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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Death of a dictator

How Caesar’s murder set the template for political assassination.

The assassination of Julius Caesar on 15 March 44BC (“the ides of March” by the Roman system of dating) is the most famous political murder in history. Caesar had recently been made “dictator for life”, and he was killed in the name of “liberty” by a group of men he counted as friends and colleagues. In the aftermath, the assassins issued coins with a design specially chosen to celebrate the deed and press home the message: it featured the memorable date (“EID MAR”), a pair of daggers and the image of the small hat, “the cap of liberty”, regularly presented to Roman slaves when they were granted their freedom. This was liberation on a grander scale, freeing the Roman people from tyranny.

Several of the characters whose biographies feature in Plutarch’s Lives – Caesar, Brutus, Cicero, Antony, Pompey – had a role in the story of the murder. Julius Caesar was the victim, his dying moments vividly described by Plutarch. In this account, there were no famous last words, “Et tu Brute?” or whatever; after a futile attempt to fight back, Caesar pulled his toga over his head and took the 23 dagger blows that killed him. Brutus was the leading figure behind the assassination, a frankly messy business, as Plutarch makes clear (with several of the assassins “caught in friendly fire”, accidentally wounded by blows from their own side), and he was soon more or less forced to leave the city.

Cicero, the Roman politician, philosopher, poet, wit and orator, was not party to the plot but was very likely an eyewitness of the murder, and was straight away consulted by the assassins about what on Earth to do next (one of their main problems was that they had not thought ahead). Antony was Caesar’s right-hand man, gave the address at his funeral, and tried to take on the role of Caesar’s defender and successor – though he soon found an even more powerful rival for that position.

Pompey was already dead by 44BC. He had been killed four years earlier in a civil war, leading those Romans who had then been prepared to resort to pitched battles to resist the growing power of Caesar. But his shadow hung over the assassination. Caesar was murdered in an expensive new meeting hall whose building Pompey had funded, and he fell in front of a statue of Pompey, splattering it with his blood. It was as if Pompey was finally getting his revenge.

 

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The death of Caesar has provided the template for assassination ever since and has been the focus of debate on the rights and wrongs of political violence. In 1865, John Wilkes Booth used the word “ides” as the code word for the planned date of the assassination of President Lincoln. Shakespeare in Julius Caesar, largely drawing on an early translation of Plutarch’s biography, used the events of 44BC to reflect on the nature of political power, ideology and moral conscience. Others have seen the assassination as a useful reminder of the futility of such attempts at direct action. For what did it achieve? If the assassins had really wanted to quash the rise of one-man rule in Rome, if they had wanted to kill the tyranny as well as the tyrant, they were strikingly unsuccessful. More than a decade of civil war followed (a major theme in Plutarch’s biographies of Brutus and Antony), but the end result was that Caesar’s great-nephew – “Augustus”, as he was later known, and the man who rivalled Antony as Caesar’s heir – became the first Roman emperor. He established autocratic rule on a permanent basis. So much for the return of “liberty”.

In the long history of Rome – founded, as the Romans calculated it, around 750BC – the murder of Caesar, for all its later notoriety, was just one of many political crises, which became particularly intense and violent in the 2nd and 1st centuries BC. This was a period of expansion, political change, even revolution. There were vast Roman conquests overseas and, as a consequence, an enormous influx of wealth into the city. Gleaming marble from Greece, rather than local brick and stone, began to be used for temples and other public buildings in the city; slaves started to make up the majority of the workforce; and so many people flocked to Rome that its population topped a million, the only Western city of that size until London in the early 19th century.

But this age also saw repeated outbreaks of civil war at home, political disintegration, mass pogroms of citizens and the final fracture of what had once been a more or less democratic system of government. As a leading politician, Caesar was almost typical in coming to a violent end. None of the men I have mentioned died in their beds, nor fighting some “barbarian enemy”. They were killed in conflict with other Romans, by Roman hands, or on Roman orders. Pompey, for example, after losing in battle to Caesar, was decapitated by an Egyptian eunuch, ably assisted by a couple of Roman veteran soldiers; Cicero was put to death in 43BC in one of the pogroms, on Antony’s instructions, his head and hands later pinned up in the centre of Rome as macabre trophies for the crowds to leer and jeer at. A little over a decade later, Antony ended up killing himself after he lost in battle to Caesar’s great-nephew and successor.

The Romans described and fiercely debated the stresses and breakdown of their political system, trailing all kinds of explanations and possible solutions. For this period was also one of intellectual revolution in Rome, when the rich tradition of Roman literature began. Starting in the early 2nd century BC, Roman writers for the first time tried to tell the history of their city, to reflect on its problems and on how they thought it should be governed; and they used writing, too, for political attacks, insults in verse, self-advertisement in public, and personal letters in which they shared their aspirations, fears and suspicions.

When Plutarch in the early 2nd century AD was writing these biographies, he could base his narrative on plenty of contemporary material from the age of Caesar. Some of this we can still read, including Caesar’s one-sided account of his campaigns against the tribes of Gaul and later against Pompey (one of the very few eyewitness descriptions of ancient warfare to have come down to us) and volumes of Cicero’s political speeches, philosophical treatises and hundreds of his private letters, made public after his death by his loyal heirs. This writing helps us to understand what lay beneath all that chaos.

The rapid growth of the Roman empire was a crucial and destabilising factor. For us, why Rome grew in a few centuries from a small, moderately successful town in central Italy to one with control over more of Europe and the Mediterranean world than any state before or since is one of history’s big puzzles. Most modern observers put it down to some unfathomable combination of greed, a highly militaristic ideology, a dose of good luck and a happy knack of converting those they conquered into Roman citizens, and so into new soldiers for the Roman cause. The Romans were less puzzled on this score, pointing to the support of the gods, their piety and a succession of defensive rather than aggressive wars, in which they intervened to protect allies under threat. They were more troubled by the consequences of overseas growth for society and politics back home.

Despite their popular modern image, the Romans were not simply thoughtless and jingoistic imperialists. Some worried that the wealth and luxury that came with conquest overseas undermined what they saw as old-fashioned Roman austerity, a few about the cruelty of conquest (there was even
one, perhaps not entirely serious, proposal to put Caesar on trial for genocide during his conquest of Gaul). Others faced the question of how to adapt the traditional structures of Roman government to cope with new imperial demands. For how could you control and defend a vast empire, stretching from Spain to Syria, with a power structure and a system of military command developed to run nothing more than a small town?

That was one of the big issues behind the revolutionary changes of this period, and one of the factors that promoted the rise of dynasts such as Caesar. The political traditions of Rome, going at least as far back as the end of the 6th century BC, had been based on the principle that power was only ever held on a temporary basis and was always shared. The citizens as a whole elected the city’s officials, who combined both military and civilian duties, held office for just one year at a time, ideally not to be repeated, and never had fully independent decision-making power.

That there had always been not one but two consuls (the most senior of these annual officials) is a clear sign of that long-established commitment to power-sharing. But it was a principle ill suited to governing a far-flung empire and to fighting wars that might take place several months’ distance from Italy; you could hardly travel there and back in the regular year of office.

The Romans improvised various solutions to that problem: sending men out to the provinces, for example, after their year of office in Rome. But increasingly the Roman people voted more and more power into the hands of ambitious individual politicians on an almost permanent basis, even though those votes were often ­controversial and sometimes violently resisted.

 

 

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Caesar was not the first to challenge the traditional model of power-sharing. Despite leading the traditionalists against Caesar in 49BC, Pompey had, only 15 years or so earlier, been granted unlimited power for years on end across the whole of the eastern Mediterranean, first to deal with the pirates and human traffickers operating on the sea, then to deal with one of Rome’s remaining enemies in the East, King Mithridates of Pontus (in modern Turkey). Cicero was one of those who successfully spoke up, in a speech whose text we can still read, to quell the opposition to this grant, which was regarded as a dangerous step in the direction of one-man rule.

Even Brutus, despite his fine slogans on the subject of “liberty”, seems not to have been entirely immune from similar dreams of personal power. The coin celebrating Caesar’s assassination may have displayed the daggers and cap of liberty on one side. But on the other was an image of the head of Brutus. In Roman eyes, heads of living people on coins smacked of autocratic ambitions: Caesar was the first to risk such a display at Rome, Brutus the second.

So one side of the age of Caesar, richly documented in Plutarch’s Lives, was a series of “big men”, bankrolled by the vast profits that followed imperial conquests, competing for personal power. And that competition often came down to open fighting – whether in the streets of Rome, where there was no police force or any form of peacekeepers to maintain order, or across the empire more widely (the final battle in the Roman Civil War between Caesar and Pompey was fought in northern Greece, and Pompey was brutally finished off on the coast of Egypt). As the coin of Brutus hints, Caesar’s murder came too late to put the clock back to old-fashioned power-sharing. If Augustus had not established permanent one-man rule, Antony or some other rival would surely have done so.

Another important side of the period was the increasingly intense debates about what we would call “civil liberties”. How was it possible to protect the rights of the individual Roman citizen in this violent turmoil? How were the rights of citizenship to be balanced against the safety of the state? This came to a head almost 20 years before Caesar’s assassination, in 63BC. As Plutarch and others described it, Cicero was consul and believed that he had uncovered a terrorist plot, masterminded by a bankrupt and desperate aristocrat named Catiline, to eliminate some of the leading politicians, Cicero included, and to burn down much of the city. Once he had frightened Catiline out of Rome, Cicero rounded up those he believed were his accomplices and had them all executed without trial, even though they were Roman citizens and, as such, had a right to due legal process. “Vixere” (“They have lived” – that is, “They are dead”), he said in a particularly chilling euphemism, as he left the jail after super­vising their execution.

Not everyone at the time approved. Caesar was among those who stood up and objected. He was what we can still recognise as a classic populist, combining – as many have since – aspirations for dictatorship with a knack for popular rhetoric and an ability to appeal to the interests of the people (though, unlike some more recent examples of his kind, he also had a strong sense of popular justice). But in general Cicero was hailed as a hero who had saved the state from destruction.

The approval did not, however, last for long. Despite claiming the protection of an ancient equivalent of the Prevention of Terrorism Act, Cicero was banished into exile, on the charge of executing citizens without trial. He was recalled within a few months but, during his absence, his house had been demolished and a shrine to the goddess Liberty had pointedly been erected on the site.

The rights and wrongs of this case were debated ever after. How far, the Romans wondered, were elected officials allowed, or obliged, to transcend the law to save the state? We now debate very similar issues; how far the interests of homeland security make it legitimate to suspend the rights and protection that citizenship ought to ­offer, or how far we can stomach the idea of detention without trial, or summary deportation, if it prevents the “bad dudes” from doing us harm. That is why this is one of the Roman causes célèbres that speak to us most directly.

 

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The age of Caesar, then, was one of political murder, street violence, constant warfare both inside and outside Rome and fundamental disagreements about how the state should be run, how democracy and liberty might be preserved, while the demands of empire and security were met. It is impossible not to wonder what it was actually like to live through – and not just for the elite, rich and male political leaders who were the leading characters and celebrity victims in the conflicts and the focus of all ancient writers. What of the ordinary men and women who were not in the limelight? Did life for them go on much as before, while the big men and their armies fought it out? Or did the violence and bloodshed touch almost everyone?

It is hard to know and wrong to generalise. Just occasionally, Plutarch does take his eyes off those at the top of the pile and throw a fleeting glance at ordinary people carrying on with their lives more or less as usual in the chaos around them. We meet in passing Cicero’s wives and his daughter, Tullia who, like so many women in the Roman world, died from complications of childbirth, along with her infant son. We have a glimpse of an enterprising trader from northern Italy, a man called Peticius, who in 48BC just happened to be travelling in his ship along the coast of Greece when he spotted Pompey, on the run after his defeat by Caesar – and gave him a lift south.

Most engagingly of all, thanks to information he had picked up from his grandfather, Plutarch gives us a tiny but vivid insight into the practices “below stairs” in the kitchens of the palace in Alexandria that – to the horror of many Romans – Antony eventually came to share with Queen Cleopatra. Apparently, the cooks were so concerned about preparing the wild boar to perfection, whenever the company upstairs decided to eat, that they had eight boars roasting, each put on to cook at a different time, so that one would be sure to be just right when dinner was summoned (do the cooks at Mar-a-Lago or, for that matter, Balmoral have the same problem?). It is a nice image of ordinary people living in their own world and dealing in their own way with (and maybe laughing at) the capricious demands of the world leaders they served.

But not all were so lucky. One memorable story told by Plutarch, repeated and made even more famous by Shakespeare in Julius Caesar, tells the fate of an unfortunate poet called Cinna. This man was not quite as ordinary as Peticius or the cooks in Alexandria; he was a friend of Caesar but he was not in the political mainstream. A couple of days after the assassination, he went to the Forum to see his friend laid out for his funeral and fell in with a crowd of Caesar’s mourning and angry supporters. These men mistook the poet for a different Cinna, who had been one of the assassins, and so tore the poor man limb from limb.

The message of the story is clear. Assassinations have innocent victims, too. Simple cases of mistaken identity (and there must have been many of those at Rome, in the absence of any form of official ID) can leave a blameless bystander dead. Shakespeare’s plaintive line “I am Cinna the poet, I am Cinna the poet” is a haunting reminder of the many who must have been caught in the crossfire when the leaders of the Roman world clashed.

“The Age of Caesar: Five Roman Lives” by Plutarch, translated by Pamela Mensch and edited by James Romm, is newly published by W W Norton

This article first appeared in the 06 April 2017 issue of the New Statesman, Spring Double Issue

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