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

Manhattan in the 1970s. Photo: Getty
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How Woody Allen's Manhattan became Donald Trump's New York

Trump took everything that Allen hated about California - charity galas, golf, awards fever, architectural bad taste - and brought it to New York.

The transformation of faded, fire-ravaged, job-bleeding ‘third-world’ New York (signature headline: “President to City: Drop Dead”) into a safe, clean, smug, wealthy, first-world-problems kind of place (presiding logo: “I ❤ NY”) is popularly associated with the work of three men, Ed Koch, Donald Trump, and Woody Allen.

In their different ways, they embodied – when they didn’t help to engineer – all manner of civic, fiscal, economic, municipal, cultural, and spiritual change. 1978 was the turning-point. That year, Koch became mayor and went about healing the crises that had occurred under the previous incumbent, Abe Beame. Trump, exploiting the city’s new tax incentives, bought the decrepit old Commodore Hotel – later the Grand Hyatt – and began negotiating the sale of the Bonwit Teller flagship store, just south-east of Central Park, the future site of Trump Tower. In that same year, Allen – who was born in Brooklyn in 1935, the year that Trump’s developer father, Fred, began to concentrate his business in that borough – co-wrote, directed, and starred in Manhattan, which was released the following April.

The film, which has just been reissued in a 4K print, is an attempt to salvage New York from its scuzzy 1970s manifestation, and an exercise in what the cinematographer Gordon Willis called “romantic reality”. In glistening widescreen black-and-white, abetted by a Gershwin score, Manhattan presents the borough as an assemblage of highlights: Bloomingdale’s, John’s Pizzeria, the Dalton School, Hayden Planetarium (actually a set), 30 Rock, MOMA, the Guggenheim, Elaine’s, the Russian Tea Room, and so on. Sitting in the park at Sutton Place, in sight of the Queensboro Bridge, Allen's character Isaac Davis says, “This is really a great city. I don’t care what anybody says. Really a knockout.” (The moment required some airbrushing. The crew had to find a bench from somewhere and on the original poster the image was tinkered with, to reduce the size of the buildings in the background.)

The case-against had been made, or at least heard, two years earlier, in  Allen’s first proper New York film, Annie Hall. At one point, Alvy Singer (Allen) says that his friend Rob (Tony Roberts), who loves Los Angeles and thinks Alvy ought to move there, should be doing Shakespeare in the Park. “I did Shakespeare in the Park," he replies. "I got mugged.” In Manhattan going to Shakespeare in the Park is invoked as just another pleasant thing to do and the only threat to safety is the occasional rain storm. Nobody troubles to talk up LA. (The reasons that praise for that city falls on deaf ears in Allen’s work include its lack of seasons, its love of prizes, its congenital faddishness, and the necessity to drive.)

The film’s opening is a montage of over thirty images (pedestrian excitement, New Year’s fireworks, a pre-Trump skyline), garnished with Gershwin, and set to a voiceover of Isaac contemplating possible first paragraphs for a novel. It’s also the sound of Allen airing his conflicted feelings. The first begins, “He adored New York City. He idolised it all out of proportion.” He proceed to dismiss draft versions as too corny, too angry, too preachy. He eventually settles on one that begins, “He was as tough and romantic as the city he loved” and ends “New York was his town and it always would be.” But in every version, there is some acknowledgement of Isaac's romanticism – the rosy tint of his perspective.

On Manhattan's release, the New Statesman film critic John Coleman, used it as an occasion to knock Annie Hall and Interiors (1978), in the process eliding some very large differences. He described the films' shared setting as “elitist, snob-cultural New York chic, full of encounters in OK restaurants between people with time on their hands and themselves on their minds”. Coleman was following a critical agenda set by Joan Didion in the New York Review of Books (“the sense of social reality in these pictures is dim in the extreme”). However, Didion was a self-confessed apostate from New York worship – leaving the city was the subject of her essay “Goodbye to All That” – so maybe she was just the person to miss the point entirely? James Wolcott, looking back in his memoir Lucking Out – in some ways a riposte to Didion's neuroses – calls the film's opening “a balm for every bruise that New York had taken in the seventies, a relieved sigh from the trenches signaling that perhaps the worst was over, somehow we had come through”.

Allen made no attempt to defend the city against a more general, less time-specific charge – what might be considered the "Manhattan libel".  As Alvy Singer puts it, “The rest of the country looks upon New York like we’re left-wing Communist Jewish homosexual pornographers.” He speaks for his creator when he adds, “I think of us that way, and I live here.” In Allen’s view, New York was not just decaying but decadent, heaving with snobs as well as lowlifes, its integrity under threat from above and below. Sitting with Annie on a park bench, he pokes fun at the passersby, among them a cigar-chewing mafioso and “the winner of the Truman Capote lookalike contest” – in fact, Capote himself. The film stages encounters with both kinds of bad New Yorker, who are placed in implicit contrast with a pair of European film-makers who, to Allen, embodied the right balance of refinement and modishness, sophistication and popular appeal. Waiting outside a cinema to see Bergman’s Face to Face, Alvy, a stand-up comic, is accosted by a pair of Italian-Americans who vaguely recognise him from television. Queueing elsewhere for a documentary, he winces as a academic from Columbia complains about the new Fellini.

In Manhattan, the gangster types are gone, but the film reinforces the idea of New York as a phoney-magnet. After bumping into his married friend Yale (Michael Murphy) with his lover Mary (Diane Keaton), Isaac complains to his girlfriend Tracy (Mariel Hemingway), a seventeen-year-old high-school student, that Yale has always been a sucker for the kind of women who involve him “in discussions of existential reality.” Though Isaac soon falls for Mary himself, a glimpse of their first date shows him throwing up his hands as they emerge from a screening of the silent Soviet film Earth, and we cut to them reentering her apartment as he says that as far as he’s concerned, a great movie is something with W.C. Fields. In the next scene, standing before a sculpture, he mockingly deploys Mary-ish terms like “negative capability”. She ends up back with Yale.

***

Allen managed to sustain his adoration of the city by associating its true nature exclusively with things and types he doesn’t loathe. It’s an incoherent vision – or at least fixed according to his unique set of peccadilloes, his narrow definition of what isn’t philistine and what isn’t pretentious, what occupies the space between the anti-rational and hyper-rational. Alvy Singer calls himself a “bigot but for the left,” but Allen's position is a little more paradoxical. He abhors mass-culture phenomena like pop music and television, but worships baseball and basketball and old movies (often watched on late-night cable). He looks with equal disdain on haute couture and academe, corruption and radicalism, accountancy and flower power. He loves museums and jazz and Chinese takeaways but is suspicious of conceptual art and rock and fast food. He likes pizza but not punk, smutty jokes but not foul language, gazing at bridges but not crossing them, psychoanalytic vocabulary but no other kind of jargon, Broadway but not modern theatre, cultural references but not high-culture seriousness (what Alvy calls “fake insights”), city parks and rivers but not the country, kooks and innocents but not hippies, the yuppie-crowded Upper East Side – “the zone” – but not Wall Street or, really, any of the downtown area. (Gershwin is a kind of ideal – a graduate of Tin Pan Alley, immersed in the French art song and Austrian modernism, who wrote jazz and "folk opera".)

At the end of Manhattan, Allen names eleven things that make life worth living – a hodgepodge that reflects his arbitrary high-low aesthetic. Seven of them are strongly associated with New York: Groucho Marx, Willie Mays, Louis Armstrong, Brando, Sinatra, the crabs at Sam Wo’s, “Tracy’s face.” Even Cézanne’s "incredible" Still Life with Apples and Pears is housed at the Met.

The gentrifying processes that occurred during Ed Koch’s administration made Manhattan-worship a more obvious pastime – and an easier position to maintain. There were fewer problems of the crime-and-garbage variety, although it’s possible Allen over-stressed the revamp. Less overly romantic than ManhattanHannah and Her Sisters (1986), which concerns the extended circle of an Upper West Side family, prompted the charge of white-washing. Even Mia Farrow’s mother, Maureen Stapleton, who appears as the matriarch, said that the film was so beautiful “it almost makes you forget all the dog poop on the streets.”

Allen has said that his 1989 film Crimes and Misdemeanors was intended as a retort to Hannah and Her Sisters, in which, he felt, he’d been too easy on the characters. (His original title was Brothers.) But there are also signs of Allen becoming tougher on his setting. Early on, Clifford Stern (Allen) and his niece emerge from a screening of Hitchcock’s Mr and Mrs Smith and confronts “awful”, rain-lashed Greenwich Village, the real city diverging from the sparkling pre-war paradise.

And if the city's economic revival had done something to bridge this chasm and return Manhattan to its pomp, it had its downside – no, not the escalating rents but the influx of vulgarians, responding to the re-found hipness. As Allen softened on artsy types, he redoubled his aversion to the airhead. In Hannah and Her Sisters, there's a young record company executive – Dusty – whose approach to art collection is entirely determined by size and colour scheme. And in Crimes and Misdemeanors, Clifford’s brother-in-law Lester (Alan Alda), a television producer with a “closet full of Emmys”, a dyed-in-the-wool Los Angeleno, is considering a move to the city, a place he describes, in one of many pseudo-epigrams, as “thousands of straight lines looking for a punchline.” (Allen’s twin bugbears, philistinism and prentension, are perfectly combined in Lester’s reference to a university course on “existential motifs in my situation comedies”.) Husbands and Wives (1992) revealed more fears of a total Californification of the city's tastes and habits, the full list of pathogens that had blown eastwards including charity galas, long speeches, astrology, aerobics,  golf, health food, cocktail dresses, awards fever–and architectural bad taste.

The chief representative of these changes – the vulgarian-in-chief – was Donald Trump, another immigrant from the outer-boroughs (Queens, in this case) who as a boy had made saucer-eyed visits to Manhattan. To the adolescent Allen, New York was the place depicted by Hitchcock in Mr and Mrs Smith, the formula he lovingly re-created in the film within The Purple Rose of Cairo (1986): tuxedos, evening gowns, white telephones, theatre trips. For Trump, it was the Midtown bustle and neon that made New York feel like “the center of the world.” Allen, starting out, aspired to be like S.J. Perelman, or Groucho. Trump emulated his developer hero Bill Zeckendorf. Fred Trump did most of his work in the outer boroughs. (He even inspired a song by another Woody, Guthrie, who was appalled by the segregation policies in Trump senior's housing projects.) But in The Art of the Deal, Trump recalls that he had “loftier dreams and visions” and couldn’t shake his determination that Manhattan was where the action was – or would be. He claimed that though the city was at a low – “suffering from a crisis of confidence” – it didn’t keep him “up nights”.  Things “ultimately” had to turn around. In the meantime, “I saw the city’s trouble as a great opportunity for me.”

In 1971, the year he became head of his father’s company, Trump Management, Donald Trump moved into a run-down flat on the Upper East Side – with the coveted 10021 zip code – which he jokingly called his penthouse. Meanwhile, Allen was living barely three blocks away in a penthouse duplex that Dick Cavett likened to the hero’s home in the 1930s New York film The Man Who Played God. But Trump soon caught up in the grandeur stakes, nabbing the penthouse triplex atop the Trump Tower, and a Park view from 57th and Fifth rather than 74th and Fifth. Allen was chauffeured round the city in a cream Rolls-Royce, Trump in a silver Cadillac (with his initials on the number plate). With Ed Koch being perennially single, Trump and Ivana competed with Woody and Mia as the leading couple of 80s Manhattan – both relationships lasted the whole decade before hitting the buffers in similar tabloid style – but they represented altogether different versions of the new New York. 

There’s a brief, almost perfunctory moment in Manhattan where Isaac notes a group of construction works pulling down an old building. “Can’t they have those things declared landmarks?” Mary asks, and Isaac reflects that the city’s “really changing”. The next film Allen made in modern New York, Broadway Danny Rose (1984), was supposed to have a 1940s setting, but Allen said that he couldn’t find “a half block” of Times Square that hadn’t been “junked up”. In Hannah and Her Sisters, an architect whose own work strains to respect the atmosphere and proportions of the surroundings does a tour of local charms which ends with a concrete, hole-punched slab on the Beaux-Arts-heavy East 62nd Street, an edifice that the journalist Joe Klein described as resembling a cheese grater. “What’s permitted in this city is just terrible; it’s a crime,” Allen said, the year the film came out. (In Annie Hall, architectural inconsistency is strongly associated with Beverly Hills: “French next to Spanish next to Tudor next to Japanese.”) By the time of Husbands and Wives, he had a character who worked for the Landmarks Trust. A magazine editor played by Liam Neeson tells her, “I don’t believe in capital punishment except for certain New York developers.” (Preparing the way for the Tower, Trump had refused to preserve – in fact, cosigned to the jackhammer – the bronze grillwork and a pair of art-deco fifteen-foot-high bas-relief of goddesses dancing over Fifth Avenue.)

Trump had received a name-check in Crimes and Misdemeanors when Lester says into his dictaphone: “Idea for series: a wealthy, high-profile builder who’s always trying to realise grandiose dreams à la Donald Trump, to be shot in New York.” Though the idea is supposed to reveal Lester’s frivolity and self-absorption – he's mid-conversation at the time – it’s telling that even he shows a hint of scepticism. 

Then came Celebrity (1998), the satire which to date remains Allen's final statement on modern New York. The film is a reply to Manhattan, its use of black and white and an opening onslaught of New York locales seeming darkly ironic – as if this hell-hole is worthy of monochrome and montage! Although the central character, the journalist Lee Simon (Kenneth Branagh), seems to be writing the same book as Isaac in Manhattan, this time the city fails to come through. At one point, a mad young movie star (DiCaprio) takes Lee to the Trump Marina in Atlantic City for a boxing match and a foursome. Later, Lee’s ex-wife, a teacher-turned-TV host, wanders around a fashionable restaurant, Le Bijou, making small talk for the camera with an estate agent to the stars, a disgraced senator, a gossip columnist – and Trump himself. It was an inspired manipulation of available resources. Le Bijou was really Jean-Georges, which is based at the lobby level of the Trump International Hotel and Tower–an attack on New York in the 90s could hardly do without one of his branded buildings – and Trump often demanded an appearance in films that made use of his buildings. (Ed Koch’s cameo, in the short film Oedipus Wrecks, came at Allen’s request.) Here Trump reports plans – invented, but only just – to erect a "very, very tall and beautiful building" on the site of St Patrick’s Cathedral. The new fame-and-lifestyle obsession is aligned with the desire to dislodge a priceless monument in favour of a shear-wall phallus.

Manhattan could only have been made during a very short period.  It’s a snapshot of a city in transition, at just the point when the horrors of the 70s were beginning to fade and the horrors of the 80s – by Allen’s lights – had yet to declare themselves. For the next twenty years, even as he yearned to idealise New York, Allen couldn't ignore the new realities, and Celebrity marked the point at which the scales tipped. Since then he has sought alternative routes to a romanticism of place, setting his films against an unspecific, attractive New York movie-backdrop (Anything Else, Melinda and Melinda), venturing to Europe (London, Barcelona, Paris, Rome), and travelling back in time. Starting with Zelig (1983), he has paid half-a-dozen visits to New York’s hallowed past. After all, the decades of greed, kitsch, and indifference to history furnish varied opportunities for nostalgia. His next film, Wonder Wheel, concerns a Coney Island amusement park, and takes place in the late 1950s – just moments before Fred Trump started work on Trump Village, the twenty-plus-storey apartment complex that overshadowed Steeplechase Park and dwarfed its prize ride, the Parachute Jump, the so-called Eiffel Tower of Brooklyn.

Leo Robson is the lead fiction reviewer for the New Statesman.

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