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 great escape

Almost a thousand people drowned in the waters between Libya and Italy in May. Yet still more migrants come. Can anything be done, or are we experiencing a crisis without end?

On 14 June 1985, representatives of five out of the ten members of the then European Economic Community (EEC) – Belgium, France, West Germany, the Netherlands and Luxembourg – gathered on the Princess Marie-Astrid, a boat moored on the banks of the Moselle River in Luxembourg. Their pens were poised over a pact that aimed to dissolve the internal borders of Europe. The agreement was named after the nearby ­riverside town: Schengen.

There were only five signatories because the other EEC members – including Britain – were dragging their feet. But the bureaucrats had only to glance at the vineyards outside to remember why they were here. To the east of the river lay Germany; a short distance upstream was France. Belgium was only a bike ride away and the Netherlands a cursory drive. The people who lived in this corner of Europe criss-crossed national borders all the time. Wouldn’t it be marvellous if they didn’t have to be scrutinised as if they were spies when they were only nipping over the river to buy a sausage or deliver a letter?

It was also an evocative place in another way. This terrain of hills and forests was haunted by centuries of bloodshed. It was where France, Germany and Britain had fought many of their wars: Waterloo was an hour or so to the west by car; Verdun was even closer; the Battle of the Bulge had raged just north of here in 1944 and early 1945. The Schengen Agreement was an attempt to lay such awful ghosts to rest. From now on, people would not have to show passports but could simply “drive slowly” across the frontiers.

David Cameron has received much flak for reminding voters of this detail but it would be shallow to ignore it. The agreement had a significant effect not just on daily life but on tourism, trade and commerce. In the 1990s, many of the old and new members of the European Union signed up and the expansion continued in the 2000s with the joining of non-members such as Norway, Iceland and Switzerland. Today, the Schengen Area is made up of 26 European countries. All the while, Britain and Ireland, anxious behind their sea walls, shook their heads.

Schengen was an optimistic idea and anyone who has worked or holidayed in ­Europe since 1985 has felt the ease that it has brought to the crossing of borders. But as it celebrates its coming of age, 21 years since its inception, Schengen is in the dock. Those who designed it to liberate movement in Europe did not imagine international migration on today’s scale. Partly as a result of the speed of modern travel and communications, more than 240 million people now live outside the country of their birth. This is one of the most important facts of modern life and, because Europe is among the nicest places in the world to live, it is forcing politicians and electorates to ask awkward questions about the way they conduct themselves.

Migration makes people twitchy, for understandable reasons. It would be a mistake to think of the present commotion as a topical issue that can easily be fixed. Last year, a million people fled Africa and the Middle East for Europe. This month, as footballers gather in France and the Mediterranean warms up, it is happening all over again.

Almost every week there is news of a fresh disaster. The EU deal with Turkey – in which the country will be paid €3bn in aid and granted other concessions in return for policing and processing its three million refugees more rigorously – has calmed traffic in the Aegean. Yet the people smugglers have shifted their attention back to the perilous sea crossing between Libya and Italy. Almost a thousand people drowned there in the last week of May, bringing the total to 2,500 so far this year, and there are aquatic graveyards for 4,000 Syrians who have died in Greek waters in recent years.

We cannot be sanguine about the prospect of the English Channel becoming the stage for similar scenes as the summer advances. It could hardly be on the same scale as what is happening in the Mediterranean, but there are already sporadic attempts to make the crossing and there will almost certainly be more. This is no passing cloud. It may even be a permanent shift in the wind.

***

uman beings have always migrated, moving from place to place in search of kinder skies, better food or nicer neighbours. Mobile phones and the internet have made it much easier for migrants to communicate and gather information. Nonetheless, today’s Mediterranean exodus involves people walking from Syria to Sweden – far from a hi-tech manoeuvre. Some politicians want to depict the migrants as trespassing, heavily armed intruders but most people can see that they are both ordinary and desperate: brothers-in-alms.

This may be one of those historic population shifts that mark the story of Europe. One thinks of the swirl of German and Scandinavian peoples in the first millennium – the Franks, Angles, Saxons, Goths and Norsemen who created early Christendom; the flight from Europe between 1850 and 1910, when people emigrated to the New World at a rate of almost a million a year; or those who were displaced after the Second World War. Is it possible that today’s turbulence is the first sign of something along those lines? The EU border force, Frontex, estimates that there were 1.8 million illegal border crossings in 2015, six times as many as in 2014, and the true figure is probably higher. It is no wonder that no one knows what to do.

Until now, this migration has been viewed as a response to urgent pressures such as war, poverty, religious violence and famine. Yet what it most resembles is an ­alteration in the prevailing weather: people are swirling between areas of wealth and poverty, just as air is squeezed between high- and low-pressure zones. The disparities between Europe, Africa and the Middle East are profound. This is not about foreign chancers wanting to try their luck in Swindon. It is demographic climate change.

It may be beyond the ability of governments to resist this. They don’t like to admit it but they find controlling the movement of peoples as hard as nailing down their currencies. David Cameron vowed to reduce the number of immigrants to the “tens of thousands” in 2010 but he hasn’t come close. While his enemies enjoy depicting this as a broken promise, it is a sign that politicians have only so much power.

There are other reasons to be fearful. Quarrels over water will shape the next century just as oil shaped the last one. In 1950 there were 500 large dams in the world; now, there are more than 45,000. On any map of future water shortages, the warning signs flash over North Africa and the Middle East – and when the wells dry up, people will move.

The nations involved in today’s ­exodus are relatively small. The populations of Afghanistan, Eritrea and Syria together amount to 60 million. If war or disaster were ever to engulf larger countries such as Egypt or Pakistan, Europe would have an even bigger headache. These two nations have a combined population of 264 million.

Fortunately, there is some good news. Hard though it is to believe in the current atmosphere, migration is a force for good. The noisy claim that it presents a threat to our crumbling infrastructure and cultural blood pressure may sound like common sense but it is a myth. Migrants do not drive down wages, steal jobs, overwhelm social services and displace “true-born” Brits. The opposite is true: in the long run, at least, they expand the economy and promote innovation.

Study after study confirms this simple point. Periods of high migration correlate with economic growth – which is no surprise, given that migration allocates people to places where they can be most productive. This is why the UN estimates that 1 per cent of migration translates into a boost in GDP of 1.5 per cent. And this is why J K Galbraith wrote:

Migration is the oldest action against poverty. It selects those who most want help. It is good for the country to which they go; it helps break the equilibrium of poverty in the country from which they come. What is the perversity in the human soul that causes people to resist so obvious a good?

This is not to say that there are not bottlenecks. There are. But although it seems to be an ingrained human assumption to believe that more for you means less for me, the fear that migrants overwhelm services and create social deprivation has a flimsy basis. The Merseyside borough of Knowsley is the second most deprived area in Britain, yet one of the least affected by immigration. Governments should do more to relieve deprivation but this could involve building hospitals or schools, rather than electrifying borders or watching people drown.

The second item of good news is that even the most alarming statistics in this area are soft-centred. Anti-immigrant campaigners enjoy gasping at the idea that some 300,000 people, roughly the population of Plymouth or Newcastle, are arriving in the UK each year; they imply that these people are swelling the queues for health care, housing and schools. But more than half this number (167,000 in 2015) is composed of students, who pay high fees to attend British institutions; tertiary education is an important export. And migration today is no longer a once-in-a-lifetime decision but a fluid and intricate process. Migrants drift this way in search of jobs; some stay, while others drift out again. Many even go home for the weekend, or the summer.

It is almost impossible in the present maelstrom to think of migration as a boon. Loud voices insist that migrants are a nuisance, a burden and a threat. It almost defies logic to see them as an energetic itinerant workforce of ordinary people. But the larger truth is that it hardly matters what we think. The question now is not whether or not we wish migration was happening, but how to make the best of the reality that it is.

***

he migrant crisis has commercial implications. This summer’s holidaymakers are likely to shun Greece and Turkey in favour of Spain, which is looking forward to a record-breaking year.

The most striking consequence, however, is the surge of nationalist politics across Europe, from Golden Dawn in Greece and the Freedom Party of Austria to the UK Independence Party. The nationalist wrecking ball is swinging.

In Britain’s case, this has taken the form of an assault on the European project, which, though not racist, encourages the expression of some ancient prejudices. As the day of the referendum approaches, the leaders of the Brexit campaign are playing what we might call the Donald Trump card by attacking immigration. The weightier cultural issues are drowned out in the urge to warn Daddy that there are strangers coming up the drive.

This urge is strong and, in the EU debate, creates odd bedfellows – George Galloway and David Owen on one side; Jeremy Corbyn and George Osborne on the other. It also persuades men such as Michael Gove, Boris Johnson and Iain Duncan Smith to abandon their lifelong sympathy for the pro-business argument and pose as soulmates of the working man. But the biggest irony is of a different order. It would be perverse if the reflex hostility to migration leads us to take to our little coracle just when the real storm is beginning.

This brings us back to the fragility of Europe’s supposedly porous borders. In truth, they have never been set in stone. Various time-lapse videos on the internet (such as the one on viralforest.com) race through a millennium in mere minutes. The Holy Roman Empire spreads from Sicily to Germany and Muslims press into Spain. The ­Mongols advance and recede; central Europe explodes into a galaxy of tiny princedoms and France’s eastern border wriggles like an angry snake. The Ottoman, ­Austro-Hungarian, German and Soviet empires bulge and fall back. Nations come and go in a flash.

It is a salutary reminder that the nation states of Europe have long been elastic and that if the nation state is not yet dead – declarations of its demise are premature – it can at least be said that nations and states are not the same thing. When people yell that we have “lost control” of our borders, they are imagining a past that never was: in the great rough and tumble of Victorian England not a soul was turned away. Britain has been secure on its island but Europe has never been a fortress. If we instal the apparatus of a police state at our ports and harbours – watchtowers, searchlights, paramilitary officials – we may be able to deter some paperless hotel workers and scare off a few students. But this would come at a heavy price.

If stable borders are a modern idea, so, too, are passports. The first identity papers for “safe conduct” were issued in the England of Henry V but the modern passport is a child of the French Revolution. An uprising that dreamed of liberating the citoyens wasted no time in introducing state surveillance: it feared the enemies of the revolution. Britain followed suit in 1794. It wasn’t until the First World War that photographic identification became mandatory. Before then, as A J P Taylor once wrote, “a sensible, law-abiding Englishman could pass through life and hardly notice the existence of the state”.

It is hard to imagine such a time now. There are few more emotive reminders of it than the refugee encampment at Calais known as “the Jungle”. A new exhibition on the quiet resilience of the people stuck in that Anglo-French limbo – “Call Me By My Name”, which recently opened at the Londonewcastle Project Space in Shoreditch, east London – highlights again the way in which inflammatory abstractions (“Immigration chaos!”; “Take back control!”) can trounce ordinary human responses. After all, when the von Trapp family, the illegal migrants in The Sound of Music, finally make it over the border, there isn’t a dry eye in the house.

In medieval times Calais was a major English town, a bustling centre of its wool trade. Dick Whittington was its mayor; there was a royal mint. The inhabitants of the Jungle may not know it, but their footsteps have led them to a resonant spot. l

Robert Winder is the author of Bloody Foreigners: the Story of Immigration to Britain (Abacus)

This article first appeared in the 16 June 2016 issue of the New Statesman, Britain on the brink