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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No peace after progress

How the death of the industrial way of life gave us choice – and stoked resentment and fear.

Now that the making of useful and necessary things in Britain is only a shadow of what it once was, we can see more clearly the effects of the Manufacturing Age. The cost was high to the producers of prodigious wealth; a ten-year difference in life expectancy remains between people living in the richest areas and those in Glasgow. The (fleeting, it now seems) visitation of industrialism has made life more comfortable and its dismantling has liberated millions from choiceless occupations. The legacy is one of spectacular improvement, unequally shared.

Perhaps the most dramatic experience of the 20th century was the suddenness with which profligate plenty replaced a skinflint subsistence. Was it the speed of this that distracted us from wondering why, instead of the secure sustenance that generations of needy people had asked of an unyielding economic system, we were offered a promiscuous spillage of goods, promoted with quasi-religious zeal by the converts of a capitalism that had previously delivered to most of its captive workers a life of penury? Such a rapid reversal might have alerted us to changes beneath the surface that elided losses incurred.

The greatest of these was certainly not the extinction of the industrial way of life itself, release from which has been an unqualified blessing. But the transition from relentlessly work-driven lives (in the 1950s, two-thirds of Britain’s workers were still manual labourers) was marked by perfunctory obituaries for the disintegration of industrial communities, with no acknowledgement that, for a century and a half, they had represented the inescapable destiny of the people they sheltered.

Even less recognition was given to the fortitude with which they had borne a long, coercive labour. A way of life, buried without ceremony in the unmarked grave of progress, could not be mourned; and this has generated some social pathologies of our time: resentment over an arbitrary obliteration of industry, disengagement from a party of labour by those it called, like feudal lords, its “own people”, loss of memory of the economic migrants we also were, passing from the goad of industry into the pastures of consumption, and thence into the liberating servitude of technology.

Grief makes no judgement on the intrinsic value of what is lost. Absence of the known and familiar is the object of melancholy in its own right, even if replaced by something immeasurably better. Objectively, there was little to mourn in the vanished industrial way of life: insufficiency and humiliation, malice of overseer and manager, officiousness of poor-law administrator and means-test man. Male industrial workers exhausted in body and spirit, instead of protecting those for whom the power of their hands was the only shelter against destitution, visited similar punishment on their wives and children. There is nothing to be lamented in an end to the penitential life of women, scrubbing not only the red tiles of the kitchen floor, but even an arc of pavement outside the front door; their interception of men on payday before wages were wasted on beer and oblivion; the clenching against joyless invasion of their bodies in the boozy aftermath. But it was the only life they knew, and they adhered to it with grim stoicism and even pride.

There is much to be said for their resistance. The fragile lattice formed by women’s arms was often the only safety net against destitution. Trade unions and friendly and burial societies that shielded folk from economic violence foreshadowed the welfare state and the National Health Service.

The life of labouring people in Britain was strikingly homogeneous, despite diversity of occupation, dialect and local sensibility. There was the same collective experience: terraced house with parlour reserved for celebration or mourning; the three-piece suite, plaster figure on a stand behind the window, chenille curtain against the draught, engraving of The Stag at Bay on the wall; the deal table and Windsor chairs in the living room, the mantelpiece a domestic shrine with clock, candlesticks and pictures of soldiers smiling before they died; the music of cinders falling through the bars in the grate; cheerless bedrooms where husband and wife slept in high connubial state, more bier than bed, where sexual enjoyment was ritually sacrificed as flowers of frost formed on the inside of the window.

And everywhere photographs: wraithlike children with ringlets or in sailor suits, fated never to grow up; weddings in the back garden, a bouquet of lilies and a grandmother in boots and astrakhan hat; the smudged features of a kinsman no one can now identify. Identical memories, too: the shotgun wedding in the dingy finery of a Co-op hall; the funeral tableau around the grave, amid ominous inscriptions of “Sleeping where no shadows fall”; queues outside the ocean-going Savoy or Tivoli to watch Gone With the Wind; the pub where “Vilia” or “The Last Rose of Summer” was hammered out on a discordant piano.

The opening up of such sombre lives might have been expected to call forth cries of gratitude. Instead, a synthetic joy has emanated largely from the same sources that, until recently, offered people grudging survival only, the change of tune outsourced to producers of manufactured delight, purveyors of contrived euphoria to the people – a different order of industrial artefact from the shoes, utensils and textiles of another era.

***

A more authentic popular res­ponse exists beneath the official psalmody, a persistent murmur of discontent and powerlessness. Anger and aggression swirl around like dust and waste paper in the streets of our affluent, unequal society. As long-term recipients of the contempt of our betters, we know how to despise the vulnerable – people incapable of work, the poor, the timid and the fearful, those addicted to drugs and alcohol. Sullen resentment tarnishes the wealth of the world, a conviction that somebody else is getting the advantages that ought to be “ours” by right and by merit.

Rancour appears among those “left behind” in neighbourhoods besieged by unknown tongues and foreign accents: people who never voted for unchosen change, as all political options are locked up in a consensus of elites. “Give us back our country!”
they cry; even though that country is not in the custody of those from whom they would reclaim it. There was no space for the working class to grieve over its own dissolution. If, as E P Thompson said, that class was present at its own making, it was certainly not complicit in its own undoing.

Grief denied in individuals leads to damaging psychological disorders. There is no reason to believe that this differs for those bereaved of a known way of living. The working class has been colonised, as was the peasantry in the early industrial era. When the values, beliefs and myths of indigenous peoples are laid waste, these lose meaning, and people go to grieve in city slums and die from alcohol, drugs and other forms of self-inflicted violence. Though the dominant culture’s erasure of the manufacturing way of life in Britain was less intense than the colonial ruin of ancient societies, this subculture was equally unceremoniously broken. It is a question of degree. The ravages of drugs and alcohol and self-harm in silent former pit villages and derelict factory towns show convergence with other ruined cultures elsewhere in the world.

Depression is a symptom of repressed grief: here is the connection between unfinished mourning and popular resentment at having been cheated out of our fair share, our due, our place in the world. If we are unable to discern our own possible fate in suffering people now, this is perhaps a result of estrangement from unresolved wrongs in our own past. Nothing was ever explained. Globalisation occurred under a kind of social laissez-faire: no political education made the world more comprehensible to the disaffected and disregarded, people of small account to those who take decisions on their behalf and in their name.

Anyone who protested against our passage into this changed world was criminalised, called “wrecker” and “extremist”. The miners’ strike of 1984 was the symbol of this: their doomed fight to preserve a dignity achieved in pain and violence was presented by the merchants of deliverance not only as retrograde, but also as an act of outlawry. Resistance to compulsory change was derided as a response of nostalgics protecting the indefensible, when the whole world was on the brink of a new life. Early in her tenure of Downing Street, Margaret Thatcher, that sybil and prophet who knew about these things, warned that Britain would become “a less cosy, more abrasive” place: a vision confirmed by the Battle of Orgreave – redolent of civil war – and the anguish of Hillsborough.

It is too late to grieve now. Scar tissue has healed over the untreated wound. Though no one expects the ruling classes to understand the distress of perpetual “modernisation”, the leaders of labour might have been able to recognise capitalism’s realm of freedom and a gaudy consumerism that concealed hardening competitiveness and the growth of a crueller, more bitter society.

The ills of this best of all worlds, its excessive wealth and extreme inequality, are on show in hushed thoroughfares of London, shuttered sites of “inward investment”, where the only sound is the faint melody of assets appreciating; while elsewhere, people wait for charitable tins of denutrified substances to feed their family, or sit under a grubby duvet, a Styrofoam cup beseeching the pence of passers-by.

Unresolved feelings about industrialism, enforced with great harshness and abolished with equal contempt for those who served it, are certainly related to the stylish savagery of contemporary life. The alibi that present-day evils are an expression of “human nature” is a poor apology for what is clearly the nature – restless and opportunistic – of a social and economic system that has, so far at least, outwitted its opponents at every turn.

Jeremy Seabrook’s book “The Song of the Shirt” (C Hurst & Co) won the Bread and Roses Award for Radical Publishing 2016

This article first appeared in the 23 June 2016 issue of the New Statesman, Divided Britain