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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The alien among us: searching for the meaning of David Bowie

A tribute to the man who reinvented pop culture and changed Britain, by John Gray, Olivia Laing, Philip Hoare, Kate Mosse, Paul Du Noyer, Kate Mossman, John Burnside, Will Self and Yo Zushi.

First published in a special issue of the New Statesman on 15 January, 2016, marking the death of David Bowie (8 January 1947 – 10 January 2016).

Philip Hoare: Lighting up a blacked-out Britain

In the hot summer of 1976, in white school shirt, black evening waistcoat and trousers, my hair slicked back and sprayed gold, I took the train to London where Kraftwerk’s crackling nuclear “Radioactivity” and the surreal brutality of Luis Buñuel’s Un chien andalou gave way to the man himself, sunken-cheeked, too thin to be caged by the fluorescent array of strip lights behind him. In the oceanic darkness of the arena, I felt I was utterly alone with him, like everyone else. He was in his new incarnation, as dark as the times: Jean Genet out of Man Ray, burned black and white into our monochrome dreams, singing of “the return of the Thin White Duke/throwing darts in lovers’ eyes”. He arrived at Victoria in a slam-door train and was driven away standing in an open-top car like our great dictator.

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John Gray: The shifting shaman of the modern age

If your aim is to be original, you will most likely end up looking and sounding highly derivative. Striving for self-expression, you turn yourself into a mouthpiece for the ruling clichés. David Bowie did the opposite. Knowing himself to be – as a matter of fact or fate – utterly singular, he chose to become a clairvoyant who served as a channel for the shifting spirit of the age. Along the way a succession of selves emerged, each of them novel and original. A commonplace view has it that Bowie was a chameleon who kept reinventing himself in order to exploit the turns of fashion. But his changes served a deeper end. By becoming Nobody, he became many people and at the same time himself. . .

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Kate Mossman: Reading the runes

A week ago, critics were reviewing his new album, Blackstar, and trying to locate the surprise. It had to lie in the music this time, when last time it was all about the delivery. He’d gone and got himself a jazz band, the Donny McCaslin Quartet, whom he first saw playing the 55 Bar in Manhattan early in 2013 (with a power only Bowie could wield, he sent the sax player out to do some of the promotional interviews for the album). Many of the songs are semi-improvised, with a ponderous, ambulatory structure that adds to a sense of mystery unfolding.

The centrepiece title track is a strange, ten-minute movie-of-the-mind that starts in the unsettling soundworld of eastern deserts and then breaks, unexpectedly, into a light Motown-tinged ballad with a tune that wouldn’t be a million miles from Adele’s “Make You Feel My Love”, if you laid one on top of the other. This epic track actually came out last year, along with the album’s two other substantial offerings, “Lazarus” and “Sue”. I wondered if the joke, this time round, was that when you finally got your hands on Bowie’s new album you realised you’d already heard the best stuff for free.

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Yo Zushi: In defence of “bad” Bowie

Tonight remains the Bowie album I return to most often. Its critical panning seems, now that Bowie is gone, an aberration: no album that begins with the seven-minute masterpiece “Loving the Alien” and contains the rocking “Blue Jean” should have received the drubbing it got. The TV-special-style cover of the Beach Boys’ “God Only Knows” is as stirring, in its cold, almost Brechtian way, as Station to Station’s “Wild Is the Wind” (1976) – it’s like watching Elvis in Vegas through a sheet of ice.

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Kate Mosse: King of the outcast girls and boys

Where were you when you heard the news? My ma had always said she could remember precisely what she was doing, how the day felt, when she heard Elvis Presley had died. I’d never understood what she meant, not really, until today. I thought I would never forget the white of the tablecloth at the Santa Catalina Hotel, the swirl of Spanish and German, a little Russian and English being spoken around me. A half-eaten piece of bread and a third cup of coffee, growing cold. A little cheese and an apple cut in four.

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Will Self: A vaudeville star who spun new worlds

Unlike “Sir Mick” and “Sir Elton”, Bowie had refused state honours from the British government. And he’d done it not once, but twice. The message was clear: he didn’t seek status or preferment in this world, at least not the sort politicians dole out. I never met him myself. Indeed, my only direct connection with him was fairly bizarre: a copy of Alethea Hayter’s classic work of literary-critical history Opium and the Romantic Imagination, with “David Bowie” inscribed on the flyleaf, together with his Swiss address, in charmingly juvenile, cursive handwriting. I’d acquired the book from a friend, Kevin Armstrong, who at the time (mid-1980s) was playing guitar in Bowie’s Tin Machine band. It kicked around the house for some years until, suffering from my conscience, I mailed it back to him.

He never thanked me, even though I’d put a return address, but I bore no ill-will; I reasoned he must be busy. Or, if not busy, like some deity who’d created not just one world but many, he was resting from his ­labours. I wouldn’t claim to have an exhaustive familiarity with Bowie’s oeuvre but then I don’t need to – his music, in common with that of the Beatles, constitutes the backdrop on to which the transitory experiences of my own life have been projected; a romantic imagination indeed.

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A Martian up a ladder throwing paint at a canvas

Bowie turned up at the Factory wearing white Oxford bags and yellow Mary Janes, a slouchy bibbety-bobbity hat pulled low over his long blond hair. He sang his homage “Andy Warhol” to the master (“Tie him up when he’s fast asleep/Send him on a pleasant cruise”), who was reportedly not wholly flattered. Then he performed an earnest mime for the nonplussed Warhol in which he opened up his heart and let his guts spill on the floor.

It spoke, perhaps, of what was to come: the annihilating effects of serious, cult-level fame; the sense of being haunted by his own creations, of careering with them into places inimical to physical and mental health. Bowie was always willing to take a risk, to expose himself, to go further out than anyone else might have thought possible. Album after album wore its influences on its sleeve: the avant-garde German expressionism of Heroes and Low, the Chatterton-meets-Beau Brummell lushness of The Man Who Sold the World.

Like many other rock stars, he started collecting art, including a pair of Tintorettos, a Rubens and a Frank Auerbach. But at some point in the 1980s he began making it, too. He’d got himself stuck creatively, and as a way of edging out of the doldrums he switched media, using painting as a way of swimming back to himself. At first it was a private business, a respite and release from music, and then a fertile way of solving problems and nudging around blocks.

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Paul Du Noyer: Close encounters with the Bromley boy

Where the former Beatles turned their speech into Scouse-American sing-song and Mick Jagger trademarked a high-camp mockney drawl, Bowie’s pronunciation remained as neatly clipped as a Beckenham privet hedge. He chose his words with studious precision and delivered them with the quiet stoicism of an Ealing Studios RAF pilot. He knew that journalists are easily seduced by famous people who remember their names, and could flatter you with earnest inquiries about life back in England.

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This article first appeared in the 14 January 2016 issue of the New Statesman, David Bowie