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 working class revolts

In the spirit of William Cobbett, a young writer travels by bicycle through Britain’s former industrial heartlands before and after the vote for Brexit.

One recent afternoon I set out on my old Raleigh bike on a tour of post-Brexit Britain. Two years earlier I had travelled the country on my bike as I researched a book. Now, after the vote for Brexit, I began another journey, this time with an even stronger sense of political disorientation. I wanted to discover what had become of the euphoria and, indeed, anger so present after the referendum of 23 June. For two weeks I cycled through the ex-industrial towns and cities of the Midlands and the north of England, two of the regions I visited in 2014.

My method then had been basic and, to some, ill-advised. Over the four months I cycled, I either wild-camped or stayed in the homes of people who had heard about my venture by word of mouth, or whom I’d met along the road, and I asked people, simply: “What is life like here?” I received a bewildering range of responses, from ­worries about wages or what world their children might inherit, to explanations about ecological and community projects built on a sense of renewal and hope. I encountered generosity and insight into different ways of life in Britain, and last summer published my findings as Island Story, a travelogue in the spirit of William Cobbett and Orwell.

Many of the areas I had written about are now readily associated with Brexit, such as Barnsley (68 per cent Leave), the former mining town in South Yorkshire. Covering the immediate aftermath of the referendum, Channel 4 News sent a crew there. Its report featured a local man who explained why he had voted Leave: “It’s not about trade or Europe or anything like that, it’s all about immigration. It’s to stop the Muslims coming into the country, simple as that.”

The presentation of what people in this town or Sheffield and Wakefield nearby had called “Barnsley Man” had been a sore point. In Sheffield (51 per cent Leave) Allie, an artist and teacher, felt it absolved the wealthier south of responsibility, even though the south had voted in far greater numbers to leave. Barnsley Man – old, white, working class, ignorant, racist, and unable to speak without losing his temper – was a sign of a prevailing narrative of Brexit as a catastrophic revolt by a misinformed and alienated northern working class, an explanation that became increasingly unsatisfactory as I travelled and talked to people.

“Damn good thing it were, too,” said one former miner at a working men’s club, as we discussed Barnsley’s vote to leave. Some agreed, others shook their head. I had passed “Vote Leave” stickers plastered on the walls of a derelict social club, and encountered common justifications that cited uncontrolled eastern European migration, resulting in the loss of local jobs. But people’s concerns were not about immigration itself, or cultural identity; rather, they centred on low wages and employment. “There’s nowt round ’ere ’cept call centres,” said Rory, a young betting-shop worker.

Many customer-service centres operate in the nearby Dearne Valley. The work is insecure, stressful and subject to a demeaning level of surveillance (call response rates, targets met, time spent in the toilet). Other sources of employment include distribution warehouses and factories of several major clothes retailers. I was told repeatedly that these companies recruited and bussed in Polish workers from Warsaw to work on a seasonal basis for low pay, at the expense of local people.

“I’ve been trying to take it to the papers,” a young woman said to me as the issue was raised in the back room of the Red Shed, the Labour club in Wakefield, West Yorkshire (66 per cent Leave). She had become aware of the practice of bussing in through a friend at one factory, but my later research showed that it’s an open secret. One must attribute some validity to such stories, at least in terms of how local people feel. They hint at the complex and contradictory stories and motivations behind Brexit in former industrial areas such as these.

“It’s divide and rule,” said a woman who had earlier told me about her involvement in the miners’ strike pickets thirty years earlier. “We have to fight to push up their wage, and challenge the bosses.”

 

***

 

In what the political economist William Davies calls a “shadow welfare state”, many people across the north are employed in poorly paid call-centre or service-sector jobs, subsidised by in-work tax credits. Child and working-tax credits, implemented by the New Labour government, in effect benefit low-wage employers as much as workers, and cost the state £30bn a year. A further £9.3bn in housing benefits was paid to private landlords last year. Though tax credits and housing benefits provide a lifeline to workers and their families struggling to make ends meet, they do nothing to address the underlying problems of low wages or unemployment, or the need for a new public strategy to encourage higher-skilled, higher-waged work.

Cycling from one former industrial town to the next, I observed that the primary contributions to the built environment in the past three decades or so are the retail park and out-of-town supermarket. Like the call centre or the distribution warehouse, they are the principal points of Britain’s service sector, and are enabled by unskilled local workforces on state-subsidised low wages and the complex logistics of globalised trade. Spread across Britain and similar in appearance everywhere, these bland structures signal the possibilities and pitfalls of state investment guided by short-term economic gain.

Workers are increasingly caught in a cycle of insecure and unpredictable shift patterns, thanks to zero-hours contracts. This makes claiming housing benefit difficult, and includes spells of unemployment during which credit cards, payday loans or borrowing from friends and family become the main means of subsistence. A recent Trades Union Congress report found that 3.2 million households were in “problem debt”, spending more than 25 per cent of their household income on unsecured debt repayments. Of this number, 1.6 million households are in “extreme debt”, handing over more than 40 per cent of their earnings to creditors. Some of the poorest households choose not to join the electoral register, fearing that their details will be shared with debt collection agencies, and are thus locked out of political representation.

In the wilted yet cheerful seaside town of Morecambe, Sonya painted a stark picture of her work as a private lettings agent. Over £9.3bn of public money was paid to private landlords in housing benefit last year, a doubling over ten years, and far more expensive than building affordable accommodation. Sonya’s tenants are “trapped” in cycles of poverty and debt, with no obvious reprieve or refuge. “What good are food banks when people can’t afford to pay their gas or electricity to heat the food?” she said.

Although such stories illustrate the UK’s gaping wealth inequalities, they also show the dismal progress in some areas in the quarter-century since John Major’s pledge of a “classless” society and the infamous (mis)quote of John Prescott that “we are all middle class now”. The political effects of such social shifts have not yet fully come to light. The surge in support for Ukip across the ex-industrial north and east over 2014-15 has been stalled, for now, by uncertainty about the party’s leadership since Nigel Farage’s resignation. But I was struck by a pessimism in these communities, so many of which felt overwhelmed by an unfair fate. The horizons of political possibility had been hemmed in by the miseries of economic hardship.

Many I met felt untouched by politics, perhaps because politicians of all stripes rarely speak with any insight into the difficult decisions involved in juggling household debt, or the mixed feelings involved in claiming benefits. It has become a banality to invoke the Stakhanovite image of “hard-working families”; less often do we hear directly from these individuals, with the occasional exception of exploitative TV series such as Channel 4’s Benefits Street or The Great British Benefits Handout (Channel 5).

On the road, few people spoke about political leaders, and Labour’s spate of self-flaying in its second leadership election since May 2015 prompted indifference or disappointment. Talk of Trident or renationalising the trains may be too theoretical, even middle class, in places where basic poverty is an elementary concern. Usually, luminaries on the left, such as the polemicist Owen Jones, address the comfortably converted, gathered punctually in town halls, immune from the debate among the depoliticised masses in the pubs, supermarkets and bedrooms of this island.

 

 

***

 

Cycling around Britain, I would set out most days without knowing where I’d end up. Such nomadism came not without stresses. But it was a fair exchange for serendipity – sunset conversations with shepherds along Loch Eriboll, blue jokes in the lock-ins of Liverpool and Dalmellington, or the drama of lugging a weighty steel mule up the steeps of Snowdonia and the eye-watering wonder of plunging down the other side.

I had no map, and sometimes relied on the tent and a discreet field or park for a place to kip, but more often I found contacts through a blog and social media. Pulling over on street corners or stopping at fast-food outlets, supermarkets and pubs, I would mine passers-by for clues.

As I travelled through Northamptonshire, Lincolnshire and Yorkshire, I listened to people projecting the effects of austerity on to migrants. In Corby, Scottish workers told me that Poles had “overrun” the area. “I just don’t like the ones claiming [benefits],” said a barmaid in one town-centre pub. Others such as Ashgar, a former steelworker in Rotherham, blamed the “greed” of “London” or factory owners for the loss of local steel jobs, rather than any government policy or trend towards deindustrialisation.

Stories of feeling left behind by the economic development of “London” were common. “London” had privatised industries and utilities, and cut funding from communities to prop up a corrupt banking system while people outside the capital were sanctioned for minor or non-existent benefit improprieties. “London” had imposed a narrow political and cultural vision on the rest of the country which gave communities no great say in how they were governed. To many of the people I met, the word “London” carried the same negative connotation as “neoliberalism” or “globalisation”, and had a similar meaning.

The chain stores may stock the latest cheap gadgets and clothes from the Far East, but for many communities the loss of jobs, community buildings, social care and affordable rents has been too high a price to pay. Voting Leave became a kind of protest button, pushed in anger at decades-long disempowerment. Brexit, a largely English independence movement ostensibly against the EU, is at times indistinguishable from a movement for independence from “London”. Voters judged that the potential hardships associated with leaving were a price worth paying to regain sovereignty from the capital.

In Nottingham (51 per cent Leave), David talked of friends in his home town of Long Eaton, Derbyshire, who had voted overwhelmingly in favour of Brexit. “A whole two generations of massively disenfranchised people put two fingers up to the elite,” he said. To Jeremy Corbyn’s chagrin, many Brexiteers live in safe Labour seats.

For the painter John Wilkinson, the problem was clear: “In England it is already yesterday.” Among left-wing artists in the exhibition “Fighting for Crumbs” in Sheffield, the mood was disillusioned yet reactive. In these pessimistic visions, the future seemed lost or abandoned. Beside Wilkinson’s paintings were photos by Connor Matheson capturing teenage ravers, food banks, Grimethorpe miners celebrating Thatcher’s death, and more mundane moments amid allotments and council estates festooned with St George flags. Reconstructions of the past seemed to preoccupy many people, as they struggled to identify new sources of pride in their decaying environment.

Dependency on benefits to subsist in boring, insecure or difficult low-wage work does not inspire gratitude. Writing in June in the London Review of Books, James Meek made a similar observation about farmers, many of whom supported Brexit even though they are heavily reliant on EU subsidies to augment the plummeting prices paid by supermarkets. “It’s an unholy mess that’s developing,” said Eden, as we spoke on his sheep-rearing smallholding beside a large Argos distribution centre in Darlington, on Teesside. Globalisation has reduced prices and forced many farmers into a race to the bottom. “People want to blame the poor for the situation they find themselves in,” he said.

But it’s not only farmers who feel beleaguered, their pride or way of life tested by recent developments. The collapse of manufacturing, mining and steel since the late 1970s has resulted in what Jeremy Seabrook, interviewing people in the West Midlands last summer, called “unhealed social and psychological lesions of class”. In his book Cut Out: Living Without Welfare, Seabrook argues that these areas were not given the chance to grieve for the industries they have lost and around which generations of communities had developed.

Travelling through the same parts, I found it common to hear of cities spoken about in the past tense. In Wolverhampton it was locks and furniture; Nottingham, bicycles and lace; in Bradford and Halifax, textiles. Each town had its trade. “It’s got a lovely history,” said Ian in Wolverhampton. “Shame it’s a s***hole now.” For there is no belonging or co-ownership in the glut of retail parks left behind, nor in the finance sector or on the property ladder. “We used to make things,” said Steve in Derby, using his own city’s economic uncertainties as a symbol of something broader.

Emma, a part-time teacher working in the Midlands in Tipton and Dudley, told me about young mothers to whom she taught basic budgeting and childcare. “People complain about scrounging . . . Most people I meet, they’re just trying to get by.”

The Brexit vote has exposed rather than initiated this incoherence. If a shared sense of place or identity is defined by making or doing, then those who cannot make or do – from welfare recipients to foreign nationals who use the NHS – become, in the eyes of some, despised. Two implications follow. First, pride in work correlates to a misleading notion of a “traditional working class”, readily linked to manual work, social conservatism and older age, such as that of Barnsley Man. This understanding of class as primarily cultural (through which the concept of a beleaguered, mythically homogeneous “white working class” often arises) obscures what is the original and more obvious economic definition of “the working class”: those who must work, will work, or have had to work full-time for a basic living. Class is no longer clear.

A second implication of pride in work emerges in how this is internalised where such work isn’t readily available, as in Barnsley or Rotherham, or the struggling former industrial cities of the north-east, such as Ashington and Middlesbrough, or Newport in south Wales. In Langley Moor, County Durham, Clarissa and her daughter told me about the high suicide rate among young men. Elsewhere I heard tales told, in hushed tones, of brothers, fathers and friends who had taken their own lives – each for different reasons, but so often in places bereft of investment and hope. Where communities, certainties and “jobs for life” are disarrayed by forces so distant and complex they might well be confused with fate, the individual effects can be terrible.

 

 

***

 

Pessimistic narratives of decline and “Broken Britain” are tedious, and also stand as obstacles to imagining political alternatives. Seismic changes to the fundaments of the United Kingdom will have consequences over the coming decades, but exactly how so remains unclear. Absent from most of the debate during the Brexit campaign was a discussion about the future of the political union between not only Britain and Europe, but also the UK’s member states. What kind of society do, say, the English desire? How will it be powered, how will its people house and employ themselves, and how will it be governed?

Across my post-Brexit journey, I quizzed people about the kinds of political transformation they would like to see. In Nottingham, I heard compelling arguments for a universal basic income and a 30-hour working week, aided by automation and progressive taxation. In Sheffield, the artists Glen Stoker and Anna Chrystal Stephens invited me on a group trespass of a patch of derelict wasteland near the city centre. Discussions about what this site could become in public hands led to wider questions about who owns much of Britain. In Manchester (60 per cent Remain), Jen enthused about rediscovering politics along with neighbours in her community and Steve refused to acknowledge what some would call realism – the necessity of compromising one’s political intentions. In Liverpool (58 per cent Remain), Brian, an indefatigable trade unionist, debated with international students the need to invest in green energy.

All were inspired by developments in Scotland, where a very different-natured independence campaign has led to lasting discussions about a progressive and better future for all. Instead of reactions against low wages, or perceptions of immigration or the effects of austerity, here there are ­discussions about renewable power, buying back local land into common ownership, as well as rediscovering local histories and the Scots Gaelic tongue.

Is it naively idealistic to imagine that the same could happen here, elsewhere in our post-Brexit land? Perhaps, but within such hope lies the motivation to act.

J D Taylor’s book “Island Story: Journeys Through Unfamiliar Britain” is published by Repeater

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