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

RALPH STEADMAN FOR NEW STATESMAN
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The Tory wars

How the EU referendum exposed a crisis in the Conservative Party that will endure long after the vote.

The Conservative Party is approaching not only a historic referendum, but a historic moment of crisis. It is deeply divided over whether or not to stay in the European Union, and the divisions are unequal. At the top, most want to stay in: not out of conviction, but because most ministers have found it politic to agree with David Cameron, even if they cannot support his view that he got a great deal from other EU countries after his supposed “renegotiations” with them. Among MPs generally the mood is far more hostile; and at the party’s grass roots it is predominantly in favour of leaving. Where this ranks in the history of Tory party crises is not easy to say.

It smells a little like the division over the Corn Laws in 1846, when Robert Peel needed to rely on the Liberals and Whigs to secure repeal, because most of his party was against him. It looks greater than 1903, when a minority of the party sympathised with Joseph Chamberlain over tariff reform. Where it differs from both of those is that for 28 and 19 years, respectively, the Tories had a long wait before coming back into power for a full parliamentary term after their split. Now, Labour itself is so divided, and its leader viewed as so marginal by people outside the party, that the prospect of the Tories losing power for a couple of decades is highly unlikely.

So perhaps we should look at 1922, when a rebellion in the party caused the end of the Lloyd George coalition and put Stanley Baldwin into Downing Street, first briefly, in 1923, and then, after the short-lived first Labour government, for five years; or the more drawn-out legacy of Neville Chamberlain, who left the stain of Munich on the party. In that case, the wound did not heal for 25 years: one of the reasons Harold Macmillan disapproved of R A Butler was that he had been an avid appeaser, and it helped lose Butler the Tory leadership – ironically, to a man, Lord Home, who had been Neville Chamberlain’s private secretary. Divisions over appeasement had already had the effect of putting Churchill into Downing Street in 1940 ahead of Viscount Halifax. Factionalism in the party was one of the causes of the 1945 landslide defeat by Labour, and of the narrow one in 1964.

The current division is open and is breeding hostility, luxuries afforded by one of the Tories’ few unifying beliefs: that Labour poses no threat at the moment, and they can have a quarrel that may even verge on civil war without fearing electoral consequences. Whatever the outcome, the present quarrel allows the opportunity for a major realignment of the party without it having to go out of office. A minister who is (just, and after much soul-searching) committed to our staying in the European Union told me frankly last week that the Tory party was “a mess” and that, whatever happened on 23 June, the referendum would be the beginning and not the end of a painful process for the Conservatives.

Whereas so much of what goes wrong for David Cameron has been down to his arrogance, and his failure therefore to grasp the likely consequences of his actions (think of the policy on Libya), the “mess” of a divided and recriminatory Tory party is, paradoxically, down to a fear of failure. He had, in the first instance, promised a referendum on our membership of the EU in order to see off Ukip. However, like the rest of us, Cameron had never believed he would be in a position where he would have to abide by his promise, because he had, like the rest of us, expected either to lose last year’s election or to be able to govern only with the help of the Liberal Democrats: who would, to his delight and relief, never allow him to call a plebiscite. But he and his party did not fail. The referendum is now just two and a half months away, and it is shredding the Tory party.

***

There is dismay among most of the pro-EU Tories, because they sense they are losing. In his now famous savaging of Boris Johnson in the Times last month, Matthew Parris, who has a record as a level-headed and, if anything, understated columnist, threw in the aside that he thought defeat for the Remain camp was increasingly likely. “I am aware,” another minister told me, “that I, like all of my colleagues, have so far failed to make a convincing case for staying in.” He expressed foreboding about how things could get worse for the Remainers: “One more terrorist outrage that can be attributed to open borders in Europe, or film of the Mediterranean full of boats of refugees, and we’re done for.”

A couple of ministers have told me that their personal loyalty to Cameron was what persuaded them to support him, but that such support is contingent on an understanding that they will not be asked to go out and make far-fetched claims about what will happen if the UK leaves. There is embarrassment even among pro-Europeans about some of the hyperbole retailed so far, not least because of the damage wild and easily disprovable claims do to the credibility of the Remain case. Such is the paranoia about the party post-23 June that no one sensible is keen to speak attributably about how things are, or how they might turn out.

Leading Tories note the disparity between the motivations of the two camps. Whereas groups such as Grassroots Out and Leave.EU have held rallies all over the country, some drawing in 2,000 people, there have been no comparable manifestations of popular enthusiasm to keep Britain in. There seems an inevitable inertia among those happy with the status quo that contrasts with the energy and dynamism of those who want change. And, for the avoidance of doubt, rallies by Leave campaigners have not been packed solely with Ukip stalwarts and disaffected Tories, but have included groups of Labour supporters and trades unionists who have cheered on speakers such as Kate Hoey. After all, many who put Jeremy Corbyn into the leadership are, like him, long-term Bennites, with a Bennite view of the EU: and, unlike their leader, they are saying so.

Tory MPs on the Remain side talk resignedly of the dislocation between them and their activists. Most Conservative associations are minuscule compared to what they were in the Thatcher era, and some MPs say they struggle to find a single activist willing to vote In. In the Commons, an estimated 150 Tory MPs out of 330 have indicated that they are Leavers, and many among the payroll vote who have declared their support for Cameron have done so purely for reasons of job security. Few believe that those who have exercised their right to differ and support Leave can be sure of keeping their jobs, with one or two important exceptions. The whips have been unpleasant and forceful about job prospects, as one MP put it to me, “almost to the point of caricature”.

The unpleasantness starts with David Cameron. The conversation the Prime Minister had with Iain Duncan Smith when the former work and pensions secretary decided to resign is characterised by Duncan Smith’s friends as one in which “expletives were used”. Insiders believe that some of those around Cameron are absolutely ruthless. They sense the argument is going against them and they will do what they must to turn it round. The Queensberry rules do not apply. Hence the threats by whips, the sendings-to-Coventry, the cutting people dead in corridors, the meetings of a “White Commonwealth” of ministers that excludes anyone known or feared to be opposed to Cameron’s view.

Of the six ministers with a seat in cabinet who came out in favour of Brexit, both Iain Duncan Smith and Chris Grayling are said to have long believed they would be sacked after the referendum, and so felt they had nothing to lose. Some think Theresa Villiers, the Northern Ireland Secretary, is in that category, too. John Whittingdale, the Culture Secretary, is treading carefully, and colleagues think Priti Patel ticks too many boxes to be sacked – being a woman from an ethnic minority who is good on television.

Michael Gove’s position is interesting, to say the least. He, unlike any of the other five ministers who came out in February as Leavers, was part of Cameron’s social circle, and clung on there even after his demotion from education secretary to chief whip in favour of the considerably less able Nicky Morgan. He alone of all the six has made a coherent and rigorous case for leaving the EU, and his combination of intellect and conviction makes him by far Cameron’s most dangerous opponent within the party.

He has studiously avoided any personal element in his criticism of the Prime Minister or his colleagues; he rushed to George Osborne’s defence after Duncan Smith’s resignation and when other Leavers were using the Chancellor’s failings to undermine him; and he is maintaining a general decorum at all times. “But the main reason they daren’t touch Gove,” an insider tells me, “is that he knows too much.”

What worries the Cameron camp, and invigorates Leavers, is the perception, shared by anyone over the age of 55, that what is going on now is totally unlike 1975, when the only other referendum on our participation in Europe was held and the United Kingdom decided by a margin of 2 to 1 to stay in the European Economic Community. Veterans remember people saying at the time that Britain had been in only two years, and it had to be given a chance to work. That argument no longer applies. Also, the cast list of serious politicians advocating exit, which in 1975 was Tony Benn, Michael Foot, Peter Shore and Enoch Powell, is now a widening array of people, in and out of politics.

Because a defeat for Cameron is so possible – a poll in last Sunday’s Observer showed Leave 4 points ahead of Remain, 43 to 39, with 18 per cent still to decide – many Tories are spending much time thinking and talking privately about potential outcomes. One that is ruled out by all is that either side will win by a substantial margin: whether we vote to leave or stay, it will be close.

“If we vote to leave, then we leave,” a ­Remain minister tells me. “That’s the end of it, and it’s the end of Cameron, too. It would be like a vote of confidence for him. We need a government to negotiate the terms of our exit and a shedload of trade deals, and it can’t be him in those circumstances. But the nightmare scenario is that we vote narrowly to stay in. That’s when things turn really ugly.”

The “nightmare” is what occupies the thoughts of an increasing number of Tories. The mood among the Remainers is already so bitter – especially, it seems, among those around Osborne, rather than those around the Prime Minister, for they see their man’s promotion prospects as hanging entirely on the outcome of the vote – that calls for magnanimity in victory may not be heeded. Given the profoundly anti-EU temper of the Tory party, such an attitude would be dangerous for its unity and health even if the victory were on the scale of that in 1975. If, as is more likely, the difference is of a few percentage points, the consequences of such an atmosphere of recrimination could be devastating.

“If David wins by a decent margin we can then settle down and face the important challenges the rest of the world offers us, and stop obsessing about Europe,” a close confidant of the Prime Minister told me. “Russia is a growing threat, China is a problem and America could end up being far from reliable. If we win well, then I and many like me will try to persuade David to change his mind about leaving before the next election [in 2020] come what may, as he is manifestly the best man to see us through these problems.” Such sentiments are widespread among Cameron’s friends, and reflect other factors of which they are keenly aware: the recognition that Osborne is deeply damaged, that Boris Johnson would be a disastrous leader and prime minister, and that Gove is rather better at politics than they might like.

***

There is an idea on both sides that scores will have to be settled after 23 June, and, the way things are going with party discipline and out-of-control aides in Downing Street, such an outcome is inevitable. Should Remain prevail, a wise prime minister would understand that this was a time to heal wounds and not deepen them. It remains a matter of conjecture how wise Cameron, whose vindictive streak is more often than not on the surface rather than beneath it, is prepared to be.

Those who work for his party at the grass roots, and on whom MPs depend to get the vote out at elections, will be unimpressed by a purge of those who have not backed him over Europe. There isn’t much of a voluntary party left, and there will be even less of one if he acts rashly in victory. If it is a narrow victory – and it is, at this stage, hard to envisage any other sort – his party could become unmanageable unless he acts with restraint and decency.

It won’t help Cameron, who is already considered out of touch because of his personal wealth and the life he leads as a consequence, that (as a result of the Panama Papers) we now know that part of his family’s wealth was based on precisely the sort of systematic tax avoidance that Osborne has branded “immoral”.

Yet things could be worse for the Prime Minister. Tory Leavers believe that if only Corbyn would say what he really thinks about the EU their side would be assured of victory. It does not seem to worry them that that, if true, would be the end of Cameron, for whom they have the sort of disdain the Heseltine faction had for Margaret Thatcher in the late 1980s, or the “Bastards” had for John Major after Britain ratified the Maastricht Treaty in 1993.

Conservatives worried about the stability of their party believe that only Labour under a new, more effective and less factional leader could present the serious electoral challenge to them that would shake them out of these unprecedentedly acrimonious and self-indulgent divisions. We can only imagine how differently the In campaign would be conducted if Labour had a nationally popular and an obviously electable leader.

As it is, many more dogs are likely to be unleashed. Things promise to become far nastier, dirtier and ever more internecine for the Tories, not just before 23 June but for a long time afterwards: and with the party in power for at least four more years, one can only guess what that means for the governance of Britain.

Simon Heffer is a journalist, author and political commentator, who has worked for long stretches at the Daily Telegraph and the Daily Mail. He has written biographies of Thomas Carlyle, Ralph Vaughan Williams and Enoch Powell, and reviews and writes on politics for the New Statesman

This article first appeared in the 08 April 2016 issue of the New Statesman, The Tories at war