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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They know where you live

Imagine your house being raided by armed police. That’s what happened to Mumsnet’s Justine Roberts after she fell victim to an internet hoaxer.

At around midnight on Tuesday 11 August 2015, a man dialled 999 to report a murder. A woman had been killed in her London home, he said, before hanging up without offering his name. A second call followed. This time, the man claimed to be the killer. He told the operator that he had now taken the woman’s children hostage at the Islington address. They were locked with him inside a room in the house, he said. The police responded with reassuring speed. Fifteen minutes later, eight officers, five of them armed with automatic weapons, accompanied by saliva-flecked dogs, arrived at the scene and took up position in neighbouring front gardens. When one officer banged on the front door of the house, the team was greeted, moments later, not by a masked murderer but by a blinking and bewildered au pair.

Justine Roberts, the woman whom the caller claimed to have killed, was in fact nearly 2,000 kilometres away – in Italy, holidaying with her husband and children. After explaining this to the police, the au pair called Roberts, who assumed that the incident was an unfortunate misunderstanding, one that could be unpicked after the vacation. It was no mistake. Roberts had been the victim of “swatting”, the term given to a false emergency call designed to bait an armed unit of police officers to storm someone’s home. It wasn’t until a few days later, as the family was preparing to return to London, that Roberts discovered that she had been the target of a planned and sustained attack, not only on her household, but also on her business.

Roberts is the founder of Mumsnet, the popular British internet discussion forum on which parents share advice and information. A few days before the swatting incident, members of 8chan, a chat room that prides itself on being an open, anonymous platform for free speech, no matter how distasteful, had registered accounts on Mums­net with the aim of trolling people there. When legitimate Mumsnet users identified and then ridiculed the trolls, some retreated to 8chan to plot more serious vengeance in a thread that the police later discovered. Roberts wasn’t involved in the online skirmish but, as the public face of the site, she was chosen as the first target.

After the initial armed response, Roberts’s perception was that the police were unconcerned about the swatting attack. “We were told that there was no victim, so there was not much that could be done,” she told me. The hoax caller, however, was not finished. In the days after the incident, there was chatter on Mumsnet and Twitter about what had happened. A Mumsnet user whom I will call Jo Scott – she requested anonymity for her own safety – exchanged heated messages with a hacker who claimed responsibility for the 999 call.

“It descended into jokes and silliness, like many things do,” Scott said. “I didn’t take it seriously when the hacker said he had big surprises in store.” She doesn’t believe that what happened next was personal. “I think I was just easy to find.”

A few days after police were called to Roberts’s home, Scott was in her bedroom while her husband was sitting downstairs playing video games. At 11pm, she heard a noise outside. “I looked out of the window and saw blue flashing lights in the street,” she recalled. “I could hear shouting but I didn’t pay it much notice.” Then she heard her husband open the front door. Police rushed into the house. An armed officer shouted upstairs, asking Scott if she was hurt. When she replied that she was fine, he told her to fetch her two young children: he needed to see them. Scott shook her sons awake, explaining, so as not to alarm them, that the police had come to show the boys their cars. As the three of them went downstairs, the officers swept up through the house, repeatedly asking if there were any weapons on the property.

“I was beyond confused by this point,” Scott said. “Everyone was carrying a gun. They had little cutaway bits so you could see the bullets. My eldest asked one of the officers if he could have a go on his gun and went to touch it.”

As Scott sat with an officer downstairs, she asked what had happened to her husband. “I later found out that the noises I’d heard were the police calling for him to come outside,” she said. “He dropped the PlayStation controller as he left the room. It was only later that we realised it’s a good job he did: in the dark, the controller might have looked like a weapon.”

Outside, Scott’s husband had been surrounded and arrested. Other police ­officers were on the lookout in the front gardens of nearby properties, having warned the couple’s neighbours to stay indoors, away from their windows. “One of the officers said it was beginning to look like a hoax,” Scott said. “Then he mentioned swatting. As soon as he said that word, I twigged that I’d seen the term that day on Twitter in relation to the Mumsnet hack.”

***

The term “swatting” has been used by the FBI since 2008. “Swat” is an acronym of “Special Weapons and Tactics”, the American police squads routinely called to intervene in hostage situations. It is, in a sense, a weaponised version of a phoney order of pizza, delivered as a prank to a friend’s home, albeit one that carries the possibility of grave injury at the hands of police. For perpetrators, the appeal is the ease with which the hoax can be set in motion and the severity of the results. With a single, possibly untraceable phone call, dialled from anywhere in the world, it is possible to send an armed unit to any address, be it the home of a high-profile actor whom you want to prank or that of someone you want to scare.

In America, where swatting originated, the practice has become so widespread – targets have included Tom Cruise, Taylor Swift, Clint Eastwood and the Californian congressman Ted Lieu – that it is now classed as an act of domestic terrorism. In the UK, where Justine Roberts’s was one of the first recorded cases, swatting is classed as harassment, though that may change if these and other forms of internet vigilante attacks, such as doxxing, become increasingly commonplace.

Doxxing involves the publication of someone’s personal details – usually their home address, phone numbers, bank details and, in some cases, email address – on the internet. It is often the prelude to swatting: after all, the perpetrator of a hoax cannot direct the police to the target’s home address until this is known. (During the week of the Mumsnet attacks, one of the perpetrators attempted to locate another target using their computer’s IP address, which can identify where a person is connected to the internet, often with alarming precision. Their calculation, however, was slightly out; police were called to a neighbour’s address.)

Though doxxing has a less dramatic outcome than swatting, the psychological effects can be just as severe. For victims – usually people who are active on the internet and who have outspoken opinions or who, in the eyes of an internet mob, have committed some kind of transgression – the mere threat of having their personal information made available on the web can cause lasting trauma. A Canadian software developer whose home address, bank details, social security number and email history were published online in 2014 told me that he now keeps an axe by his front door. “I still don’t feel safe here,” he said. “It’s terrifying.”

Christos Reid, a social media manager for a software company, was doxxed last year. Reid’s information came from a website he had registered seven years earlier. “I woke up one morning to find a tweet announcing my personal details,” he told me. When he asked the Twitter account holder to take down the address, he was told to commit suicide. Reid said he was “OK for about half an hour”; but then, after he went out, he broke down in the street. “I’ve become more paranoid,” he said. He no longer gives out business cards with personal information.

Reid lives in London, but at the time of the doxx he was attending an event in Nottingham, home to the British police’s largest cybercrime division. He was impressed with the police response, even though they told him that they had not heard of the term “doxxing” before. “I was interviewed by two separate people about my experiences who then compiled everything into a case file and transferred it to the Met. When I arrived home, an officer visited me to discuss what happened and my options.”

The policeman explained harassment law to Reid, and offered advice on how to improve security at his flat and what to do if someone hostile turned up at the address. Reid shouldered the repercussions of what had happened alone; no suspects were identified. A spokesperson for the Metropolitan Police similarly said that although detectives from Islington CID have investigated the swatting attacks made on Roberts and Scott, no suspects have been identified “at this time”, even as “inquiries continue”.

Doxxing may seem to be a mild form of harassment but it carries with it an implicit threat of impending violence; the worrying message is: “We know where you live.” Unlike swatting, which is always malicious, doxxing is sometimes viewed by its perpetrators as virtuous. In November 2014, hackers claiming to be aligned with the internet group Anonymous published personal information allegedly belonging to a Ku Klux Klan member from Missouri. The hackers said that their action was a response to the KKK’s threat to use lethal force against demonstrators in the city of Ferguson, Missouri, protesting against the killing of the unarmed black teenager Michael Brown by a white police officer. In January 2015 hackers claiming to be from Isis took over US Central Command’s Twitter account and posted information about senior military officers, including phone numbers and email addresses. In each case, those carrying out the doxxing believed, however mistakenly, in the virtue of their actions and hoped that the information could be used to bring punishment or ruin to the subject.

The term “doxxing” may be new but the practice is an old one. The Hollywood blacklist revealed the political beliefs and associations of actors and directors in the late 1940s as a way to invite shame, deny employment and dissuade others from following their example. “But it has become a lot easier to find people’s private details with the help of the internet,” Jeroen Vader told me. Vader owns Pastebin, a website that allows users to upload and distribute text documents, and where much of the personal data is anonymously uploaded and shared. “People post their private information on social networks,” he said. “A lot of people aren’t aware that their information is so easily available to others.”

In Justine Roberts’s case, the perpetrator may not even have needed to look at social networks to mine her personal information. “If you’re on the electoral roll, you’re easy to find,” she said. “There’s not much you can do to stop people getting hold of your data one way or another, whether it’s for nefarious reasons or simply to better advertise to you. We live in a world that is constantly trying to gather more information about us.”

Jeroen Vader said he has noticed an “upward trend” in the number of doxxing posts uploaded to Pastebin in recent months, but insisted that when someone uses the site’s abuse report system these offending posts are removed immediately.

Across social media companies, action is more often reactive than proactive. Victoria Taylor, a former director at Reddit, one of the largest community-driven websites in the world, said that the rule against publishing other users’ personal information has been “consistently one of the site’s most basic policies” and that “any violation of this rule is taken extremely seriously by the team and community”. Still, she was only able to recommend that victims of doxxing send a message to the site’s administrators. Similarly, when asked what a person can do to remove personal details that have been published without permission, a Twitter spokesperson said: “Use our help form.”

The spokesperson added: “There has def­initely been an overall increase in doxxing since 2006, both on Twitter and on the internet more generally.” She attributed this rise to the emergence of search engines such as Intelius and Spokeo, services designed to locate personal information.

***

The surge in the number of dox­xing and swatting attacks is in part a result of the current lack of legal protection for victims. Confusion regarding the law on doxxing is pervasive; the term is even not mentioned in either US or European law. In a tutorial posted on Facebook in 2013, the writer claims: “Doxxing isn’t illegal as all the information you have obtained is public,” and adds: “But posting of the doxx might get you in a little trouble.”

Phil Lee, a partner in the privacy, security and information department of Fieldfisher based at the law firm’s office in Silicon Valley, said that differing privacy laws around the world were part of the problem. “Various countries have laws that cover illegal or unauthorised obtaining of data. Likewise, some of the consequences of releasing that data, such as defamation or stalking, cover elements of what we now term doxxing. But there is no global law covering what is a global phenomenon.” Indeed, Roberts believes that her London address was targeted from America – the 999 call was routed through a US proxy number.

One challenge to creating a law on doxxing is that the sharing of personal information without permission has already become so widespread in the digital age. “If a law was to state something like, ‘You must not post personal information about another person online without their consent,’ it wouldn’t reflect how people use the internet,” Lee said. “People post information about what their friends and family members have been doing all the time without their consent.

“Such a law could have a potentially detrimental effect on freedom of speech.”

Lee believes that a specific law is unnecessary, because its potentially harmful effects are already covered by three discrete pieces of legislation dealing with instances where a person’s private information is obtained illegally, when that information is used to carry out illegal acts and when the publication of the information is accompanied by a threat to incite hatred. However, this does not adequately account for cases in which the information is obtained legally, and then used to harass the individual in a more legally ambiguous manner, either with prank phone calls or with uninvited orders of pizza.

Susan Basko, an independent lawyer who practises in California and who has been doxxed in the course of her frequent clashes with internet trolls, believes that the onus should be on the law, rather than the public. She points out that in the US it is a crime to publicise information about a government employee such as their home address, their home and cellphone numbers, or their social security number, even if the information is already online. “This law should apply to protect all people, not just federal employees,” she said. “And websites, website-hosting companies and other ISPs should be required to uphold this law.”

Basko said that doxxing will continue to increase while police have inadequate resources to follow up cases. For now, it is up to individuals to take preventative measures. Zoë Quinn, an American game designer and public speaker who was doxxed in 2014, has launched Crash Override, a support network and assistance group for targets of online harassment, “composed entirely of experienced survivors”.

Quinn, who spoke about the problem at a congressional hearing in Washington, DC in April last year, recently posted a guide on how to reduce the likelihood of being doxxed. “If you are worried you might some day be targeted,” she wrote, “consider taking an evening to stalk yourself online, deleting and opting out of anything you’re not comfortable with.”

Both Scott and Roberts have changed their privacy habits following the attacks. Scott is more careful about interacting with strangers online, while Roberts uses scrambler software, which ensures that she never uses the same password for more than one online site or service.

For both women’s families, the effects of their encounters with armed police have also lingered. When one day recently Roberts’s husband returned home early from work, the au pair called the police, believing it was an intruder. And Scott is haunted by what happened.

“What if my husband had made a sudden move or resisted in some way? What if my eldest had grabbed the gun instead of gently reaching for it? What if people locally believed that my husband did actually have guns in the house?” she asks. “I don’t think the people making these sorts of hoax calls realise the impact.” 

This article first appeared in the 28 April 2016 issue of the New Statesman, The new fascism