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

André Carrilho
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The army of one

How the writings of an al-Qaeda strategist inspired the spate of small-cell terror attacks in Britain and other Western countries.

Again. The attack on London Bridge and Borough Market on  3 June has claimed seven lives, with many more people still receiving intensive care for critical injuries. Within hours of the terrorist attack – the third within as many months in England – Islamic State released a statement claiming responsibility, as it did for the two outrages in the UK that immediately preceded it. At least one of the three attackers, Khuram Butt, had a long history of extremist activism and associations in Britain. He was a member of one of the Islamist networks that emerged during the 1990s and then proliferated after the al-Qaeda attacks of 11 September 2001. Although most of the preachers who founded these groups – such as Omar Bakri Muhammad, in the case of Butt and al-Muhajiroun – are no longer in the country, their legacy endures.

Bakri founded al-Muhajiroun (meaning “the emigrants”) in 1996. Now outlawed, it was a radical group committed to the re-establishment of a caliphate. After Bakri was finally excluded from the UK in 2005 (he is now in prison in Lebanon), he was succeeded by Anjem Choudary, the well-known British jihadist who assumed leadership of the network. From its inception, al-Muhajiroun embraced ever greater extremism, declaring support for Osama Bin Laden, for the 9/11 attacks and for al-Qaeda. Scores of its members have been convicted of terrorist offences. Choudary was sentenced to five and a half years in prison in September 2016 for supporting IS.

Several individuals from his network have travelled to Syria in recent years. Among them are Abu Rahin Aziz, originally from Luton, who became involved in active attack planning for IS operations against the West. He was killed in a US drone strike on Raqqa in 2015. Another prominent member of the group, Abu Rumaysah from London, moved his wife and five children to IS-held territory. Along with another British member of the group, Mohammad Ridha Alhak, Rumaysah is believed to have appeared in execution videos for IS.

Those who have remained at home can be found on the edges of terrorist plots. Butt, a 27-year-old British national born in Pakistan, was featured in a recent Channel 4 documentary about British supporters of Islamic State. He glorified and revelled in the barbarism of IS.

Butt will not be the last British jihadist to carry out a terrorist outrage in this country. The London Bridge attack may have seemed chaotic and amateurish but that is the jihadists’ purpose. And behind even the most unsophisticated attack is a considered strategic theory of global jihad, the antecedents of which are long and extend from Afghanistan into Yemen and Syria.

***

Al-Qaeda concentrated on carrying out the 11 September 2001 attacks with such tunnel vision that it gave little consideration to what might come next. The group reasoned that the US would be forced to respond to the atrocity, as Bill Clinton had done in 1998 after groups affiliated with Osama Bin Laden bombed US embassies in Tanzania and Kenya. The Clinton administration launched a series of retaliatory cruise missile strikes against sites associated with Bin Laden in Sudan and Afghanistan. But the response was otherwise muted.

Nonetheless, al-Qaeda had learned an important lesson. Push the US hard enough and the president will be forced to act – which is what al-Qaeda wanted. What the group had not anticipated was the ferocity of American resolve.

As the Taliban melted away after the US invasion of Afghanistan in late 2001 – and with much of its leadership captured, or killed, or on the run – al-Qaeda feared it had overreached. What good had the 9/11 attacks achieved if the global jihad movement would now crumble?

This provoked an intense debate within the movement about its future. Two competing schools of thought arose, which were considered mutually exclusive until Islamic State’s emergence brought them together.

The first view came from a theorist called Abu Bakr Naji (this is a pen name). Naji argued that al-Qaeda should promote an asymmetry of fear by adopting especially brutal and gruesome tactics. He believed Western societies were ultimately weak and lacked the resolve to endure the long war. Instead, he reasoned, jihadists should continue to escalate their depravity and barbarism. This would in turn allow them to re-establish formal control over territory as the Taliban had done, creating safe havens and launchpads for future attacks.

Naji’s view was robustly opposed by another theorist, Abu Musab al-Suri (a nom de guerre for Mustafa Setmariam Nasar, a Syrian strategist within al-Qaeda). He argued that the American response to 9/11 was too severe and that the group would never be able to regain the freedom it had enjoyed under the Taliban. The global jihadi movement would have to embrace the new reality.

According to the Norwegian scholar Brynjar Lia, who has written an authoritative biography of Suri, he opposed the 9/11 attacks precisely because he feared al-Qaeda would be unable to withstand the ferocity of the US response. When it eventually came, Suri felt vindicated.

It reaffirmed a long-standing view of his that the global jihad movement could succeed only if it was decentralised. Suri had begun to advocate decentralisation in the early 1990s, arguing that formal hierarchies did not well serve the jihadist cause. At the time, militant groups were being rounded up in Egypt, Libya and Algeria because their members congregated in large structures.

The most formative influence on Suri’s views, however, was the uprising led by the Muslim Brotherhood in the Syrian city of Hama in the late 1970s and early 1980s. He wrote about the experience in a 900-page book, The Islamic Jihadi Revolution in ­Syria. The uprising was brutally repressed by President Hafez al-Assad, father of Bashar al-Assad. Too much centralisation and formal structuring had caused the revolution to be lost, Suri reasoned. What the movement needed was smaller and more autonomous cells, which could wage a form of low-intensity guerrilla warfare, grinding down the local populations.

Although Suri had been formulating his ideas since the early 1990s, it was only after 9/11 that they coalesced into a coherent theory. Towards the end of 2004, he published his seminal work, The Global Islamic Resistance Call, which outlined his vision for the future of the global jihad movement.

Suri took a more strategic view of terrorism and its outcomes than Bin Laden or his al-Qaeda network. They obsessed about “spectacular”, large-scale attacks such as the 1998 twin embassy bombings, 9/11, the Madrid bombings, or the 7 July 2005 attacks in London. Suri welcomed the successful execution of these attacks but above all what he wanted was continuous, low-level action of the kind we are now experiencing in Britain. Despite overt displays of resilience and camaraderie, these have succeeded in making the public more fearful and angry.

“The jihad of individual or cell terrorism, using the methods of urban or rural guerrilla warfare, is fundamental for exhausting the enemy and causing him to collapse and withdraw,” Suri wrote in The Global Islamic Resistance Call.

To justify indiscriminate attacks on civilians, he invoked verse 8:60 of the Quran, which states: “And prepare against them whatever you are able of power and of steeds of war by which you may terrify the enemy of Allah and your enemy and others besides them.” The passage is often invoked by jihadi theorists to rationalise acts of mass and indiscriminate terror. “This generous verse has ordered preparation for the purpose of terrorising the assailants’ and God’s enemies among the infidels and their servants,” Suri wrote.

He interpreted its invocation to “terrify the enemy” broadly, arguing that “terrorism is a religious duty, and assassination is a Prophetic tradition”.

This is what is known as the doctrine of the “army of one”. The idea is simple: individuals are empowered to carry out deadly and destructive attacks without an overriding command-and-control structure. Having no command structure makes their attacks harder to intercept and oppress. The reality is, the antecedents of the threat we face in Britain today were first theorised in the mountains of the Hindu Kush more than a decade ago.

***

Al-Qaeda’s central leadership favoured Suri’s doctrine, believing that Naji’s approach was too fantastical. What Suri offered was a simpler, more tangible vision of how the global jihad movement should proceed.

However, it was al-Qaeda’s branch in Yemen (known as AQAP) that capitalised most on this doctrine. Under the spiritual tutelage of Anwar al-Awlaki, a Yemeni-American cleric who was eventually killed in an US drone strike, an aggressive doctrine of global jihad was launched.

What made Awlaki so dangerous was not just his charismatic appeal, but his experience of living in the West. He understood the motivation of Western Muslims and knew how to radicalise them.

AQAP published a magazine called Inspire, a precursor to the glossy IS magazine Dabiq, which has glorified as well as inspired attacks against the West. Inspire published Abu Musab al-Suri in English translation. Much of his work is untranslated and remains lost in Arabic texts, making it inaccessible to many Western Muslims. AQAP changed this by bringing the most devastating sections of his writing directly to readers in the West.

Most importantly, Inspire created and promoted a programme of Open Source Jihad (OSJ), which is the strategy of inspiring lone-actor attacks. It offered simple instructions for launching unsophisticated attacks on civilians: pipe bombs, stabbings and vehicle-based assaults.

The impact was considerable. According to original research by Alexander Meleagrou-Hitchens in his forthcoming book on Awlaki, between 2009 and 2016, of a total 212 terrorism cases in the United States, 66 plots could be directly linked to the cleric in one form or another. Put another way, Awlaki was responsible for or inspired almost one-third of all terrorism cases in the US over a seven-year period.

“In this section, the OSJ [Open Source Jihad], we give our readers suggestions on how to wage their individual jihad,” is how Inspire magazine described its OSJ programme. “It allows Muslims to train at home instead of risking [sic] a dangerous travel abroad.” Awlaki explained that this was “a disaster for the repressive imperialistic nations . . . America’s worst nightmare”.

Its effects were felt not only in the United States. In May 2010, Roshonara Choudhry, a then 21-year-old university dropout, attempted to murder Stephen Timms, the Labour MP for East Ham at his constituency surgery in London, because he had voted in favour of the Western war in Iraq. During her trial, Choudhry explained how she had been motivated to stab Timms during a constituency surgery after she became a devotee of Awlaki and his OSJ programme.

The murder of Fusilier Lee Rigby by Michael Adebolajo and Michael Adebowale in May 2013 was another Awlaki-inspired plot. Rigby was attacked on the streets of Woolwich, south-east London. His attackers first rammed him with a vehicle and then stabbed him with knives.

Documents seized by the United States following the raid in which Osama Bin Laden was killed show that the al-Qaeda leader was uneasy about AQAP’s strategy. He felt that attacks using vehicles against civilians were wrong as well as amateurish. And he believed they were so brutal that they would reduce support for violent jihad.

***

Islamic State has never worried about public opinion. It emerged in 2003 after the invasion of Iraq, in a period when the murderous Abu Musab al-Zarqawi, a Jordanian, was leading the organisation. Unlike al-Qaeda’s central leadership, which found itself on the defensive in Afghanistan, Zarqawi, who revelled in barbarism, was presented with an opportunity to confront some of the group’s biggest enemies – America and Britain – in the heart of the Arab world.

In these circumstances, he favoured Naji’s nihilistic doctrine of brutality. His methods have been played out in Syria and Iraq, producing especially egregious acts of barbarism against the local populations over which IS has ruled. Yet, for the group’s attacks in the West, it continues to embrace Suri’s model of decentralisation.

IS has produced significant amounts of literature promoting gruesome attacks in its followers’ home countries. In its Rumiyah (Rome) magazine, one infographic promotes truck attacks, describing their use as “just terror”. It advises readers to acquire a vehicle that is “large in size, heavy in weight” and which has a “slightly raised chassis and bumper”. Among its suggested targets are “congested streets, outdoor markets and large outdoor festivals”.

Another infographic disseminated by the group on social media advises supporters to “kill the civilians of the crusaders, run over them by vehicles [sic]”.

The Nice attack in 2016 which killed 86 people demonstrated just how effective a relatively unsophisticated plot carried out by a lone actor can be. This is one of the ways in which terrorism works: a successful attack gives confidence to others, inspiring and emboldening imitators. The wave of terrorism that is now sweeping the UK is born of this.

Terrorists will take encouragement from others and we have seen comparable spikes in attacks across the European continent, with the French and Germans enduring periods of similar activity.

***

None of this occurs in a vacuum. For many years we allowed radical preachers such as Omar Bakri Muhammad, Anjem Choudary, Abu Hamza and others to preach on the streets and in the mosques of Britain. They spread a deadly message of separateness, telling young Muslims not to identify as British. In many cases, they invoked the very same verses of the Quran as al-Qaeda theorists such as Abu Musab al-Suri in order to spread their message.

A leaflet produced and distributed in 2006 by the same network from which Khuram Butt emerged brazenly glorified terrorism of the kind he unleashed in London. “Jihad against the Kuffar [infidels], the enemies of Allah, puts fear in their hearts and terrifies them,” it stated. “This will give Islam victory, humiliate its enemy and put happiness into the hearts of believers.”

Al-Muhajiroun frequently celebrated terrorist atrocities at home and abroad. What we have, therefore, is a culture in which young men are growing up in Britain who are divorced from our society and its values. They are invested in the fortunes of foreign conflicts instead, exposing us to the turbulence of distant wars. Once it was Yemen and Anwar al-Awlaki who posed the greatest threat to Britain, when al-Qaeda regrouped and established a base there. Yet the potency of his message sharply tailed off after he was killed in 2011.

There is a lesson to learn. The message of leaders and movements, however ideological, still requires them to have an active presence. When they are killed, or pushed back through military action, their potency is much reduced.

In recent times, Islamic State has been able to project a message of momentum and success. Now that the group is suffering significant setbacks in Mosul – where it has practically lost the entire city – its prestige is diminished. Its de facto capital in Raqqa, Syria, is also being slowly encircled by coalition troops.

As with the efforts in Iraq, reclaiming the city will be difficult and dangerous, but Raqqa will fall. In the meantime, attacks from the “army of one” will only intensify and increase in frequency, yet this is a critical phase through which we must pass if the overall threat from IS and other such groups is to be defeated decisively. Our security can only be built over their ruins.

Shiraz Maher is a contributing writer for the New Statesman and a senior research fellow at King’s College London’s International Centre for the Study of Radicalisation.

This article first appeared in the 08 June 2017 issue of the New Statesman, Election special

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