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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Ruth Davidson: “Brexit could deliver a hit we can’t recover from”

The Scottish Tory leader has revitalised the party north of the border. Is she now destined to occupy the hottest seat of all?

Ruth Davidson has had a good summer. At the age of 38, she has finally bought her first house. It’s a two-bedroom mid-terrace in an Edinburgh suburb that she will share with her Irish fiancée, Jen, and their cocker spaniel, a failed gun dog called Wilson (“It’s just as well he’s handsome because, by God, he’s stupid,” she tells me). The hyperactive leader of the Scottish Conservatives is eager to put down roots. “I’ve always moved for work,” she says. “I worked out that since I left home to go to uni at 17, I’d had more than 20 flats. This is the first time I’ve had a home. It’s nice.”

On 29 August, her opposite number in the Labour Party, the well-liked Kezia Dugdale, resigned. Her replacement is likely to drag the Scottish party in a more Corbynite direction on issues such as nationalisation, taxation and public spending. This will put pressure on the SNP – now the party of choice for many disaffected Labour lefties – to do the same. That would leave space in the centre ground that Davidson’s Tories will be more than happy to fill.

“If I’m perfectly honest, I am by nature a centrist,” she says. “I’m fairly hard-core on some justice and fiscal policies. I’m a proper Tory there. But in terms of social policy and things like that, I’m absolutely a centrist. But it’s because I think it’s right. It brings people with you and, if you’re looking towards [forming a] government in a way that as a party in Scotland, five to ten years ago, we could never have conceived, it’s about bringing people with you and making the arguments for being bold and radical.”

This sounds familiar. Is the great young hope of British Conservatism a much more youthful, female version of Tony Blair? That won’t go down well in the Shires or the leader columns of the Daily Mail. “No! I didn’t go to Fettes, I don’t own… rental properties around the world, I don’t holiday with pop stars, so I don’t consider myself to be a Tory Tony Blair. There’s some things I think he did very well. I think in terms of foreign policy, his idea of humanitarian interventionism that he used in Sierra Leone and in Kosovo was bang on. It was the right thing to do and it saved lives. However, I’m probably the only Tory leader who has been on one protest march in their life and that was against the Iraq War in 2003, so there are things I don’t agree with him on. Actually, I joined the Territorial Army about a month later because I wanted to serve in some way – though not in Iraq.”

Ruth Elizabeth Davidson grew up in a Presbyterian family in Selkirk, where her father worked in a wool mill and she attended a comprehensive school. After a career in broadcast journalism, she entered politics and became leader of the Scottish Tories in 2011; she has since revitalised the party in one of the great contemporary political feats. With Davidson at the helm, a party that was wiped out in the 1997 election (it won none of Scotland’s 72 Westminster seats) and that had shown only a flicker of life since then has supplanted Labour as the official opposition at Holyrood. In June’s general election, the Tories won 13 seats (out of 59) in Scotland, an increase of 12. Between the 2015 and 2017 general elections, the Scottish Tories put on more than 320,000 votes; in the May local elections, they more than doubled their share of Scottish council seats to 276.

There is a good chance that in 2021, when the next Holyrood elections are held, Davidson will find herself leading Scotland’s largest party and becoming first minister. Already she regularly attends Theresa May’s political cabinet in London and is spoken of at Westminster as a future prime minister – some would parachute her into No 10 tomorrow if they could. Members of her small back-room team say that they are besieged by media interview requests and invitations from around the world. Everyone wants a piece of Ruth Davidson’s magic.

***

When we meet in her small office on the Conservative floor of the Scottish Parliament, I sense the low hum of military-style planning, even though Holyrood is still in recess. After ten days in Ireland, Davidson is rested and recharged. “I think along with almost every other person involved in politics [or] journalism about politics, and the voters, I went into the summer absolutely knackered. But I’m ready to go again. We’ve had a really good 18 months. We’ve had three elections where we’ve come from third to second each time, we’ve more than doubled our number of MSPs, more than doubled our number of councillors. We’ve gone 13 times our number of MPs, though that maybe talks more about the base level than anything else…”

It’s certainly true that the old joke about there being more giant pandas in Scotland (there are two) than Tory MPs (there was one) has run its course. “The pandas are going to have to do a lot of listening to Barry White music to catch up with us now.”

Yet Davidson is far from satisfied. “I don’t want this to have been a peak. This is a platform for us to build on. In the five-and-a-half years I’ve been leader, between referendums and elections, I’ve fought eight national campaigns. Scotland is tired of politicians shouting at each other with no end product, and we need to use this period – which is the first we’ve had in years with no imminent election – to reduce the temperature in Scotland and in the political discourse. We need to use it to do some of the heavy intellectual lifting that’s not been done in this place [Holyrood]. We need to start asking questions about long-term solutions in important policy areas.”

The 20th anniversary of the referendum that licensed Tony Blair’s creation of the Scottish Parliament falls on 11 September and is inevitably inspiring some reflection and soul-searching north of the border. Not many would claim that the institution’s first two decades have been a shining example of policy innovation and political daring. “Are we as a country more dynamic, braver, more advanced, better educated, with better health than 20 years ago? I’m not so sure,” says Davidson. “Honestly, I think it’s been timid. I think devolution was designed to be more ambitious than what previously existed, and I’m not sure that ambition has been realised within this building at Holyrood.”

If given the opportunity, she wants to make good on the parliament’s potential. She accuses her SNP rivals of big talk but little action: “They’ve been very good at saying whatever issue of the week they’re getting hammered on is their top priority and that they’re going to have a commission, or there’s going to be a review. At some point, you actually have to start making tough decisions.”

The day after our interview, Davidson unveiled proposals for a series of new towns in Scotland and for 25,000 homes to be built annually. On education, she wants to encourage innovation by giving head teachers autonomy over budgets. She aspires to boost the status of the teaching profession, allow high- and low-performing schools in the same localities to “buddy up”, and encourage different types of school to open, including technical and state-funded schools that opt out of local authority control.

Davidson wants to introduce Teach First, which fast-tracks high-performing graduates into the teaching profession, to Scotland. “We used to pride ourselves at being the best in the world at education. Well, let’s have a bit of humility and let’s look at what’s happening in the world that’s better than what we’re doing.

“I understand that the SNP were trying to keep a broad collective together because they were working towards the goal of independence, but it’s not good enough that an entire generation’s life chances have been thwarted because you’ve been afraid to take on the teaching unions, or you’ve been afraid to make the changes that perhaps parents wouldn’t understand and you’d have to explain to them.”

Measures to tie the NHS and social care together will receive proper attention in the next few years, she says, as will the economy. “Part of centrism is about understanding the need for private industry, private enterprise, free trade, the idea that you can lift all boats. Inequality in the UK is at its lowest level for 36 years, but it doesn’t feel like that to people out there. They see these millionaire footballers or Russian oligarchs in London with their gold-plated Bentleys while they’re struggling and that disconnect is really tough.”

The ambition is clear, although the dissimulation and cant of the conventional political interview are replaced by a refreshing frankness. “We’re getting ready to change from a strong opposition to looking like an alternative government of Scotland,” she says. “We don’t look like that now. We know that. We’ve got a lot of work to do, but we’re up for it. I have to make sure I’ve got the team, the vision, the policies, the ideas, and that we’ve got the tone right – the civility that we can bring back into politics in Scotland, because it’s been at fever pitch for a really long time.”

She continues: “We have people who are serious, thoughtful, who probably ten years ago wouldn’t have changed career to do politics. But this big, cataclysmic referendum [in 2014] happened where people said, ‘The Scotland I want is worth fighting for.’ Whether you were for Yes or No, it dominated so much that a lot of people who would have just sat on the sofa and shouted at Question Time decided to get off their backsides and do something about it.”

In Scotland’s predominantly leftist political culture, there are those for whom a Tory – centrist or otherwise – can never be anything more than a stone-hearted friend of the moneyed elites. Davidson’s electoral success and personal popularity are all the more luminous when contrasted with the miscalculations and missteps that have gored the reputations of several senior London colleagues, including the Prime Minister and the Foreign Secretary.

Davidson says she isn’t worried about cross-contamination, but an indication of how Westminster decisions can trip her up came earlier this year when the UK government announced plans to restrict child tax credits to the first two children. An exemption was announced for women whose third child was a result of rape, but campaigners were furious that victims would be expected to prove their circumstances to the DWP.

Davidson defended the so-called “rape clause” and found herself in a difficult spot. “It was said I looked uncomfortable talking about it – well, yes. But do I want to make sure people who have had children in the very worst circumstances have the financial support that they need? Yes, I do. Nobody was putting forward a better way of doing this.”

Were her opponents in Scotland using the issue to tarnish her reputation? “Look, I’m not going to say that. But it’s interesting that even Jeremy Corbyn didn’t think it was an issue on the campaign trail.”

***

Davidson was a staunch Remainer. She aggressively debated Tory Leaver colleagues during the referendum campaign – most notably roughing up Boris Johnson, for whom she has little time, at a debate at Wembley Arena in London. She accepts that Brexit “is going to happen. You’ve got no major political party likely to be in government advocating that it doesn’t happen and no electoral event that would give them the mandate to stop it before it happens.”

Yet she is far from uncritical of the government’s performance. Of the fraught beginning to the Brexit negotiations, she says, “I think one of the things the UK government didn’t do that they should have done was pitch-roll this: remind the British public that when it comes to European negotiations – and we’ve had several decades of them – we are told no until five past midnight and then suddenly a deal gets done in the wee small hours of the morning. I don’t think the country was prepared for this period that we’re currently in. People in a room talking and then walking out and up to a bank of microphones and saying entirely different things while standing next to each other is part of what negotiation is. I think the UK government has not just an obligation but a duty to negotiate as hard as they can on behalf of the country.”

What is her biggest concern about the impact of Brexit? She pauses. “Interesting question… My real fear is that if there’s a short-term economic hit, we don’t bounce back from it.”

Would she like a prolonged transition period during which Britain maintains access to the single market? “I’m for free trade and want to make sure that people from Scotland and the UK have access to – and the greatest ability to operate within – the single market, which I believe are the exact words the Prime Minister used in her Lancaster House speech back in January. The mechanism for how we get to that I’m less aerated about, as long as that’s where we get to.”

We have reached, at last, a mention of the invisible Prime Minister, in office but not in power, counting down the days until her colleagues decide to free her from the burden of empty leadership. I say that it’s brave of Theresa May to get on with the job each day. It can’t be fun. “She’s absolutely straight down the line,” Davidson says. “She’s not a game player. And the kind of clichés that you hear about her, about her believing in service and public duty, are absolutely true. Everything that she said about being there for the long haul, as long as the party and the country want her – she will get up and she will put in a shift.”

Could Davidson end up occupying that hottest of seats? David Cameron once told me that he “never put a limit on her abilities and ambitions. She has got what it takes in politics. She’s got oomph, she’s got spirit, she’s got brains.”

One friend who has watched her astonishing progress concedes that even Davidson has been surprised by her success. “She has had to get her head around how good she is and how much potential she has – that she can play on the biggest of stages. Each time we think she’s reached a plateau, she climbs the next one. I genuinely think she could do just about anything she wants to, and maybe she’s starting to believe that.”

For Ruth Davidson, the next plateau is in sight. “When 2021 comes around, people will be looking for a first minister, and the option they’re going to have is Nicola Sturgeon again or me,” she says. It’s a remarkable statement, given recent history, to come from the lips of a Scottish Tory leader – but she means it, and we should take her seriously.

Chris Deerin is the New Statesman's contributing editor (Scotland). 

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