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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Extreme Scottish unionists: how the hard right has muscled into the independence debate

During the last Scottish referendum, pro-union campaigners tried to ignore the most extreme members of their own side. But can they afford to do so again? 

This is one of a two-part series. For the article on extreme Scottish nationalists, click here.

Robert Somynne is a London-born Scot of African-Caribbean heritage. When the Scottish referendum was announced, he was inspired by the civic nationalism of the pro-independence campaign. But when he shared his support online, he found it came at a cost.

“The comments ranged from being called 'filthy Aids wog' to 'fuck off what you doing in Scotland anyway?’” he remembers. “These were usually comments from people who prior to the statements would talk about union and British unity.”

Another time, he was canvassing in the bustling Edinburgh neighbourhood of Leith, when three members of the Orange Order, a Protestant organisation viewed by many as sectarian, surrounded the stall.

“That was the first instance of physical confrontation,” he says. “They spat on the floor close to us, but walked away grumbling.”

With most newspapers focused on the online “cybernats” and pro-independence thugs, Somynne felt ignored. “As a BME pro-Indy person you had to sit and listen to the narrative about Indy people being abusive wondering if you were invisible,” he says. 

Read more: The extreme Scottish nationalists

With a second independence referendum looking increasingly likely, Somynne fears that the pro-union parties warning about “division” are creating a self-fulfilling prophecy. 

“As for physical confrontation,” he says. “I'm honestly worried about certain sections of the No-supporting extremes, who see the independence movement as some kind of 'Jacobite plot' to destroy their British identity.”

In 2014, pro-union parties fought under a banner of economic realism, with the additional message that it was OK to be “Scottish and British”. After the experience of the EU referendum, though, there are murmurings that a second pro-union campaign would have to be fought on more emotional turf. 

So what is behind what Somynne calls “the dark underbelly” of the pro-union campaign? And how likely is it to rear its head again? 

One night in George Square

For many independence supporters, suspicions that the pro-union campaign had resonated with the far right were confirmed on the evening after the referendum. A group of crestfallen, mainly young independence supporters turned up at Glasgow’s George Square, where they were confronted by a group of union supporters waving Union Jacks, singing Rule Britannia and giving Nazi salutes. 

Glasgow SNP councillor Austin Sheridan, who is gay, was at the City Chambers that day, an imperial building on George Square. He left the building to see what was going on. “All of a sudden a guy came up and shouted at me,” he remembers. A video he made on his phone shows middle-aged men calling him “fucking poofter” and “nationalist scum”. 

Sheridan believes the homophobic attack was “clearly organised”. He says: “The group of people arrived at the square all at the same time.” 

In 2014, mainstream political parties succeeded in the most part in distancing themselves from the far-right unionists. 

Scots were treated to the rare sight of the Liberal Democrats, Labour and Conservative leaders agreeing on the need to stay in the UK. 

This cross-party unity did not, however, extend to some of the other groups opposing independence – the British National Party, the UK Independence Party and the Scottish Defence League (which shares anti-SNP posts alongside warnings of a Muslim “invasion”). 

While the fringes continue to share both far-right and an anti-independence messages, Facebook groups purely focused on a passionate defence of unionism have also flourished. Here, the First Minister Nicola Sturgeon is mocked as the TV comedy character "Wee Jimmie Krankie", or the "ginger poison dwarf". 

One of the grassroots groups most consistently pushing the pro-union message is A Force For Good (its Facebook page has more than 4,000 followers). During the 2014 referendum it was not affiliated with the Better Together campaign and describes itself as providing “a historical and cultural background to the Union and the British identity”. 

Its posts mainly thank Theresa May for objecting to a second Scottish independence referendum. However, the founder of the site, Alastair McConnachie, was forced out of Ukip after questioning aspects of the Holocaust (when I asked McConnachie if he still held these views, he referred me to a 2007 blog post in which he acknowledges the Holocaust but adds: "I've questioned and doubt, from a historically-interested point of view, some aspects, specifically with regard to the existence of execution gas chambers.") 

Unionism... and Unionism

There was a second undercurrent to that appearance in George Square. “The violence in George Square was sectarian,” says Dave Scott of anti-sectarian organisation Nil By Mouth, who wrote about the incident at the time. (You can read about sectarianism and the pro-independence campaign here).

While there is no direct link between the pro-union campaign and Protestantism (Jim Murphy, a prominent Better Together supporter, is a practising Roman Catholic), some of the most passionate supporters of the UK are from Protestant groups.

The Orange Order is a controversial Protestant brotherhood that dates back more than 200 years. It is based in Northern Ireland, but has other branches around the world, the largest of which is in Scotland. Orangemen traditionally march on 12 July to celebrate the triumph of the Protestant monarchy over the Catholic King James II. Critics accuse the Orangemen of stirring up sectarian hatred and bringing unrest to the streets (in 2016, 13 people were arrested for minor offences during an Orange march in Glasgow). 

In 2014, the Orange Order campaigned on behalf of remaining in the UK. Roughly 15,000 supporters from both Scotland and Northern Ireland turned up in Edinburgh on the weekend before the referendum for a march through the Scottish capital.

The organisation continues to comment on Scottish politics. The front page of the March 2017 edition of the house journal, The Orange Torch, was dedicated to the prospect of a second referendum. When I speak to Robert McLean, the executive officer of the Grand Orange Lodge of Scotland, he confirms that if there is another referendum, his organisation will get involved again. 

I put to him the complaints of independence campaigners that the Orangemen were a divisive presence. He responds: "If anything, the referendum caused division. If anyone's causing division, it's Nicola Sturgeon." The Orange Order have been in Scotland for 300 years, he adds.

What next for the pro-union campaign?

Orange Order marches – and their sister activity, flute bands – have traditionally been abhorred by what Kevin McKenna, a Scottish columnist, calls the “liberal, godless, political classes” in Holyrood. The Better Together campaign was visibly embarrassed by its orange friends. But that was before Brexit. 

While pro-union political parties in Scotland are still working out their plans, organisers must grapple with the fact that “Project Fear” failed to win the EU referendum. Better Together's victorious campaign in 2014 was similarly pragmatic, with messages of economic stability and - crucially - the promise of staying in the EU. 

In the patriotic fervour of Facebook groups like “Do Not Break Our Unity”, there is a different kind of unionism. It waves the Union Jack with pride, wears the poppy, celebrates the monarchy, approves of Theresa May and voted Brexit. As McKenna wrote in the summer of 2014:

The people who will decide the referendum will not be those in the chattering, political classes but the tens of thousands in the housing schemes across the country… both sides had better start properly to understand their language and their curious ways.

The question for mainstream politicians in Scotland – as in England – is what to do about this well of passionate, patriotic unionism. Can they channel it into an emotional case for unity? And would doing so come at a price? 

Somynne, the independence campaigner and freelance journalist who has written about the referendum campaign, wants to see “calm and constructive” debate on both sides. But he worries it won’t turn out that way. “You're asking fundamental questions about the way we define ourselves and challenging political realities,” he says. “It's never going to be clean when that happens.”

Read more: The extreme Scottish nationalists

Julia Rampen is the digital news editor of the New Statesman (previously editor of The Staggers, The New Statesman's online rolling politics blog). She has also been deputy editor at Mirror Money Online and has worked as a financial journalist for several trade magazines. 

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