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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Syria’s world war: how the West allowed Russian and Iran to take control

As the civil war rages on, Syria has become a theatre for great-power rivalry, with Russia and Iran turning cynical opportunism into high policy.

It is getting harder to make sense of Syria’s agony. In fact, unless a distressing photograph of a suffering child – most recently Omran Daqneesh in Aleppo – goes viral and reminds us all for a moment of the human cost, it is probably harder to get anyone to pay any attention at all. The situation is increasingly complicated, politically and morally. There is a shifting array of militias both supporting the regime and on the opposition sides, all with their own internal tensions. None of the external actors seems to be fighting with quite the same purpose as the others. No one is articulating a vision of what a post-conflict Syria should look like: perhaps because there isn’t one, except for the harsh, reductionist version offered by Islamists. The one thing that’s sure is that this conflict isn’t about the Sykes-Picot Agreement, whose hundredth anniversary fell in May, triggering a flood of sanctimonious commentary. The borders we see in the modern Middle East were the product not of a 1916 Anglo-French stitch-up, but of the Paris Peace Conference, the Treaties of Sèvres and Lausanne, the League of Nations mandates, subsequent interstate agreements in the 1920s and sometimes – as in the case of Saudi Arabia and much of the Persian Gulf, or Yemen – even later. Nor is it about Israel, whose own dilemmas seem ever less exceptional as we look at other communal conflicts across the region.

Russia in particular has made cynical ­opportunism into high policy. As a party to the conflict, it has managed in the past year to kill roughly 2,500 civilians, including over 200 children and 28 medical staff (more than Islamic State). But it is also apparently Washington’s preferred partner for peace. Russia has historically had predatory designs on Iran but the latter now lets it use one of its airbases, a dubiously constitutional act that Russia gleefully proclaims to the world, to the apparent disquiet of some in Iran. It is aligned with Bashar al-Assad but also with some Kurds. It co-ordinates tactically with Israel but fights alongside Hezbollah. Russia was previously hostile to Turkey, which opposes Assad but is now trying to halt the advance along the Syrian-Turkish border of the same Kurds whom his air force is bombing. Turkey is making eyes at Iran. And the Chinese have just offered extra training to Assad’s army.

The problem is not that borders are disappearing but that some states are fragmenting within these borders. This produces horrors such as Islamic State and other, publicly more cautious and sometimes divided, but still savage Salafi-jihadi groupings such as Jabhat al-Nusra (JaN) or Ahrar al-Sham (AaS). It also provides other states with an excuse to colonise the hollowed-out husks of their neighbours in ways that might prove far more enduring than the international settlements of the 1920s.

If you happen to be in the Israeli-occupied Golan (as I was recently) and drive up beyond Katzrin to the de facto border with Syria, you can see through field glasses the movement of armed groups associated with JaN or IS. The most significant of these, Liwa
Shuhada’ al-Yarmouk, occupies an enclave in southern Syria, to the south-west of the Golani town of Quneitra, whose main buildings were dynamited flat in the 1973 war. They are surrounded by elements of the Free Syrian Army (FSA) and other armed opposition groups, including JaN.

This is remarkable. This border was for four decades the quietest of all Israel’s frontiers with its enemies. When you ask senior Israelis – civilian and military – what this means for them, they shrug and say things like, “At least they are behaving themselves,” by which they mean, of course, that they are not attacking Israel. But if you probe, you discover a wider unease. This is only partly assuaged by the efforts Israel has made over the past three years to keep tabs on the situation by, for instance, offering medical treatment at Israeli hospitals to well over 1,000 wounded Syrians (by some accounts double that number), mostly opposition combatants. The treatment is delivered partly by Druze doctors whose historically irredentist community straddles the border.

If you go next to Jordan and talk to senior Jordanians, you will detect a similar unease. Some of it comes from the same concern about the threat from Salafi-jihadi groups – the murderous Abu Musab al-Zarqawi was Jordanian, after all – or the continued presence on Jordan’s northern border of increasing numbers of refugees whom the country simply cannot absorb. Some comes from greater Russian activity on the same border, most notably the recent air strikes on the FSA outpost at Tanf, halfway to al-Bukamal,
one of the major crossing points on Syria’s border with Iraq and, together with its counterpart in Iraq, al-Qaim, the nearest hub of Sunni jihadi insurgency. But in both countries there is a feeling that the conflict in Syria may ultimately produce a realignment of forces within Syria and Lebanon that will constitute a far more formidable threat to Israel than anything we see today.

***

This does not mean the continued killing in Syria does not matter. It does and it is shameful. The UN’s special envoy Staffan de Mistura said in April that the total number of deaths had reached approximately 400,000, mostly killed by regime action. Half of Syria’s entire population has fled or is internally displaced. For want of an alternative policy, the US administration has been casting around for ways of bringing influence to bear through Russia, which, alongside Iran, is the main external actor in the conflict. This influence remains focused on combating IS, JaN and other jointly designated armed Sunni Islamist organisations, an appalling group of people, but not the only ones by any means. We have had frequent reports of another proposed deal between the US and Russia under which the two countries together would designate areas where there is a confirmed JaN presence for joint or independent targeting – as well as continuing air operations (few of which have been Russian) against Islamic State. You might think that developments around Aleppo in recent weeks would make this less likely: but in Syria, conventional reasoning has ceased to apply.

In any case, the agreement would have little bearing on the operation of the Syrian air force, which would remain free to drop barrel bombs anywhere it liked – as long as it didn’t get in the way of joint Russian-US operations. It would not prevent any other sort of military activity by Assad’s forces – through artillery bombardments or ground-to-ground missiles, for example, which are already the regime’s principal tactics. Clearly it has had no impact on Russia’s current air operations, which redoubled in intensity after opposition gains in Aleppo in the past few weeks. And it would not obviously reduce support from the Gulf and Turkey for elements of the armed opposition.

The thwarted coup in Turkey will complicate matters further. President Recep Tayyip Erdogan had already been making overtures to Assad – who, when I was ambassador to Syria in 2007, publicly claimed that Turkey was Syria’s best friend in the region. Now resurgent with a newly providential purpose but also conscious of his and his government’s vulnerability, Erdogan may, after purging the army and security forces, decide to focus on the constitution, the economy, his internal enemies and the Kurds, who remain, in his view, the main threat to national security, both inside and outside Turkey. His visit last month to Moscow to repair relations with Vladimir Putin (who has been cultivating the Kurds to spite him), Prime Minister Yildirim’s warm words after Foreign Minister Javad Zarif’s visit to Istanbul in March, and the Turkish army’s support for the Arab/Turkmen intervention in the town of Jarabulus, previously a target of the largely Kurdish Syrian Democratic Forces, all point in the same direction. If that means supporting a militia – Nour al-Din al-Zenki, which filmed its men beheading a 12-year-old boy in Aleppo – too bad. As a result, the Turks’ commitment to the fight against IS (never entirely convincing) – or indeed, to any intervention in Syria that does not serve their own purposes – may weaken further, especially if there are more attacks inside Turkey like the suicide bombing of a wedding party in Gaziantep on 20 August.

There are reports that traces of nerve gas have been found once more in Syria. There have also been claims recently of the continued military use by the regime of phosphorus and incendiary thermite, and by both sides of other chemical substances.

I remember vividly the last week of August 2013, when Assad was going to be punished for stepping over that particular “red line”. I was in Riyadh at the time and involved in seeking, on behalf of the British government, senior engagement by the Saudis in an international response, which they were willing to give. The sense of frustration when the UK and US stepped back was palpable. It was palliated a little by the US-Russia deal to remove Syria’s stocks of chemical and biological weapons material and Assad’s agreement to sign the Chemical Weapons Convention. There have been numerous suggestions since then that this deal was never as clear or complete as proclaimed. But most people shrugged the objections off as the best being the enemy of the good. What was a barrel of chlorine between friends? It was a great international achievement and showed what could be achieved by not doing “stupid shit”.

If the nerve-gas and other reports are true – and a UN investigative report suggests they are – it maybe doesn’t look such a great achievement after all. It may even begin to look like an enabler for Assad – in the same way as all the subsequent little bargains with the Russians do and, indeed, the mother of all international achievements, the Iran nuclear deal. It will also represent yet another erosion of international norms, the very thing that we in the West say we value above all else.

***

As we approach the end of the second and final term of the Obama administration, experience extraordinary scenes at the Republican and Democratic conventions and await the decision of the American people on their new president in November, what does the balance sheet in Syria look like? Not so good – even for those who see Sunni Salafi-jihadi groups as the main enemy. It is true that Islamic State remains under severe pressure in parts of Syria and Iraq and has lost territory, most recently the strategically sited border towns of Manbij, al-Rai and now Jarabulus in Syria, doubtless reflecting an improved US-led military strategy. Yet IS has also shown considerable resilience. The 21 May audio statement by Abu Muhammad al-Adnani, its official spokesman, on the meaning of victory – now amplified by a recent editorial in its weekly Arabic newsletter, al-Naba’ – suggests that IS is preparing to regroup outside urban centres within Syria and Iraq if it loses Raqqa and Mosul – and to send shards of Islamist violence flying in countries across the world through the agency of true believers everywhere. JaN may just have announced a tactical disaffiliation (though significantly not a break) from al-Qaeda, but this is designed to enable the group to hide in plain sight. It continues to grow in strength in north-western Syria and is imbricating itself in the defence of Aleppo, at the heart of the armed opposition groups acceptable to the West. Past Russian air strikes have only reinforced its position: other armed groups are heavily involved in many of the same battles and it is hard to disentangle them. In any case, no one is going to stand idle as the Russians target one of the most effective groups of anti-Assad fighters.

The Geneva III peace talks on Syria have ground to a predictable halt, with the Russians using their willingness to shape the conflict to influence US policy, too. Meanwhile, the humanitarian situation remains appalling. Aleppo remains doubly besieged, in spite of the latest fighting and opposition success in reopening a narrow access point in the south-west of the city. The Russians, supported by Hezbollah and Iraqi Shia militiamen, are targeting the area and their offer of humanitarian corridors and pauses looks ever more bogus. The UN, whose own relationship with the regime has raised concerns, is warning of another disaster in the making as non-combatants in the deeply divided city become trapped between the hammer of Assad and his allies and the anvil of the armed opposition.

***

As we obsess about Sunni violence, Hezbollah continues to prosper. The Lebanese Shia militia has lost large numbers of men – as many as 2,000 since the start of the conflict. That is more than it lost against Israel between 1982 and 2000: there have been mutterings about this in the Shia community in Lebanon. Hezbollah fighters, too, may be starting to blame the Syrian army’s lack of offensive spirit for some of their casualties, if recent tweets from the Aleppo front line are correct.

They have lost senior commanders, notably (in May) Mustafa Badreddine, the successor to the infamous Imad Mughniyeh, as well as lesser figures such as Samir Kuntar, who beat a four-year-old girl to death on an Israeli beach in 1979. Mughniyeh’s own son was killed last year. And the war in Syria is costing them millions of dollars a month, at a time when their business wing is being squeezed by the US and the Gulf Co-operation Council (GCC) – a cost that Iran, under pressure of its own, is helping to meet. But Hezbollah, like the Iranians, can shrug off such losses. The gains it has made in operational capability – command and control, planning, logistics, complex battlefield management and so forth – and in terms of resupply from Iran make up for them. It has probably doubled its available military forces, to perhaps as many as 45,000 troops. It has rebuilt and improved its weapons stocks: in spite of Israeli interdiction efforts, it is believed to hold well over 100,000 short- and medium-range missiles, whose accuracy is much improved. It has become skilled at using UAVs. It is rumoured to have received air-defence systems via Iran. And, in the wider Levant, Russia’s delivery to Iran of the S-300 mobile air defence system this year, as well as Iran’s reported development of a copycat system, the Bavar-373, potentially gives Tehran the capacity to deny access to US and other aircraft, not just over Iran but over Iraq, parts of the Gulf and perhaps, in the future, Syria.

The Lebanese Shias have no serious political alternative, and no other community in their country can compete. As their armed militia’s presence in Syria corrodes the communal consent on which Lebanon’s own political system rests, their ambitions, like those of their patron and now partner Iran, may be growing.

***

When the conflict ends or stabilises, as one day it will, Hezbollah will almost certainly be militarily stronger, unless Assad loses. It is unlikely to believe in a federal solution in Syria any more than its analogues do in Iraq. Admittedly, it would be easier to achieve such a structure in Iraq, where federalism is enshrined in the constitution and already applies in the Kurdish north. But federalism is anathema to Assad. And in both places, a solution that places real power in the hands of a central authority dependent on Iran is almost certainly the preferred goal. If that entails managing continued low-level conflict with Sunni insurgent groups, so be it.

In the longer run, the big targets remain Israel, the US and its regional partners. Hezbollah and Iran have lost a huge amount of support in the wider Islamic Middle East because of their sectarian involvement in Lebanon, Syria and Iraq. This has not stopped them persistently trying to make mischief: indeed, it, and power games within Iran’s highly competitive governing elite, may be precisely why they do so. That in turn is one reason why the GCC states are now taking unprecedented action against them.

But Hezbollah can live with this. Assad has reinforced his hold on Damascus with its help and is likely to remain dependent on it for the foreseeable future. It has made the protection of the Shia shrines in Syria a religious mission. It is still trying to recruit sympathisers within the occupied Palestinian territories: the Israelis recently discovered a cache of Hezbollah explosives on their side of the border. More broadly, the public appearance in Quneitra of Mohammad Reza Naghdi, the commander of the Basij – a force brigaded under the Iranian Revolutionary Guard Corps (IRGC) – peering back through his own field glasses towards the watchers on the other side of the border, and the extraordinary report that the Iranian ambassador in Damascus has taken it upon himself to appoint a new head of the Assad regime’s National Defence Forces in the nearby Druze city of Suwayda, show clear intent. And if at some point in the not-too-distant future Hezbollah and Iran are able to launch new operations against or even inside Israel from secured positions in southern Syria, the picture might change again rapidly. With or without nerve gas.

In the end, the struggle against Sunni jihadis will be long and brutal. But there is an answer available if the region’s states – notably Iraq, which in my view is still just about salvageable if we focus properly on the endgame after Mosul – are prepared to reintegrate disaffected Sunnis effectively into their domestic political processes. An Iranian-backed victory for the Assad regime in Syria would make this far more difficult.

The consequences of this struggle that we face in the West are horrific but not a threat to our existence (unless we allow them to be so) and manageable with patient and better-resourced intelligence and police work, better communications and popular resilience.

The battle against Iran’s militiafication of states in the Middle East is less tractable. Iran itself is built on this model. Its deep security state uses it to suppress internal dissent and block reformists. It exported it decades ago to Lebanon. In Iraq, the Iranian-backed Shia militias that constitute the most significant part of al-Hashd al-Sha’abi (the “popular mobilisation”) recently claimed that they were brigaded by Prime Minister Abadi with the rest of Iraq’s official military and counterterrorism forces some months ago. Whatever Abadi’s intentions may have been, they will seek to exploit this to secure a role in any assault on Mosul, the most symbolically resonant Sunni city in Iraq.

The Kurds will, as always, be caught in the middle, trying to play off more powerful ­actors against each other, perhaps tempted to seek sponsorship from Iran and Russia, and surrounded by hostile Arab communities in a cycle of displacement and revenge.

In the absence of the US, all this allows an amplification of Iranian influence across the region that in some ways poses a more general threat to the Middle Eastern order – because it is part of a long-term, transnational design backed by a powerful state – than any other. If Iran can make its projection of power through zombie states and sectarian non-state actors a permanent feature of the landscape, it would be a great achievement, overturning a hundred years of a more or less stable (if unsatisfactory) interstate Arab acquis. This would also prepare the ground for new sorts of conflict within and between states and prove very hard to undo.

That is the source of tensions between Iran and the Sunni Gulf states, which has led the latter – disappointed in the US, rebuffed by Russia but welcomed by Israel – to seek support in surprising places. It is one of the factors in the war in Yemen, which has led to accusations that Saudi-led forces have unlawfully targeted civilians and contributed to the creation of another humanitarian catastrophe. Without political change at the centre, it may lead to Shia-on-Shia conflict over the spoils of a post-Mosul Iraqi state. It has led to war before between Israel, Hezbollah and, indeed, Hamas. It will do so again. Next time will probably be worse. The capacities of all sides have been strengthened. And, given the internationalisation of the Syrian conflict, it will prompt far more states and non-state actors to make unexpected alignments. This will be a new form of instability in the region.

The Middle East will be a huge challenge for whoever is elected the new president of the United States. The usual American approach to conflict management in the region, which rested on clear political resolve, may no longer work: if Russia now shapes the battle space in Syria, who will shape it in Gaza and northern Israel? It will be a challenge for the European Union, which is intimately affected by the collapse of Arab states. And it will be a challenge for a British government that wants to show it is not retreating from a world it helped to shape – only not through Sykes-Picot.

John Jenkins is the executive director of the International Institute for Strategic Studies – Middle East. He is a former British ambassador to Saudi Arabia, Libya, Iraq, Syria and Burma and a former consul general in Jerusalem

This article first appeared in the 01 September 2016 issue of the New Statesman, Syria's world war