someone my age – 42 – in the West has a near-even chance of living as long as Grandpa Joe, and a 60-year-old is as likely as not to witness another three decades on Earth. Within the next three years, for the first time, the global number of adults aged over 65 will exceed that of children under five.

This change in lifespans has huge implications for society. We will have to work longer and save more for retirement. And what of our health? Will we be confined to bed in our final years, delicate and weak, like Charlie’s grandparents? Probably not. As Gratton and Scott note, it’s not just that people will live longer: they will be healthier for even longer. Citing various studies, including US research that showed a sharp fall in the proportion of over-85-year-olds classified as disabled between 1984 and 2004, they write: “Older people seem to be fitter and also can achieve more as technology and public support improves.”

And some of them – the mountaineer Min Bahadur Sherchan and other “super-agers” – are demonstrating that “fitter” means not merely staying upright, but also fitter in the sporting sense. Their extraordinary achievements have led scientists to reassess the possibilities of performance and ageing.

Take Ed Whitlock. Born in London, he excelled at cross-country as a teenager. After moving to Canada following university, however, he stopped running, only taking it up again in his forties.

By then, he was already past his ­athletic peak. Michael Joyner, a ­physician-­researcher at the Mayo Clinic in Rochester, Minnesota who studies human performance, says that our aerobic capacity – the functional capacity of our heart, lungs and blood vessels – generally declines by 10 per cent a decade from our thirties onwards. Our muscle tone drops in our forties and fifties, as does our speed, co-ordination and flexibility.

“We know, however, that the rate of decline into our seventies can be moderated by training and exercise,” Joyner told me.

After retiring in his sixties, Whitlock started to run seriously. In 2003, he became the first man over 70 to dip under three hours for a marathon. The next year, aged 73, he shaved four minutes off that time and clocked 2:54:48. It is regarded as one of the greatest runs ever by an athlete of any age.

A friendly, laid-back man of slight build and with flowing white hair, Whitlock had no coach and no strict diet and favoured well-worn shoes. What he was disciplined about was his training. Asked by a journalist for his secret to a happy marriage, he said: “It probably helps that I go out like a bloody fool and run for something like three hours every day.”

Whitlock’s times slowed, of course. But in October, aged 85, and just a few months before he died of prostate cancer, he ran a sub-four-hour marathon, the oldest person ever to do so.

At the same stage in her life, Olga Kotelko was barely getting started. In 2009 at the World Masters Games in Sydney, she ran the 100 metres in 23.95 seconds – at the age of 90 – faster than some of the finalists in the race for women a decade younger. Born in 1919, one of 11 siblings, she grew up on a farm in Canada and lived an active, if not sporty life until her late seventies, when she started to take track and field seriously.

According to a New York Times profile, she hit the gym three times a week and did punishing routines of planks, squats and bench presses. Even in her nineties she did push-ups and sit-ups, keeping her body strong and probably her mind, too. When researchers studied her brain in 2012, they found it had shrunk less than those of others her age. Two years later, aged 95, she became the oldest ever female competitor in the indoor sprints, long jump, high jump and triple jump at the World Masters Athletics Championships. (She died the following month.)

Perhaps the most remarkable late-life achievements of all are by ­Robert Marchand. Born in 1911, the five-foot Frenchman fought fires in Paris before being taken prisoner during the Second World War, drove trucks in Venezuela, chopped trees in Canada, and tended gardens and sold wine. Only after he retired at 70 did he return to cycling, his pastime as a young man. He rode most days, on the streets or on an indoor trainer, usually at a relaxed pace. He kept going through his eighties and his nineties, maintaining a diet heavy on fruit and vegetables and light on meat and coffee.

In 2012, he set the one-hour record for cyclists over 100, completing 15.1 miles. Then Véronique Billat stepped in. A professor of exercise science at the University of Paris-Saclay in France, Billat had found that older athletes could increase their aerobic fitness with intense exercise, but had never studied anyone as old as Marchand.

She tested his VO2 max – a measure of how efficiently our bodies use oxygen, and a strong indicator of fitness – and his pedaling power. She then gave him a new training regimen. Four in five of his workouts were still performed at an easy pace, but for the other one he pedalled much faster. After two years, and 6,000 miles on the bike, ­Billat tested Marchand again.

He had improved his peak power output by 39 per cent. His VO2 max was 13 per cent higher and in the same range as a sedentary man less than half his age. Marchand then made another attempt at the world record, now aged 102. This time he covered 16.7 miles.

In a paper published in the Journal of Applied Physiology in December, Billat and her fellow researchers said they had proved for the first time that it was possible to improve the performance of a centenarian through better training. Beyond breaking records, the quest for progress served to “add life to the life”, rather than trying to “kill the death”, they wrote.

“Robert treats each minute of life as though it’s his last,” Billat told me. “And he does not take himself too seriously.”

She credits the surge in competitive older athletes to several factors: an increase in ­leisure time, better health, the popularity of sports such as running and, crucially, disposable income. But she wonders whether it will continue if pensions become smaller.

“Super-agers” such as Whitlock, Kotelko and Marchand also share another characteristic, says Joyner, the physician at the Mayo Clinic. “If you look at a lot of them, they are humble on one level but also, in a way, pleasantly aggressive. It’s like: ‘Limitations? Who says?’”

 

***

 

That could be Min Bahadur Sherchan’s motto. He grew up poor in the village of Tatopani in the central Nepali district of Myagdi. In 1948, aged 17, and having spent a total of two months in school, he was recruited by the British army and sent for training in the Malay Peninsula before joining the Queen’s Gurkha Signals.

After five years he returned to Nepal ­hoping to study and then see the world. When his plans fell through he became involved in politics and, through his government contacts, was assigned to the Dhaulagiri expedition.

Afterwards, Sherchan forgot about moun­taineering and set about providing for his wife and seven children. He established an apple farm, which failed. “People thought I was crazy,” he says. “Apples were then a new thing in Nepal.”

Overseeing road construction was less interesting but paid the bills. By the time Sherchan retired he was living in the capital, Kathmandu. Though he often drank alcohol, he had never smoked and he kept up a stretching regime. He felt fit. And one day, when he was 72, something clicked in his head. “I should summit Everest. Yes, why not summit Everest?”

At that point, nobody older than 65 had climbed the peak. Ignoring protests from his wife, children and friends, he began to prepare, walking alone across Nepal from north to south and east to west to prove his fitness. He struggled to convince the government, though, and only in 2008 was the permit for his “Senior Citizen Everest Expedition” approved. The climb went smoothly and on 25 May of that year he crossed into the death zone and stood on the summit.

Back home, Sherchan resolved to stay healthy in case he had the chance to climb again, cutting rice from his diet in favour of maize, wheat and other grains, and cooking all his own food. Every night he drank a glass of hot milk with sugar.

In 2013 he saw his opportunity. The 80-year-old Japanese adventurer Yuichiro Miura, whose record Sherchan had broken, announced that he would attempt Everest again. Sherchan decided to defend his title. (He is a year older than Miura.)

Miura reached the top and took the record – though he had to be airlifted to safety on the descent. But Sherchan didn’t get to climb because of a bureaucratic mix-up with dates. He tried again in 2015, but the terrible earthquake that struck Nepal ended the climbing season early.

In mid-April, Sherchan will once more head to base camp. He is confident of success, thanks to his fitness regime. At the supermarket in Aldershot, owned by an ex-Gurkha hosting his brief fundraising visit to the UK, he demonstrates the twice-daily workout he has performed for the past five years: swinging his arms marching style, lifting them from his sides and rotating them in circles, stretching his hands above his head, doing squats and bicep curls.

Since the start of the year he has added two-hour walks carrying a 25-kilogram backpack to his training, in the hills or up and down the stairs of a five-storey building.

Does he not feel that age is against him? “Three things can stop you on Everest: your heart, breathing issues or the altitude,” he says. “I don’t have problems with any of these, and though I don’t have any special powers, I’m fit and have determination.”

He hopes to make Nepal proud and inspire elderly people. And even if he doesn’t make it this time, there’s always next year.

“Until I’m 87, it will be OK. After that, you never know.”

Xan Rice is the features editor of the New Statesman

Xan Rice is Features Editor at the New Statesman.

This article first appeared in the 06 April 2017 issue of the New Statesman, Spring Double Issue

0800 7318496