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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Jeremy Corbyn, Emmanuel Macron and the age of volatility

The rise of populism in Britain and France is the result of a restless “crowd electorate”. Both countries' future stability depends on their changing relationship with the EU.

Britain seems to have joined the rest of the democratic world in the volatility of its politics. Electorates are no longer armies, but crowds. Identities shaped by religion, class, region, ideology and tradition weaken. Conventional parties are hollowed out, and disoriented and angry voters turn to single-issue campaigns or insurgent populism. In every country this takes diverse forms shaped by political institutions and political cultures – Donald Trump and Bernie Sanders in America, Marine Le Pen and Emmanuel Macron in France, Beppe Grillo and the Five Star Movement in Italy, Nigel Farage’s Ukip and now Jeremy Corbyn’s Labour Party.

The trend, noticeable from the 1990s, was analysed in a now classic work by Peter Mair, Ruling the Void: the Hollowing of Western Democracy, which was published in 2013, two years after the author’s death. Elected governments had conceded powers to non-elected agencies such as the IMF, the World Bank, the World Trade Organisation (WTO), and above all the EU. Politicians had become professionals, largely detached from civil society and operating increasingly within these international institutions, “safe from the demands of voters”. Citizens were decreasingly willing to join professionalised political parties financed by large donors or public funds, or to identify strongly with them.

Membership fell across Europe and beyond, and among the sharpest falls were those in France and Britain, where levels of political participation had previously been high. Electoral turnout fell too.

As Mair saw it, “hand in hand with indifference goes inconsistency”, as low levels of participation were paralleled by rising levels of volatility. People who did vote for mainstream parties often changed allegiances at random, and made up their minds at the last minute in response to short-term factors. Others flooded into new movements, or even old ones that reinvented themselves as enemies of the system.

The political effects of the 2007-08 banking crisis are still being felt everywhere and subsequent policy failures have aggravated the discrediting of elites. Naturally, the most volatile element has been the young. Youthful radicalism is hardly new. In my youth, inspiration came from Mao, Che Guevara and even the Khmer Rouge. Now it comes from elderly white males such as Bernie Sanders, Jeremy Corbyn and Jean-Luc Mélenchon, who seem able to present old remedies as new revelations to those inevitably lacking political memory. Historians are perhaps tempted to seek precedents. My own choice is the 18th-century radical John Wilkes. His brilliantly provocative tactics made fools of successive governments and appealed to a largely London-based electorate.

Wilkes’s secret – apart from barefaced cheek – was that he was not seeking office. It has been liberating for Sanders, Corbyn and Mélenchon that they were not expected, and did not expect, to win, and hence were free to run election campaigns that were not programmes of government but protest movements aimed at generating maximum support and momentum. Brexit seems to have further liberated the British left. Only the hardest of Brexits would give free rein to a radical programme of nationalisation and support to industry, which would contravene EU legislation on equal competition and restrictions on state aids.

This kind of populism is a new phenomenon in modern British politics, because never has a major party entered a campaign with such an absolute conviction that it would lose. And never has the Labour Party been so dominated by the ideas and campaigning style of the hard Left: the ubiquitous rent-a-crowd, the conspiracy theories, the violence of language (especially online), the ruthless and immediate politicisation of national tragedies. This old recipe has been given unprecedented dynamism by social media. It is populism in its purest form: a movement purporting to represent “the many” against a corrupt and remote system.

Populism is unlikely to come to power in normal circumstances because of its evident risks. However, volatility is now “normal” and accidents happen.

The two most successful populists are Donald Trump and Emmanuel Macron. Both won only with the help of a chapter of accidents. The divisions in the Democratic Party, the peculiarities of the American voting system and the accusations directed at Hilary Clinton’s email system were crucial for Trump. The collapse of François Hollande’s Socialist presidency and the meltdown of the Parti Socialiste following Mélenchon’s populist challenge from the left, along with the “Penelopegate” scandal enveloping the conservative presidential favourite, François Fillon, have delivered both the presidency and a huge parliamentary majority to Macron. What might have resulted in Britain had the Grenfell Tower tragedy happened a few days before the poll?

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Macron’s extraordinary victory in France, which some hail as a defeat of populism, is its most brilliant success. Macron came from outside politics, set up a new movement, and pledged to “renew” and “moralise” politics by recruiting half his party candidates from civil society and half from women, and excluding all with criminal records. His La République En Marche! has crushed the other parties. Unlike Trump, he has moved smoothly into power as if born to it.

The Fifth Republic is a “republican monarchy” and Macron seems to be pushing the system as far as it will go. His inauguration ceremonies equalled or exceeded the regal style of his loftiest predecessors, Charles de Gaulle, Valéry Giscard d’Estaing and François Mitterrand. He has been dubbed “Jupiter in the Elysée”, above the public fray, refusing to speak to journalists except in circumstances of his own choosing, and tightly muzzling his aides and ministers. Macron has ensconced himself in his palace with a tiny number of trusted young advisers – perhaps, as with Trump, a direct consequence of a populism that rejects established political elites. He has also begun an intensive centralisation and politicisation of the civil service, assuming the power to decide the reappointment or replacement of several hundred top officials.

However, Jupiter has an Achilles heel. The solidity of his support in the country is uncertain, and hence much depends on his cunning and charisma. This may seem paradoxical for the leader of a populist movement, but perhaps it is a fundamental feature of a politics that bypasses intermediaries and relies on the volatile support of the crowd-electorate: Trump, Macron, Corbyn, Farage, Mélenchon, Grillo – all one-man bands.


Emmanuel Macron’s success represents a populist eruption from the centre. Photo: Getty

In France’s recent legislative elections only 43 per cent of the electorate voted –probably the lowest turnout in a national election in its democratic history – due to uncertainty or suspicion. One survey puts the level of Macron’s positive support at only 11 per cent. His left-wing opponents have announced their intention of shifting the contest from the ballot box to the street, and Mélenchon has called for a “civic general strike”. Macron’s slick middle-class populism might have to confront the tough populism of the old left. I wouldn’t care to bet on the outcome.

How French and British politics develop in this time of volatility depends on the countries’ changing relationship with the European Union. France has chronic youth unemployment and its economic performance has long been sluggish. Some of its wounds are self-inflicted, but underlying them is the problem of the eurozone and the disparity of economic behaviour between France (and southern Europe) and Germany.

As long as the eurozone is managed as at present, this problem is insoluble. Germany is permanently in surplus and presses austerity on the laggards. France, while a less extreme case than Italy, needs Germany to agree to expand state borrowing by setting up eurobonds backed by the EU (that is, by Germany) and with an EU finance minister to control national budgets – hence, removing another core function of democratic governments. France’s future rests on Macron’s success. If his bold attempt to change France and the EU fails, it is hard to see where the country can go next.

Brexit may prove an easier prospect than that facing Macron, but its successful management – not least because of its centrality in the national debate – is equally crucial to our political stability. A crisis here could mean the wreckage of the Conservative Party, Jeremy Corbyn in Downing Street, turmoil in Northern Ireland and the breakaway of Scotland. Readers may regard some or all of these outcomes with favour.

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Theresa May’s failure to secure a majority has revived doubts about how resolved the British really are. Labour’s side-stepping of the issue – accepting Brexit but not the Prime Minister’s version of it – was electorally clever but adds to the uncertainty. Adopting David Cameron’s approach to negotiation, Corbyn declares that “there is no such thing as ‘no deal’”. This inevitably encourages those in the EU who wish Brexit to be damaging enough to deter others: there have already been provocative statements from Jean-Claude Juncker and Guy Verhofstadt. Macron recently declared that “the door is always open” to Britain dropping Brexit; reversing national electoral choices is something the EU has past form on.

Quasi-Remainers of all parties are trying to strip the issue of everything except “jobs and the economy”, blithely denying the importance of democratic legitimacy, national sovereignty, immigration, strategic security and the future of the EU itself. Imagine the divisive effects on British politics and British society if a future government were forced to apologise for the referendum and asked to be readmitted to the EU: bitter recrimination, national humiliation, evaporation of international influence – all far beyond anything we are experiencing today

It would deliver a death blow to any attempt to reassert democratic choice over bureaucratic and financial power within Europe, and would mark the effective eclipse of national sovereignty for the foreseeable future. Nor would it make sense in the long run: the eurozone, if it is to survive, must create greater central control, which hardly anyone in Britain accepts; so we would in any case find ourselves on the outside.

The effort to restrict debate to “jobs and the economy” is based on reiteration of the dogma that Brexit threatens economic disaster. This revives the narrative created during the referendum campaign, whose most influential element was the official report produced by George Osborne’s Treasury. The IMF and the Organisation for Economic Co-operation and Development naturally followed Whitehall’s lead: that is how such bodies operate. The Treasury predicted that a “no deal” Brexit would cost around 7.5 per cent of GDP by 2030, an average loss of £6,600 per family. Even some Remainers were alarmed at what seemed a politicisation of the civil service. The former governor of the Bank of England Mervyn King has since described the report as “not an objective presentation of the facts”.

Nevertheless, the report had a huge impact on the referendum (most Remain voters said they were motivated mainly by economic fears) and its pessimism continues to overshadow the Brexit negotiations and provide grist to the mill of anti-Brexit groups in the UK and beyond: “we didn’t vote to become poorer”.

Significantly, the Treasury refuses to discuss with academics how it arrived at its forecast. However, a group of economists based in Cambridge, led by Graham Gudgin and Ken Coutts, has for the first time applied the standard scientific method of verification by trying to reproduce the Treasury’s results using the same economic models. Their findings, now accessible through Policy Exchange (“A Critique of Estimates of the Economic Impact of Brexit”), are startling.

Astonishingly (or perhaps not) the Treasury did not produce an estimate of the effects on UK trade of leaving the EU. Instead, it worked out the average importance of EU trade for all 28 member states, including the new eastern European states that do most of their trade within the EU. It also adopted a long time-scale, rather than focusing on the years since the creation of the euro – which have seen a slowing of intra-EU trade generally, and for the UK particularly.

This approach greatly magnifies the importance of EU trade for Britain, which is less than for any other EU country, and which has been declining in importance for years. Finally, the Treasury made the extraordinary assumption that if Britain did less trade with the EU, it would not be able to compensate significantly by embarking on more trade outside the EU – even though its non-EU trade has been growing and shows a favourable balance. In consequence of these methods, the Treasury prediction of the results of a “hard Brexit” was a considerable exaggeration.

Using the same methods as the Treasury, but applying data relating specifically to the UK rather than to the EU as a whole, the Cambridge researchers reach a very different conclusion. Even if it proved impossible to reach a free trade agreement and the UK reverted to trading under WTO rules (“falling off a cliff”, as some express it) there would be “only a minor loss” in overall GDP by 2030, as tariffs in 90 per cent of products have already been more than compensated for by the fall in a previously over-valued sterling. As for per capita GDP – that is, average living standards – they predict that this could actually rise if the rate of immigration were reduced.

So no deal is clearly better than a bad deal, including the “soft Brexit” advocated by Corbyn and others: to leave the single market but stay in the customs union. This would mean being unable to trade freely either inside or outside the EU or to influence EU policies from within.

In short, we have no reason to be frightened by the Brexit negotiations. Being inside or outside the EU has made no difference to our economic fortunes: our national wealth has increased at exactly the same rate as that of the US for the period since 1945. We are not facing economic disaster. It is not the case, as Nick Clegg recently asserted, that we face a choice between “painful concessions” and “economic disruption”.

Moreover, Britain is a major power independently of its ties with the EU. The international relations specialist and New Statesman contributing writer Brendan Simms estimates that it is the third power in the world after the US and China because of its wealth, size, “soft power”, military potency, and its relative internal cohesion and long-term political stability. A good relationship with Britain is important for the security, stability and prosperity of the whole European continent. Unless we play our hand extraordinarily badly in these negotiations, the outcome should reduce the potential of that volatile populism of which we are presently feeling the shock: volatility, after all, is a two-way process.

Peter Mair feared the democratic world was losing control of its political institutions, and thought it “not at all clear how that control might be regained”. Brexit should, as many of us hope, provide the beginning of an answer.

Robert Tombs is the author of “The English and their History” (Penguin) 

This article first appeared in the 08 November 2010 issue of the New Statesman, Israel divided