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

@Didn'tHappenUk
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Hate crimes, social media, and the rise of the “hoax hoax”

When hate crimes rise, so do the number of people trying to discredit them.

The first thing 16-year-old Kiaira Manuel did when she saw a bold, underlined sign reading “COLORS ONLY” over one of her high school’s hallway water fountains was go to her school administrators.

“They said they were going to handle it, but so many things go unnoticed at this school and they just don’t care,” says the now 17-year-old, explaining her decision to post a picture of the sign on social media that night. “So this was taped above the water fountains at my school...” she innocuously captioned the image, which has now been shared over 1,500 times.

It took a day for someone to call her a liar. Twitter user @iH8Thots tweeted Manuel a message, which was then also shared hundreds of times on the site. “We go to the same school,” he wrote. “I watched you put that piece of paper up there and take the picture.” Manuel blocked the user, which was then seen as “proof” that his accusation was true.

These tweets were first posted in January – when the sign was stuck over the water fountain – but over the last few days, Manuel has fended off a fresh flood of people taking to social media to call her a liar. The timing is no accident. Since Donald Trump won the United States presidential election, there has reportedly been an increase in hate crime in America – with the Southern Poverty Law Center receiving 200 complaints in the last week. There has also, in turn, been a surge in people trying to discredit hate crimes, by loudly labelling them hoaxes on social media.

It doesn’t take a lot of research to unravel @iH8Thots’ claims. Less than a week after the incident, he and Manuel appeared on the comedy podcast Pod Awful to talk about their viral tweets. “You’re clearly a fucking troll,” says the host within a few minutes of speaking to @iH8Thots, even though he initially believed his story. @iH8Thots refuses to explain his side of events, is unsure of his own age, and calls his lawyer – who has, in the host’s words, “the voice of a child” – to defend him on air. When I asked – over Twitter’s direct messaging service – whether he would like to speak to me for this piece, he replied: “lol. fuck the media. journalists can go to hell”.

Before all of this, however, a cursory glance at the profile of @iH8Thots – a username that, translated from internet slang, seems to mean “I hate That Hoe Over There” – was enough to disprove his accusations. Manuel claims that when he first posted the tweet, his account said he was based in California, nearly 3,000 miles from her high school in Florida. His feed was full of similar trolling messages, and if you click on his account today, you will see a man in a gas mask holding a gun staring out from his profile picture, a design for a fascist flag of America as his header, and a timeline full of pro-Trump and anti-liberal tweets. Few people, however – both when the tweet first blew up and now it has reappeared – think to check.

Manuel’s experiences are part of a current trend on social media that I will tentatively call a “hoax hoax”. It goes like this. Someone posts evidence of a hate crime on social media. Someone else uses false evidence to out their post as a hoax. This, however, is the actual hoax. It is a lie claiming someone else lied – a hoax hoax.

This is happening on fake news websites and across social media. A Twitter account @DidntHappenUk was set up last month to expose people they believe to be lying on the social network. Despite offering no evidence for who is or isn’t telling the truth in any scenario, they have over 2,000 followers – with half of these gained over the last week since the election. “A nice display of left hand writing here,” they wrote above a picture of a swastika-laden racist message that was allegedly left on a Facebook user’s car.

“People think that, after the election, people are making up hoaxes to prove that there is hate in the world. It’s so stupid. People don’t do their research on these things and now I’m being used as a prime example for it,” Manuel says.

The problem is being exacerbated by police forces using social media to encourage victims to come forward. Twitter users jumped on the journalist Sarah Harvard when she claimed her friend’s Muslim sister had “a knife pulled on her” at her university and the campus police replied saying: “This has not been reported to police. If you are in contact with anyone involved, please encourage them to give us a call.” Though they meant well, their tweet was used as evidence that the event never happened at all. This is a problem because police reports are not the be-all and end-all of proving a claim’s veracity.

Manuel says her school administrators, for example, were reluctant to act when she reported the water fountain incident, and she felt they were dismissive of her concerns. “When I put it on social media it was forcing them to actually pay attention and actually do something about it,” she says. Contrary to what many might expect, then, some people – especially those who are disenfranchised – are compelled to turn to social media over the authorities.

“That’s why we put stuff as ‘Unproven’,” says Brooke Binkowski, the managing editor of the internet’s oldest fact-checking website, Snopes, which uses “True”, “False”, "Mixture", and "Unproven" buttons to label stories. They recently labelled a story about a Muslim woman told to hang herself with her hijab in Walmart as “Unproven” after the police said they had not heard about the attack.

“We didn’t want to say ‘False’ because there’s not much we can do if two people were involved and neither of them are talking and nobody saw it. Maybe she didn’t want to go to the police. All sorts of creepy people will start threatening people who do so. And the people who are doing it certainly aren’t going to say ‘We told her to hang herself by her hijab’.”

Snopes are a non-partisan site, and investigate claims based on how many people email them to ask about a story. “Inherently, fact-checking hate crime accusations is certainly sticky,” says Kim LaCapria, a content manager and political fact-checker at Snopes, when I ask whether there are any moral considerations around investigating hate crimes. “There's definitely the idea out there it's wrong to question people who we agree with that have been purportedly attacked, but folks on the other side of the aisle clamour for a look into claims' veracity.”

It is important to note that there are undeniably hate crime hoaxes – something the right often calls “false flags” – occurring, though Binkowski says they are “extremely rare”. The conservative news website Breitbart – which has found fans among white supremacists – concludes that there have been 100 in the last ten years, a remarkably low rate of ten a year (especially considering the site’s agenda) and nothing compared to the 2,241 racially or religiously aggravated offences that occurred in the UK in the two weeks after the EU referendum. The right is also guilty of false flags, recently purporting a man was attacked because he was a Trump supporter when the incident actually stemmed from a traffic altercation.

Still, when false flag hate crimes do happen, they are seized by the right as evidence that no hate crimes are happening at all. Who can forget when, earlier this year, an openly gay pastor was forced to admit he had iced the word “Fag” onto a cake himself, and had lied that it was done by a Whole Foods employee? Just last week, a student at the University of Louisiana admitted to fabricating a story about having her hijab ripped off by two Trump supporters (it is worth noting, however, that some people may recant their stories out of fear).

It is crucial that we, as social media users, fact-check things before we share them so they can’t be used for another agenda. Just because fake hate crimes are rare doesn’t mean it’s wrong to scrutinise things you see on social media. Questioning one particular post that seems a little off is not the same as denying that hate crimes are happening.

“Even if it feels uncharitable to consider the veracity of a claim, it's important for information to be credible and not to add to the spread of bad information inside a political bubble of one's own making,” says LaCapria. “Liberals are most definitely not immune to spreading bad information or getting angry when their claims get debunked, but it doesn't help anyone's cause when a popular story inevitably proves false.”

It can be very distressing, however, for a victim to be accused of carrying out a hoax, and Manuel ended up blocking over 600 people on Twitter. “People started attacking me and calling me ‘n****r’ and all of these derogatory terms,” she says. “Two days ago, after this all blew back up, I got 50 messages in a row from one person who said he was watching me, and said my first name and last name and said my information had been leaked. That’s really frightening.”

While fact-checking, it is crucial to not cause unnecessary distress. But how?

“Even a simple ‘I haven’t verified this yet’ or ‘If this is true, it’s worth paying attention to’ marks the story as unvetted but allows people to share,” says LaCapria. “Critical thinking is important; if something sounds completely implausible, it probably didn't happen the way the person is telling social media it did. There are two good subreddits – r/thathappened and r/quityourbullshit – that just take a second (sometimes mocking) look at viral social media claims. Although users aren't always kind, they can be very good at pinpointing holes in stories.” Another, r/hatecrimehoaxes has also become popular after the election. 

Binkowski also points out that many hoaxes fall apart at the first sign of scrutiny. “They usually make it easy because they can’t handle the pressure and feel guilty so come out and recant,” she says. “Everyone should read from a variety of sources, even ones you don’t agree with. A lot of people yell at us because they think we are trying to be the be-all and end-all but we just want to be the starting point."

For Manuel, everyone being better at fact-checking would have saved her a lot of pain. At the time of writing, her Twitter mentions are still being flooded with offensive messages. In order to combat both hoaxes and hoax hoaxes, then, everyone must attempt to be non-partisan in scrutinising social media claims. 

"Even if you don’t have much time, if you read something on some site that doesn’t quite ring true or seems too perfect, then Google it, just Google it,” says Binkowski. 

Amelia Tait is a technology and digital culture writer at the New Statesman.