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 life of Pi

How the gaming prodigy David Braben and his friends invented a tiny £15 device that became the biggest-selling British computer.

If you had visited David Braben’s room at Jesus College, Cambridge in 1983 you would have found an unusual scene. Sure, it was just as cramped, muddled and tinged with the fragrance of generations of undergraduates as that of any other student. But while Braben’s neighbours lined their walls with textbooks and Hollywood posters, the shelves in his room supported cascades of cabling and copper wire. And there in the centre of the desk, amid a shanty town of screws and pliers, an Acorn Atom computer hummed.

Braben knew its insides better than his own. Such was the extent of his frequent and intrusive tinkering that he left the machine’s casing permanently off, leaving the circuitry exposed, like that of a battle-wrecked android. One winter’s day that year, he and a friend, Ian Bell, stood in front of the Atom’s chunky monitor. Braben moved his hand towards the keyboard and, with a tap, executed a Big Bang.

Elite, as Braben and Bell’s universe would later be named, was an ambitious computer simulation of endless rolling galaxies, waiting to be explored via a digital spaceship. To grow such vastness from such rudimentary technology, Braben had to pull off the equivalent of a numerical conjuring trick. Rather than manually plotting cosmic systems by typing star and planet co-ordinates into a database, he used the Fibonacci sequence, which starts with “0” and “1”, and continues the sequence by adding the two preceding numbers. This mathematical curiosity governs a variety of natural phenomena, such as the arrangement of leaves on a tree or the pattern of the florets in a flower, making it the ideal formula to spawn a seed from which virtual galaxies could be generated.

The game offered breadth and depth. You toured the universe in a spaceship, represented on screen by a few scant white lines, free to mine resources, dogfight with pirates or even become a galactic marauder yourself, preying on the cargo ships that sailed along trade routes. While most arcade games of the time brought players into their reality for a few brief minutes before kicking them out again, penniless and defeated, Elite worked at a different pace. Players could spend hours touring its innumerable systems. Braben’s contemporaries were astonished. “We stood around wide-eyed; these were feats of coding we had thought impossible on the low-powered machines of the day,” Jack Lang, a university friend of Braben’s, told me.

Braben and Bell’s invention became a sensation. Elite sold out of its initial run of 50,000 copies in less than two weeks, and went on to sell 600,000 copies across 17 different computer formats, making millionaires of its young creators. The game also inspired a generation of so-called Britsoft programmers who, over the next decade, would make Britain a leading hub for computer-game development, and produce, in Tomb RaiderGrand Theft Auto and Championship Manager, a clutch of enviable and world-renowned names.

 

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Twenty years later, when he was running Frontier Developments, one of the most successful games companies in the UK, Braben noticed a trend. Each time his company advertised a job in programming, ­fewer candidates would apply. “I was expecting the number of applicants to rise because we’d had some positive press,” he told me when I visited him at the Frontier offices in Cambridge.

Braben, who, in his black hoodie, looks significantly younger than his 53 years, runs Frontier from a spacious, glass-fronted office. Nearby, scores of artists, designers and programmers tap and toil in orderly phalanxes of computers. The company, which in 2016 turned over £21.4m, employs more than 300 staff.

“But at that time we found that we were having to hire from abroad,” Braben told me. He called some directors at other British games companies and found that they had the same problem. Then he called the University of Birmingham, where he sat on the advisory board. “They, too, were in crisis: applicants to the computer science course had dropped off a cliff,” he said. “It made no sense to me.”

At the time, Braben was running focus tests with children on one of the company’s games, and he sneaked an additional question into his survey: “What is the most boring lesson at school?” The response left him bewildered – ICT (information and communications technology). “You would think computing would be the most exciting lesson for a child at school, wouldn’t you?” he said.

He called a local schoolteacher. “The issue became immediately obvious: the curriculum was teaching children nothing more than how to use Word and Excel. Programming had been removed from lessons and, in most cases, ICT was being taught by people who were computer-illiterate.” The teacher told him that students would run riot in class. Some children had discovered that by deleting a few critical files from Windows they could ensure that the computer would fail to switch on the next time the machine was rebooted.

“Schools were having to employ people just to repair this vandalism,” Braben said. The drop-off in applicants to computer science courses at universities and for positions in development studios was, he concluded, a result of years of classroom neglect. The Britsoft industry, it seemed, was in danger of collapsing from the bottom up.

Braben wrote to Margaret Hodge, then an education minister in Tony Blair’s Labour government. “I thought they were keen on education,” he recalled. “But when we met, Hodge told me that they were already teaching computer studies. She accused me of special pleading for my industry.” (Hodge has said, through a spokeswoman, that she “does not recall this meeting”.)

Braben told Hodge that she didn’t need to take his word for it; she could simply speak to a few teachers. “It was so frustrating,” he said. “Government was pouring all of this money into things that weren’t necessarily making a difference to getting kids into computer science. I was just trying to point out that the games industry was a huge asset that could be used to inspire kids. Kids like to learn to program if it’s framed around making games.”

This was Braben’s own childhood experience. His father worked for the Cabinet Office researching nuclear physics, and the family moved around, living in Cheshire in Stockton Heath, near Warrington, then briefly in Italy and finally in Epping, in the eastern suburbs of London. All the while Braben was designing games for him and his two younger siblings to play. One of the first was a modified version of battleships, played in the back garden using pieces pilfered from other board games, and based on nautical battles from the Second World War that he had read about in history books.

After he persuaded his parents to buy him the Acorn Atom, Braben progressed to designing computer games. For one of them, he drew a map of the northern hemisphere as viewed from space. He then taped the map to the computer screen and traced the outline of the countries in code. In the resulting game, players assumed either the role of the Americans or the Russians, tasked with sending nuclear bombs arcing across the screen in an attempt to destroy their opponent’s main cities. The winner was rewarded with a rudimentary computer version of their side’s national anthem.

Braben, who attended Buckhurst Hill County High, a grammar school in Chigwell, Essex, was a natural programmer, talented at maths and physics. But the computer on which he learned his basic programming skills, the Acorn Atom – the precursor of the BBC Micro, which would soon be found in many school ICT rooms – made it easy for him.

“It came with everything you needed in the box,” he said. “People say these days that design software costs only around £100, but that’s a huge amount for a kid. The amazing thing was that, with the Acorn and the BBC Micro and many of those other early machines, you had everything you needed to learn how to program anything you could imagine right from the get-go.”

Braben’s talent extended to entrepreneurship. When he was 17, he wrote to a games publisher saying that he believed his games to be as good as theirs. A week later three men in suits showed up at his parents’ house; he was worried about taking his computer to their office on public transport, so they offered to come to him. Astonished at what the boy had managed to achieve with the hardware, they offered him a job on the spot. Braben pretended to mull the offer over for a few days, before refusing the position in favour of studying natural sciences at Cambridge.

It was the memory of these formative experiences to which he returned when he was cold-shouldered by the government. He called Lang, by then an entrepreneur in Cambridge, who said the university there was also struggling to attract computer science applicants. The pair discussed ways to get the subject taught in the classroom, and a plan formed. If they could find a way to teach programming outside the school system, perhaps the schools would follow.

Initially Lang and Braben considered designing a programming course using bespoke software. The problem was that schools and libraries around the country used different versions of Windows. Finding a one-size-fits-all solution for students to compile and run their games proved impossible. Instead, Lang suggested the idea of a budget computer, one that would allow children the freedom to tinker, customise and break things, and then restore it all at the touch of a button.

“It struck me that probably the best way these days for a young student to learn how to program is to buy an old BBC Micro off eBay,” Braben said. “That’s a bit of an admission, isn’t it? It’s also fundamentally capped by the number of BBC Micros that are still working in the world, so it’s not a general solution. But it’s such a good way of learning. It encourages you to experiment. Rebooting a PC can easily damage the software. With the BBC Micro you could do all kinds of outrageous things and then just reset it. The hardware was tough, too.”

It is possible to destroy a BBC Micro, Braben said, but very difficult. So the idea was to build a computer that reflected the Micro’s sturdiness and simplicity: a machine for all-comers, practically indestructible in form, and universal in function. In 2003 Braben, Lang and four of their friends – Pete Lomas, Alan Mycroft, Robert Mullins and Eben Upton (“slightly eccentric guys from Cambridge”, as Braben puts it) – met at a computer lab at the university and, from a shopping list of components, began to price up a microcomputer.

“We knew how cheap components were becoming because of the rise of mobile phones,” Braben said. “But when we came up with the final price we couldn’t believe how low it was.” The group estimated it would be possible to build a home computer with a single USB port and an HDMI (high-definition multimedia interface) connector – which enables the device to be connected to a compatible screen – for £15.

 

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The six men named their invention the Raspberry Pi. “Fruit seemed good; Raspberry particularly good because it’s a bit of a thumb-nose at the convention. We added Pi to make it sound a bit mathematical,” said Braben. They formed the Raspberry Pi Foundation, a charity aiming to “promote the study of computer science and related topics . . . and put the fun back into learning computing”. It was almost a decade before their vision for the micro-budget microcomputer would become a reality.

“We decided that we needed support from a large organisation,” Braben said. “We started speaking to the BBC and spent a few years discussing the project with them as potential partners.” The group even offered to give the corporation the software design free of charge. But the strong initial interest led to a series of interminable meetings, where nobody from the BBC seemed willing to be the one to make the final decision.

“The final meeting I had with the BBC really annoyed me,” he said. “They told me that I needed to seek sign-off from a group that had already signed off on the project, simply because there had been a reorganisation in that group. We were going around in circles. That’s when I realised it wasn’t going to work.”

Immediately after the meeting, a furious Braben strode to the White City office of Rory Cellan-Jones, the BBC’s technology correspondent. Cellan-Jones knew of Braben from reading Francis Spufford’s 2003 book, Backroom Boys, a biography of various British inventors in which Braben and Bell featured prominently.

“When Braben contacted me under the illusion that I was somebody at the BBC with some semblance of power, rather than an infantryman, I was delighted,” Cellan-Jones told me. Yet he was at a loss as to what he could do to help the inventor standing in front of him with a Raspberry Pi in his hand. “I thought to myself: well, there’s nothing I can do with this. I can’t get a crew to film something like that.”

Sensing Braben’s despair, Cellan-Jones suggested that he film a short video on his phone there and then; he would post it to his BBC blog and announce the Raspberry Pi to the world. Doing so might, Cellan-Jones reasoned, force the BBC’s hand. At the very least it would help to gauge public interest in the device.

In a nearby corridor, Braben held the device up to the camera and explained what it was and why it might be important. “It was short and simple,” he recalled. At lunchtime on 5 May 2011, Cellan-Jones posted the video and a story about the computer to his blog. “It’s not much bigger than your finger, it looks like a leftover from an electronics factory, but its makers believe their £15 computer could help a new generation discover programming,” he wrote.

The story went viral, receiving a quarter of a million hits that day. “I was surprised and delighted,” Cellan-Jones said. “It was a great idea from the start. But I encounter lots of great ideas. You get to the stage where you start to believe that nothing will work. Then, every now and again, someone turns up with a rocket ship to Mars.”

Despite the interest, the BBC, as Braben puts it, kept coming up with reasons why the corporation shouldn’t back it. So the six members of the foundation decided to fund the first 10,000 units out of their own pockets. On 29 February 2012, at 5am, Braben began a day of media appearances, first on BBC Worldwide, then on Radio 4’s Today programme. An hour later, the website where the public could order one of the first Raspberry Pis went live. Within five seconds it had sold out.

Unable to keep up with the demand, the website sold far more units than the team had components for. “It went very well indeed,” Braben said.

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Since then, the rise of Raspberry Pi has been inexorable, with more than seven million units sold. This fully customisable and programmable computer, no larger than a credit card and only slightly thicker, can be used for everything from controlling the lights in your garage to learning how to become a software developer. In Syria it has been used to create local radio transmitters, able to broadcast messages to towns within a range of up to six kilometres, disseminating information about nearby skirmishes and essential supplies.

The Pi computer has been used to take weather balloons to the edge of space – its four AA batteries draw just enough current to stop the device from freezing – enabling schoolchildren to send teddy bears into the stratosphere to take photographs of the curvature of the planet. It can even broadcast its position by GPS, enabling those children to locate the device when it floats back to Earth. It doesn’t matter too much if it is lost, because it costs as little as £5 in its most basic form. This year, the foundation gave away a basic Raspberry Pi on the front of the MagPi, an affiliated magazine that teaches readers how, among other things, to program a football game from scratch.

Hundreds of thousands of young people have attended the foundation’s educational programmes. In 2015 Raspberry Pi entered into a collaboration with Code Club, an organisation created as a response to “the collective failure to prepare young people for life and work in a world that is shaped by digital technologies”. Code Club now runs more than 3,800 clubs in the UK and over 1,000 more in 70 other countries. Staffed by volunteers, the clubs provide nine-t0-11-year-olds with the opportunity to make things using computers. Roughly 44,000 young people regularly attend Code Clubs in the UK alone; some 40 per cent of these youngsters are girls.

Braben’s plan to get British schoolchildren learning how to program has been even more fruitful. Since Raspberry Pi’s launch, applications for computer science degrees have increased by a factor of six. Data from Cambridge Assessment, the exams and research group, shows a significant increase in numbers of children choosing to study ICT at GCSE level, with a 17 per cent year-on-year rise in 2015.

There have been other beneficial side effects. Thanks to the buzz generated by the Raspberry Pi, and pressure from the foundation as well as Google, Microsoft and others, the government has put computer science back on the national curriculum.

“We’re seeing a huge growth in engagement with computer science in the UK, and Raspberry Pi has been a big part of that movement,” said Philip Colligan, the chief executive of the Raspberry Pi Foundation. “It came along at just the right moment and provided a physical manifestation of the idea that kids should be learning how to make things with computers, not just how to consume.”

Cellan-Jones agrees that the timing of the device’s launch was perfect. “It was certainly part of a wide movement to change how ICT was taught in schools, but of all those efforts I think it played the most important part. By having a physical object it made it tangible.”

Braben believes that the Raspberry Pi and its many imitators are dispelling the mystique that has grown around technology, driven in part, he says, by Apple’s closed systems. It is almost impossible, for example, to remove the cover of an iPhone to see how it works.

“When I was growing up, if my hi-fi was buzzing I’d take the lid off and maybe put some Blu-Tack in to stop the buzzing,” he said. “At some point, this collective fear crept in.”

For Braben, who has two stepchildren, now going on 13 and 18, it’s important for children not to be afraid of the technology on which they rely. “You only need one person in ten to actually study computer science. But for everyone else, having some understanding about, say, what goes on in your phone is incredibly helpful.

“In so many walks of life, whether you’re a builder using power tools or an accountant using accounting software, you are forever being presented with and relying upon technology. Understanding a little about what’s going on, rather than being afraid and embarrassed, is crucial.”

So, too, is having fun along the way. Braben has since returned to the stars of his youth by way of Elite: Dangerous. This sequel to the game that made him his fortune was released in late 2015. Rather than turn to algorithms to scatter the universe with stars and planets, this time the Frontier team re-created our own galaxy.

The digital sky for the revamped game includes every known star present in our own, their positions drawn from the numerous publicly available sky maps, each of which can be visited in the game using a spaceship. Altogether, the game is comprised of 400 billion stars, their planetary systems – and moons – all, like the insides of the computers on which they run, waiting to be explored.

This article first appeared in the 02 February 2017 issue of the New Statesman, American carnage