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 unholy huddle

Northern Ireland’s strict anti-abortion laws are supported by politicians across the sectarian divide. Women are paying the price.

In June 2013 a 26-year-old administrative assistant named Sarah Ewart married her long-term boyfriend in Belfast. Soon she was pregnant. At 19 weeks, “for a bit of fun”, she and her husband, Jason, paid for a scan so that they could see the baby. Instead, the sonographer sent them straight to the Ulster Hospital, where a consultant told them that their baby – a girl – had anencephaly, meaning she had no skull or brain. She would die either in the womb or within minutes of being born, and it would be a difficult and dan­gerous birth.

The couple, both devout Christians, were distraught. After much anguish they decided to terminate the pregnancy. “I couldn’t go through nine months of pregnancy to come home with nothing and simply prepare for a funeral,” Ewart recalled tearfully as she sat in her neat home on the eastern fringe of the city one recent morning.

But the consultant told her that a termination was not possible in Northern Ireland. The province never adopted the Abortion Act 1967, which legalised abortion in the rest of the United Kingdom. It is still governed by the Offences Against the Person Act 1861, which makes it a crime, punishable by life imprisonment, to administer “any poison or other noxious thing” or to “use any instrument” to induce a miscarriage. The sole exceptions are when a woman’s life, or her long-term mental or physical health, is at risk.

Ewart’s only option was to travel to England for an abortion, as many hundreds of women from Northern Ireland do each year, but the doctors were constrained even from telling her where to go, for fear of prosecution. “I am not going to prison for anybody,” one doctor declared, banging her desk with a folder. Ewart consulted the Yellow Pages and then visited a family planning centre in central Belfast, which gave her the phone number of an advice centre outside Northern Ireland. As she left the building with her husband and mother, Ewart was accosted by anti-abortion protesters brandishing photographs of dismembered foetuses. “Don’t kill your baby!” they shouted, though they knew nothing about her case. “I was in floods of tears,” she said.

She and her mother, Jane Christie, emailed all 108 members of the Stormont assembly, Northern Ireland’s devolved parliament, begging for an exemption so she would not have to travel to England. Only two bothered to reply.

Christie took out a £2,100 bank loan, because women from Northern Ireland are ineligible for free abortions on the NHS. On 6 October that year, they flew to England and checked in to a cheap hotel in Streatham, south London. At the abortion clinic Ewart joined what she described as a “conveyor belt” of girls waiting to rid themselves of unwanted pregnancies.

“While I was grieving, they were talking about what bar they were heading to that night,” she said. The foetus was disposed of without her seeing it. “It was just horrendous. I just don’t know what I’d do if I had to go through that again.” She resolved to fight to change the law. Outraged by the indifference of members of the legislative assembly, she told her story that same month to Stephen Nolan, the host of a popular show on BBC Radio Ulster.

The interview had an enormous impact, igniting a controversy over Northern Ireland’s draconian and archaic abortion law that is still raging. Ewart’s story made it impossible for the religious fundamentalists – Protestant and Catholic – who supported the status quo to continue to claim the moral high ground. It undermined the notion that abortions were the fruit of sexual promiscuity. Ewart was clearly not some feckless teenager who had slept around. She was happily married. She had desperately wanted her baby. She was, moreover, a churchgoing Presbyterian who, like the rest of her family, always voted for the Democratic Unionist Party (DUP), Northern Ireland’s biggest political party and a staunch defender of the existing abortion law. Far from demanding wholesale reform, moreover, Ewart was campaigning merely for the ban to be lifted in the case of fatal foetal abnormalities.

As David Ford, the leader of the centrist Alliance Party, told me: “The interview made a lot of people stop and think, ‘What if it was my wife or daughter?’”

“It really touched people,” Patrick Corrigan, Amnesty International’s Northern Ireland programme director, agreed. “Until then, abortion had been seen in very black-and-white terms – pro-life v pro-choice, almost good v evil. Suddenly, here was a case that introduced grey areas, and real life.”

***

For nearly three decades, from the late 1960s onwards, the Troubles trapped Northern Ireland in a time warp. The sectarian conflict dominated politics, to the exclusion of social issues. It reinforced religious identities and isolated the province from progressive outside influences.

In the late 1990s the Reverend Ian Paisley was still fulminating about “sodomites at Stormont” when Elton John gave a concert there, and hardline Protestants picketed a performance of Jesus Christ Superstar at the Opera House in Belfast because they considered it blasphemous. Even today, gay marriage is not permitted. Emma Campbell, of the pressure group Alliance for Choice, characterises sex education in some faith-based schools in Northern Ireland as “cross your legs, hold hands and wait till you are married”.

When in 2012 a private Marie Stopes clinic offering a very limited – and entirely legal – abortion service opened opposite the Europa Hotel in Belfast, uproar ensued. There were furious demonstrations, staff and patients were abused, and John Larkin, the attorney general for Northern Ireland, tried unsuccessfully to shut it down. Larkin, a Roman Catholic, declined to be interviewed for this article, but in 2008 he likened abortion to “putting a bullet in the head of the child two days after it’s born”.

Edwin Poots, the DUP assembly member and health minister, weighed in by publishing draft guidelines for health-care professionals that threatened prosecution if they breached his extremely narrow interpretation of the abortion law. The guidelines said, for instance, that they had to report women who sought their help after using abortion pills, and that doctors should consult psychiatrists before determining that a woman’s long-term mental health was at risk.

“The chill and fear went through the corridors of every hospital and every individual,” Samina Dornan, a senior consultant at the Royal Maternity Hospital in Belfast, told me. The number of abortions carried out in the province fell from 51 in the year starting April 2012 to just 16 in 2014-15.

The Royal College of Midwives (RCM) felt compelled to advise its 1,250 members in Northern Ireland to adopt a “don’t ask, don’t tell” policy if women came to them with complications that could have been caused by abortion pills. “It’s totally unacceptable that a piece of legislation dating back to 1861 is still current. It’s totally unfit for purpose, and protects neither women nor the staff caring for them,” said Breedagh Hughes, the RCM’s Northern Ireland director, when we met at her city-centre office.

The furore over the Marie Stopes clinic, closely followed by Sarah Ewart’s interview, prompted the Alliance Party leader Ford, who was then justice minister, to propose a very modest reform – that abortions should be permitted in cases of fatal foetal abnormalities.

In February this year the assembly – four-fifths male – voted on that, and on another amendment that would allow abortions in cases of rape or incest. The first was defeated 59-40, the second 64-30, with the DUP and the nationalist Social Democratic and Labour Party locked in an improbable alliance that for once transcended the province’s sectarian divide – what Ewart’s mother described to me as a “holy huddle”.

The votes flew in the face of polls suggesting that nearly 70 per cent of the public supported the amendments. They also defied a ruling three months earlier by a high court judge, Mr Justice Horner, that the abortion ban breached the European Convention on Human Rights by failing to allow exceptions for fatal foetal abnormalities and sex crimes (only the Republic of Ireland and Malta have more restrictive legislation).

“I was gutted,” said Ewart, who had joined various human rights organisations in seeking a judicial review of the law. “Winning that ruling was like winning the Lottery, only to find there was no money.”

Pro-choice activists were enraged. “Our not-in-my-backyard politicians know full well that abortions happen and are required, but as long as they’re exported, that’s OK,” said Kellie O’Dowd, who chairs Alliance for Choice. “They see any relaxation as encouragement to sexual immorality.” Breedagh Hughes said: “Our unionist politicians insist Belfast is as British as Bristol – except when it comes to this issue.”

***

Ian Paisley, the fire-and-brimstone preacher who died in 2014, created the DUP in 1971, and even today a third of its members and elected representatives are members of the small, fundamentalist and patriarchal Free Presbyterian Church, which he also founded. Followers of that Church take every word of the Bible literally, condemn drinking, smoking, homosexuality and miscegenation, and expect women to cover their head in church.

The DUP hierarchy refused to be interviewed for this article, but others who share their absolutist views were less reticent.

Peter Lynas, Northern Ireland director of the Evangelical Alliance, is a smooth-talking former barrister who recently masterminded the building of a £3m, thousand-seater evangelical megachurch in the northern town of Coleraine. As we sat in his office in Paisley’s old Belfast East stronghold, he told me he opposes abortions for fatal foetal abnormalities because they cannot be tightly defined, and for rape and incest, because proof of such crimes could not be obtained in the short time available. More importantly, he argued, destroying a life is wrong in any circumstances. A foetus is “either a human being, in which case no justification for abortion is adequate, or it’s not, in which case no justification is required. We say it is always a human being.”

Bernadette Smyth, a devout Catholic with four children, is the founder of a group called Precious Life and a self-styled “voice for the unborn child”. From a central Belfast office financed by the American anti-abortion organisation Stanton Healthcare of Boise, Idaho, she campaigns to close the Marie Stopes clinic, which she accuses of profiting from death.

Her “street counsellors” and “prayer partners” constantly picket the clinic, hanging graphic photographs of mutilated foetuses from lamp posts and accosting women going in and out, all of which has forced the clinic to offer its patients escorts equipped with body cameras and walkie-talkies. In December 2014 Smyth was found guilty of harassing Dawn Purvis, who was then the clinic’s director, and ordered to pay £2,000 compensation and to perform 100 hours of community service. Her conviction was later overturned for lack of evidence.

Smyth calls abortion “the killing of innocent, vulnerable, unborn children”. When we met at her office – all purples and greys, with the slogan “Live Laugh Love” inscribed on a wall – she showed me a framed sonogram of “David”, a 20-week-old foetus. David’s hard-pressed mother had wanted to abort him, Smyth said, until she was rescued by the Precious Life counsellors and given the financial and moral support she needed to persevere. “I’ve lost count of how many babies I’ve helped save,” she said.

Far from relaxing the law, Smyth wants even tighter restrictions on the province’s doctors. As an alternative to abortion, she and Peter Lynas of the Evangelical Alliance want women to be given more counselling and support to shepherd them through crisis pregnancies: what Lynas calls a “comprehensive and tailored pathway to care”.

They deny that their views are extreme. “What’s extreme about loving and caring for vulnerable and innocent children?” Smyth asked. “There’s nothing extreme about loving women so much you want to provide and care for them throughout whatever crisis they are in. It’s not extreme to campaign against death.”

But their brand of compassion cuts little ice with Smyth’s old nemesis, Dawn Purvis.

Northern Ireland has long produced strong women. They held their communities together during the Troubles while their menfolk fought. Purvis led the loyalist Progressive Unionist Party for three years until she resigned over the failure of its ­paramilitary counterpart, the Ulster Volunteer Force, to disarm in 2010. She also founded the Marie Stopes clinic, and when we met at the headquarters of Alliance for Choice, an industrial unit overshadowed by the giant steel-and-wire-mesh “peace wall” that still divides the Falls Road from the Shankill, she told me harrowing stories of women who have sought its help.

One had been beaten and raped by her partner for 72 hours, during which he had knelt on top of her and cut a contraceptive implant from her arm with a Stanley knife. Another woman’s partner had removed her coil with a pair of pliers. A 12-year-old girl raped by a relative had been forced to travel to England for an abortion, with police officers accompanying her to retrieve the foetus as “evidence”. Each February, Purvis said, there is a surge in the number of women seeking help because they have been raped and abused by their partner over the Christmas period.

“When I hear our politicians ranting about their views, and I mean ranting, I wish they could sit in front of these women and tell them, ‘No, you’re not having an abortion. Continue with your pregnancy and give the baby up for adoption,’” she said. “They’ve no idea about the extremely frightening and complicated situations these women face. I think it’s immoral to refuse them abortions. It’s un-Christian.”

At the Alliance for Choice office I also met a 29-year-old woman who works in human resources in Craigavon, south-west of Belfast. “Judy” – she withheld her real name for fear of retribution from the anti-abortion lobby – became pregnant in late 2013, a year after marrying. Happy and excited, she and her husband went for her 20-week scan, only to learn that their baby had a form of dwarfism called thanatophoric dysplasia. Worse, its ribcage was so narrow that its lungs could not develop, and it would suffocate at birth even if it survived that long.

After much soul-searching the couple decided to terminate the pregnancy, not ­because the baby was deformed, but because it would be “born to die, and everyone knew it”. They wanted the abortion to be performed and to begin grieving, but were informed curtly by a doctor: “That’s not going to happen.”

“In a split second she took away our light at the end of the tunnel,” Judy said. She was forced to carry the baby to term. For 15 weeks, as her bump grew, she endured the congratulations of strangers and people asking what sex it was. “It took every ounce of my strength to hold it together,” she said. Work colleagues who knew the truth avoided her, not knowing what to say. “I would just go home and sob.”

She had to mix with other pregnant women at prenatal clinics. She discovered that the baby was a girl, and had to discuss with her consultant whether she wanted her child resuscitated at birth, and how many times.

The baby was born dead, but Judy’s agony continued. People who remembered her pregnancy would ask how the baby was doing. When she told them it was stillborn they were mortified. A termination “would have diminished our suffering. Being forced to continue with this pregnancy merely added to the tragedy,” she recalled. “We’re a modern country, and not to allow women a medical procedure in their greatest time of need is ridiculous.”

***

Today both Judy and Sarah Ewart, whose radio interview ignited the debate, have healthy babies, but the controversy rages on. Officially 833 women travelled from Northern Ireland to England for abortions in 2015, though the real number is probably double that. Most were aged between 20 and 35, and 62 per cent had partners, so few were the promiscuous teenagers of the politicians’ imagination.

Many people regard Northern Ireland’s wilful exporting of its problem as shameful. “We should look after our own women,” Professor Jim Dornan, one of the leading obstetricians in the province, said. But no political redress is imminent.

Although a more liberal assembly was elected in May, and though Sinn Fein – the second-biggest party – now favours a limited relaxation of the abortion law, the DUP retains what is in effect a veto over any change, thanks to a procedural device called a “petition of concern”, which was originally designed to safeguard minority rights in the power-sharing assembly. That is how the DUP thwarted a vote in favour of gay marriage last November.

Nor is any legal redress imminent. John Larkin, the attorney general, has appealed against Justice Horner’s ruling that the present law breaches human rights. Whatever the result of that appeal, the case is expected to go first to the Supreme Court in London, then to the European Court of Human Rights in Strasbourg.

Increasingly, however, the “abortion pill” offers women in Northern Ireland a way around the ban, especially for those too poor to go to England.

The pills, easily purchased online for as little as £50, are perfectly safe if administered properly, but not if taken secretly by women who may ignore the instructions, use them too late, have pre-existing medical conditions, or hesitate to seek help if they suffer complications for fear of prosecution. There is a danger of severe haemorrhaging, and if the foetal sac is incompletely discharged the remnants can become infected, leading to potentially fatal sepsis.

Though used worldwide, such pills are still illegal in Northern Ireland. In February an anonymous, 21-year-old woman was convicted and given a three-month suspended prison sentence after her Belfast flatmates reported her to the police for ­using them. Other prosecutions are pending.

But, like latter-day suffragettes, some women’s rights activists are starting to flout the law openly, defying the police to arrest them. Last year 215 women signed an open letter in which they said they had bought abortion pills, and invited prosecution. In May three others, hoping for a showcase trial, presented themselves at a police station in Derry and asked to be prosecuted for procuring the pills. In June pro-choice activists used a drone to fly abortion pills across the border from the republic to show that the law was absurd and unenforceable.

The activists argue that, by banning the pills, Northern Ireland’s politicians are merely driving abortion underground, with potentially fatal consequences of a sort that should belong to the past.

“Making abortion illegal doesn’t make it go away. It makes it unsafe,” said a young woman called Cara, who once self-aborted in a Travelodge hotel room and now helps other women who need to have abortions. Over a drink at a pub in Belfast, she told me how, in her own caravan, she had helped a part-time shop assistant terminate her pregnancy. The woman couldn’t afford to go to England and was too ashamed to tell her family she was pregnant.

Health-care professionals are increasingly alarmed by the implications for women. “This is the modern equivalent of the backstreet abortion. It might not be coat hangers and knitting needles, but the outcome is the same,” said Breedagh Hughes, of the Royal College of Midwives. “My biggest worry is that women will be deterred from seeking the help they need, and that the old spectre of women dying from botched abortions will rear its ugly head again.” 

This article first appeared in the 28 July 2016 issue of the New Statesman, Summer Double Issue