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

JAVIER MAYORAL. IMAGE MANIPULATION BY DAN MURRELL
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A world unbalanced

Under Trump, the United States could turn away from Europe, leaving the continent exposed and vulnerable. So is it the destiny of the UK alone to stand for collective defence, free trade and fair play in a turbulent age?

Listening to the reading – from St Paul’s letter to the Corinthians – on Remembrance Sunday, the first Sunday after the earthquake of the US election, it seemed that someone, somewhere had a sense of ironic timing. “In a moment, in the twinkling of an eye, at the last trump [sic!],” the passage ran: “for the trumpet shall sound, and the dead shall be raised incorruptible, and we shall be changed.” Whatever the text really means, it brought home the fact that the election of Donald Trump has transformed, and transformed utterly, the world in which we live. We Europeans no longer know where we stand with the most powerful country on Earth, and whether it will deliver on its alliance obligations. Our world is out of balance. A terrible uncertainty has been born.

Looking out over the uniformed members of the congregation – army, RAF and Royal Navy – one couldn’t help thinking that next year they may be all that lies between Vladimir Putin’s Russia and the Baltic states. As our continent boils, the armed forces represent, to borrow the pathos of Dorothy Sayers’s 1940 patriotic verse “The English War”, “the single island, like a tower,/Ringed with an angry host”. If things continue to deteriorate, we may soon see the moment when, as the poem continues, “. . . Europe like a prison door,/Clangs, and the swift enfranchised sea [the Channel]/Runs narrower than a village brook;/And men who love us not yet look/To us for liberty”. It is in times like these, she writes, that “only England stands”.

In recent days, the shock of Trump’s election has started to wear off and the usual reading of tea leaves about the new administration has begun in earnest. Appointments and nominations are being scrutinised for clues to what a Trump presidency might mean for the world. These attempts are understandable, but they are also futile. It is clear that Trump, like all other presidents, is filling positions taking both ideology and party management into account – balancing the appointment as his chief strategist of Stephen Bannon, a leading light of the “alt right”, for instance, with that of Reince Priebus, a stalwart of the Republican establishment. Something similar is visible in the foreign policy sphere, where the two most important choices point in fundamentally different directions on one of the critical challenges facing the administration, namely Russia. General Mike Flynn, Trump’s nominee for national security adviser, is well known for his closeness to Moscow, at least in relation to Syria, while Mike Pompeo, the proposed CIA director, is deeply suspicious of Putin’s ambitions in the Middle East.

To infer from this fudge the future policy of the United States would be unwise. One should not assume that Trump’s lack of detailed knowledge of world affairs, or his rocky relationship with the Republican Party’s national security experts, will increase the influence of professionals in the state department. Nor is it right to expect the new president to fall back on Mike Pence, his vice-president-elect, as an inexperienced George W Bush did with Dick Cheney. Trump knows his own mind, especially on the big strategic challenges, and will not listen to the experts or party grandees. His estimation of Pence became clear when he almost forgot to thank him during his victory speech. Besides, Trump, who has spoken openly of possible candidate appointments as “the finalists”, in the manner of his TV show The Apprentice, can fire as quickly as he hires. There is no guarantee that anybody who is in his cabinet in January 2017 will be there a year or two later.

The speculation is pointless in another respect. We already know what kind of animal Trump is. His world-view is fully formed; his temperament is well known. Behaviourally, Trump is the silverback ­gorilla, the narcissistic peacock, the alpha male, the bull in the china shop. Politically, he is a Bourbon who has learned and forgotten nothing over the past three decades.

Here, it is essential to distinguish between rhetoric recently adopted to wage the election campaign, and long-standing positions that Trump has been espousing for 30 years. The good news for Americans is that most of the divisive language and proposed measures probably fall in the former category. His appalling inflammatory comments – too familiar and numerous to repeat here – were largely instrumental; they do not seem to have featured much in his vocabulary before his candidacy. America is not about to turn fascist. Trump is unlikely seriously to assault the constitution, and if he does so he will be repelled. There may be substantial economic and cultural rebalancing, and some pretty brutal measures against terrorism and illegal immigration, but the United States will probably be fundamentally much the same place in four or even eight years’ time. The bad news for the rest of world is that the beliefs most threatening to us are the ones Trump most genuinely holds, and that he is in the best position to implement. Europe, in particular, will be very different four years from now and it might well be unrecognisable in eight.

 

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The key to understanding Donald Trump is his quest for restoration of national “greatness” for the US, which he sees as having been lost in the retreats and compromises of the Obama years but also the interventionism of George W Bush. Economics is central to this vision, yet it is not the deciding factor. To be sure, re-establishing economic strength is important. It will enable the US to sustain Trump’s prohibitively expensive plans, especially the proposed huge infrastructure programme, his tax cuts, and the vast increase in military spending. The new president believes in not international, but national capitalism, based on construction and manufacturing rather than trade and finance. One may not share Trump’s vision of restoring prosperity and pride to America through civilian work creation, motorways, bridges and armaments, but it is a coherent programme. Unlike free-traders and globalisers, who see all boats rising on the tide of a growing world economy, Trump takes a much darker, mercantilist view. It’s not the economy: it’s the greatness, stupid.

Threatening US greatness, so the Trum­pian critique claims, are not only America’s enemies but America’s friends. Politically, the main threat is radical Islam, which he says the Obama administration refuses to call by its name, and which has been aggravated by a costly, failed “nation-building” project in Iraq. Economically, it is China and Latin America which have, in effect, stolen manufacturing jobs from America after the lowering of tariff barriers. Not much better, however, are America’s allies, such as the Japanese and the Europeans, who are free-riding under the US defence umbrella and taking unfair advantage in trade.

Globally, therefore, Trump’s administration will mark a change in four important respects. First, he will either abandon or ignore the institutions of international governance that the United States has done so much to establish. Trump will pay no heed to the United Nations whatsoever. He will not act against climate change. Here the ­appointment of Myron Ebell to lead the transition team for the Environmental Protection Agency is a straw in the wind: Ebell does not believe in global warming. Trump will press ahead with fracking and drilling on all fronts, not necessarily for economic reasons but in order to guarantee energy security for the US. He is unlikely to pull out of the World Trade Organisation but will abrogate the Trans-Pacific Partnership, “re-negotiate” the North Atlantic Free Trade Agreement and probably drop the Transatlantic Trade and Investment Partnership.

Second, there will be a “pivot” of US foreign policy towards the Middle East and the Mediterranean. In Syria, the new administration will seek co-operation with Russia and the Assad regime against Isis and other Islamist groups, if necessary in return for concessions elsewhere. That will be just the start, however. Trump’s hostility to Obama’s nuclear deal with Iran and to the Iranian regime is a matter of record, and Mike Flynn’s writings have been only slightly less anti-Iranian than they have been anti-Isis. There can be no doubt about it: for the Trump White House, Raqqa in Syria may come first but Tehran is next. How exactly it intends to go about this is not obvious, but it is clear that the planned new, 350-ship navy is needed not just to deal with Isis.

Third, Trump will take on China, at least over trade, not least because it will be critical to his domestic jobs programme. Early steps might include whopping tariffs on Chinese goods and designating China a currency manipulator. In this regard, it may be significant that Trump has expressed enthusiasm for Stefan Halper’s 2010 book, The Beijing Consensus, which takes an understandably dim view of China’s restrictive trade practices, authoritarian proclivities and regional belligerence. That said, economics aside, there is little sign that Trump has a broader political, ideological or military agenda with respect to China. His remarks, both recent and long-standing, suggest that he has little interest in maintaining the alliances with South Korea, Japan and other states keen to contain Beijing.

These plans not only risk failure, thereby causing great human hardship, but could also precipitate a major conflict. Trump fails to understand that, in Syria, most of the Syrian government forces and the vast majority of Russian air strikes are directed against the rebels: that is, the non-Isis Islamists and what is left of the Free Syrian Army. Since his election, he has reiterated his contempt for the Syrian rebels and indicated that we should wish for an Assad victory so that he can concentrate all his fire on Isis. One problem with this strategy is that it will increase the outflow of refugees – most of whom are already fleeing the Syrian regime, its Iranian allies and proxies, as well as the Russians, rather than Isis or the Western bombing. The other, and probably terminal difficulty, is the contradiction of wanting to co-operate with Tehran in Syria yet crush it in the Gulf.

In east Asia, the danger is that a trade war may precipitate another world recession, and also a full-scale military confrontation. China took its time responding to Trump’s victory, and did so with extreme truculence. Beijing vowed to retaliate against any tariffs. If backed into a corner, the Chinese might well try “horizontal escalation”– that is to say, using military demonstrations or even armed attacks to retaliate against US trade measures – in Taiwan or the South China Sea.

Unless Trump is entirely clear about how he will react, and this would require him either to reaffirm the existing strategic architecture of the region or to signal his withdrawal from east Asia, the chances of a catastrophic misunderstanding are high.

 

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By far the greatest risk to the international system, however, is not the wars that Trump will start, but the one he might not fight, and will thus fail to deter. His rallies often featured banners accusing Hillary Clinton of wanting to start “World War III”. These referred to her willingness to honour US commitments under the collective defence provisions of Article 5 of Nato’s charter. Trump, by contrast, has repeatedly questioned whether America should defend those allies that are not spending enough on their own protection. He has even referred to Nato as “obsolete”.

More worryingly, there has been a general whiff of pro-Russianism in the Trump camp. The president-elect makes no secret of his admiration for Vladimir Putin, the man who has annexed Crimea, unleashed a proxy war in eastern Ukraine and threatens Nato’s eastern flank, to say nothing of his other crimes. This summer, one of Trump’s leading backers, Newt Gingrich, described Estonia as a mere “suburb” of St Petersburg. The close Russian connections of many others in Trump’s penumbra are too well known to require repetition. The frightening truth is that, with regard to Russia, there is much more going in the Trump camp than the (entirely understandable) irritation with European free-riding.

All this reflects a much broader, and deeply troubling, “de-Europeanisation” of the American strategic mind, if not in national security circles then in politics and among the population at large. Once upon a time, a strong stance against the Soviet Union united Cold War liberals with the working classes, including many from Poland, Ukraine and the Baltic states. Gerald Ford’s gaffe in a televised election debate against Jimmy Carter in 1976, in which he denied Russian domination of eastern Europe, may have cost him the White House. Likewise, many of the “Reagan Democrats” of the 1980s were working-class “deer hunters” of eastern European origin who wanted him to stand up to the Kremlin.

That constituency is no more, and it is a sign of the times that Gingrich, who had written support for the integration of former Warsaw Pact countries into Nato into his Contract for America two decades ago, should now hold the alliance so cheap. All the same, it has been surprising to see the flippancy and vehemence with which a sixty-year transatlantic bond has been put in question, not reluctantly, but with a whooping rebel yell.

The president-elect poses another, more insidious, but no less fatal menace to Europe. His victory has blown wind into the sails of the European far right. “Their world is falling apart,” Florian Philippot of the French Front National (FN) exulted after the result. “Ours is being built.” France’s presidential election in April and May will be won by either Marine Le Pen’s FN or – more likely – François Fillon of the conservative Républicains; both candidates are pro-Russian. It is also likely that Prime Minister Matteo Renzi will be defeated in Sunday’s referendum on reforming the powers of the Italian parliament. If he resigns, the resulting election may well bring the Eurosceptic right to power. In Germany, Alternative für Deutschland is weaker, but growing.

Given all this, the capacity of the rump European Union to deal with the security, economic and migration challenges ahead will be severely tested. The weakness of mainland Europe is also manifest at a national level. Even its two most important countries, France and Germany, have ceased to exist as separate states in vital areas: neither controls its own currency or borders, and Germany does not even have a nuclear deterrent or (sufficiently credible) conventional capability.

As such, despite the hopes of many, Angela Merkel will be too weak to lead Europe even if she wins Germany’s federal elections next year. To be sure, she has pledged to work together with the new US president only if he respects people regardless of creed, sexual orientation and skin colour. Yet Chancellor Merkel lacks the instrument to protect Europe militarily, because of Germany’s largely pacifist political culture and the EU’s failure to provide itself with anything more than a shadow capability at supranational level. She is also losing ground steadily at home. A Trump-induced fresh wave of Syrian refugees may well finish her off.

 

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In democratic Europe, therefore, only the United Kingdom stands out. Here, the widespread continental European tendency to equate Brexit with Trump misses the point. Despite all the Brexit turmoil, Britain is likely to remain infertile soil for extremism, at least once the separation from the European Union has been completed. Although many of those who voted for Brexit did so for similar reasons to those of the workers who opted for Trump, the political mainstream in Britain, including those who supported leaving the EU, remains strongly in favour of free trade, and strongly committed to Nato. Moreover, the UK is still the world’s fifth-largest economy and a nuclear power, and it retains the principal characteristics of sovereign statehood – her own currency, parliament and control over her borders.

The result of all this will be a fundamental shift in European geopolitics in favour of Britain. The election of Donald Trump has four effects, the first two of which will probably cancel each other out. On the one hand, his protectionist instincts may make him less interested in a trade deal with the UK. On the other hand, he is less likely than a Democratic administration would have been to send Britain to “the back of the queue”. Trump’s impact will be felt elsewhere, however, in the field of geopolitics and global governance. Britain will now be one of the few large economies in favour of free trade. More important still is that, with a large question mark now hanging over Nato, the contribution made by the British armed forces to the defence of Europe as a whole, and to the defence of European values against President Putin, will take on a new significance.

Britain needs to rise to the challenge. Militarily, she may have to hold the line in Europe for at least four years – possibly for eight. Consequently, a full-scale rearmament must begin now, with increased expenditure on ships, aircraft, “heavy metal” for the army, and cyber-defence. The necessary shift is comparable to the one orchestrated by the chief of the imperial general staff Sir Henry Wilson in the early 20th century, when he began to change the military mission from imperial policing and small wars to preparation for war against a major power in Europe.

Politically, Britain urgently needs to clarify its relationship with the rest of the continent. It would have been better if Brexit had never happened, or at least not before the EU had sorted itself out, but now it should be expedited without delay so that we can all concentrate on the bigger challenges. This should be based on a grand bargain in which London retains a free-trading relationship with the EU, reserving the right to restrict immigration in return for our increased commitment to European security through Nato. Britain’s EU budget contribution could be reallocated as increased defence expenditure to help defend the EU in the east. Some continental Europeans, in German business circles as much as in Poland, have already begun to see the connection between the two spheres, and the need for a trade-off.

London thus needs to take two messages, one to the EU and the other to Washington, DC. It is a great pity that the Foreign Secretary did not attend the Trump post-mortem of foreign ministers in Brussels, not to join in the pointless therapy session, but in order to read the Europeans the riot act on Russia. They have already seen that one cannot have a common currency without a common treasury and parliament (in other words, a common state); and that one cannot have a common travel area without a common border – in effect, a common state.

Now they are planning to fill the potential American vacuum with a (much-needed) European army without a European state, something that can only end in more tears. Johnson should have told them that if they wish to survive they need to form a full political union, like that which has linked Scotland and England. If that does not appeal, they must increase their individual national military budgets and, if the Americans withdraw from Nato commitments, they must fall in behind Europe’s principal military power, the United Kingdom.

Rather than supplicating in Washington, Britain should speak to Trump in language that he understands: not of realpolitik, but of real estate. The problem is not so much his belief that diplomacy is “transactional” – all political relationships are – but that he takes a very short-term and narrow view, valuing the quick buck over long-term shareholder value. He should be reminded that the US holds the largest stake in a military consortium that owns the freehold of the property on which the EU is built; the UK is the next largest shareholder, whose interests are materially affected by any change. It is true that many of its tenants are not paying their contribution to the common defence, yet some are. The problem with Trump’s approach is that he has no satisfactory way of punishing the transgressors specifically. If he turns off the heating, everyone will freeze. Besides, some of the worst offenders, in the Mediterranean, live in south-facing apartments, away from the cold Russian wind. They will be the last to feel the drop in temperature.

 

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Donald Trump must be told that the people most affected by his policies, especially those in the Baltic states, are guilty of nothing more than being born in the best property in a terrible part of town. If he withdraws Nato insurance cover, property prices will go down and people will move out. This is because collective security works rather like Bill Bratton’s New York: it depends on zero tolerance, on fixing the windows and apprehending the stone-throwers. The danger is that after four years of Trump, much of eastern Europe will resemble a declining neighbourhood in 1980s America, with broken windows, uncollected rubbish, and demoralised residents huddled around braziers trying not to catch the eye of the criminals stalking their streets.

If that happens, we may soon see a Europe where the Atlantic, once an enfranchised sea connecting America and Europe, has become an unbridgeable ocean culturally and politically; where the United States has left us to our fate; where the channel separating the home island from a turbulent continent once again runs narrower than a village brook; where Italy and France have given way to authoritarian, Russian-leaning populists; where Germany finally buckles under the strain; where the rest of Europe has scattered like minnows; where Putin rules supreme in the east; and only England stands for collective defence, free trade and fair play.

Brendan Simms is an NS contributing writer. His latest book is “Britain’s Europe: a Thousand Years of Conflict and Co-operation” (Allen Lane)

This article first appeared in the 01 December 2016 issue of the New Statesman, Age of outrage