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 age of loneliness

Profound changes in technology, work and community are transforming our ultrasocial species into a population of loners.

Our dominant ideology is based on a lie. A series of lies, in fact, but I’ll focus on just one. This is the claim that we are, above all else, self-interested – that we seek to enhance our own wealth and power with little regard for the impact on others.

Some economists use a term to describe this presumed state of being – Homo economicus, or self-maximising man. The concept was formulated, by J S Mill and others, as a thought experiment. Soon it became a modelling tool. Then it became an ideal. Then it evolved into a description of who we really are.

It could not be further from the truth. To study human behaviour is to become aware of how weird we are. Many species will go to great lengths to help and protect their close kin. One or two will show occasional altruism towards unrelated members of their kind. But no species possesses a capacity for general altruism that is anywhere close to our own.

With the possible exception of naked mole-rats, we have the most social minds of all mammals. These minds evolved as an essential means of survival. Slow, weak, armed with rounded teeth and flimsy nails in a world of fangs and claws and horns and tusks, we survived through co-operation, reciprocity and mutual defence, all of which developed to a remarkable degree.

A review paper in the journal Frontiers in Psychology observes that Homo economicus  might be a reasonable description of chimpanzees. “Outsiders . . . would not expect to receive offers of food or solicitude; rather, they would be fiercely attacked . . . food is shared only under harassment; even mothers will not voluntarily offer novel foods to their own infants unless the infants beg for them.” But it is an unreasonable description of human beings.

How many of your friends, colleagues and neighbours behave like chimpanzees? A few, perhaps. If so, are they respected or reviled? Some people do appear to act as if they have no interests but their own – Philip Green and Mike Ashley strike me as possible examples – but their behaviour ­attracts general revulsion. The news is filled with spectacular instances of human viciousness: although psychopaths are rare, their deeds fill the papers. Daily acts of kindness are seldom reported, because they are everywhere.

Every day, I see people helping others with luggage, offering to cede their place in a queue, giving money to the homeless, setting aside time for others, volunteering for causes that offer no material reward. Alongside these quotidian instances are extreme and stunning cases. I think of my Dutch mother-in-law, whose family took in a six-year-old Jewish boy – a stranger – and hid him in their house for two years during the German occupation of the Netherlands. Had he been discovered, they would all have been sent to a concentration camp.

Studies suggest that altruistic tendencies are innate: from the age of 14 months, children try to help each other, attempting to hand over objects another child can’t reach. At the age of two, they start to share valued possessions. By the time they are three, they begin to protest against other people’s violation of moral norms.

Perhaps because we are told by the media, think tanks and politicians that competition and self-interest are the defining norms of human life, we disastrously mischaracterise the way in which other people behave. A survey commissioned by the Common Cause Foundation reported that 78 per cent of respondents believe others to be more selfish than they really are.

I do not wish to suggest that this mythology of selfishness is the sole or even principal cause of the epidemic of loneliness now sweeping the world. But it is likely to contribute to the plague by breeding suspicion and a sense of threat. It also appears to provide a doctrine of justification for those afflicted by isolation, a doctrine that sees individualism as a higher state of existence than community. Perhaps it is hardly surprising that Britain, the European nation in which neoliberalism is most advanced, is, according to government figures, the loneliness capital of Europe.

There are several possible reasons for the atomisation now suffered by the supremely social mammal. Work, which used to bring us together, now disperses us: many people have neither fixed workplaces nor regular colleagues and regular hours. Our leisure time has undergone a similar transformation: cinema replaced by television, sport by computer games, time with friends by time on Facebook.

Social media seems to cut both ways: it brings us together and sets us apart. It helps us to stay in touch, but also cultivates a tendency that surely enhances other people’s sense of isolation: a determination to persuade your followers that you’re having a great time. FOMO – fear of missing out – seems, at least in my mind, to be closely ­associated with loneliness.

Children’s lives in particular have been transformed: since the 1970s, their unaccompanied home range (in other words, the area they roam without adult supervision) has declined in Britain by almost 90 per cent. Not only does this remove them from contact with the natural world, but it limits their contact with other children. When kids played out on the street or in the woods, they quickly formed their own tribes, learning the social skills that would see them through life.

An ageing population, family and community breakdown, the decline of institutions such as churches and trade unions, the switch from public transport to private, inequality, an alienating ethic of consumerism, the loss of common purpose: all these are likely to contribute to one of the most dangerous epidemics of our time.

Yes, I do mean dangerous. The stress response triggered by loneliness raises blood pressure and impairs the immune system. Loneliness enhances the risk of depression, paranoia, addiction, cognitive decline, dem­entia, heart disease, stroke, viral infection, accidents and suicide. It is as potent a cause of early death as smoking 15 cigarettes a day, and can be twice as deadly as obesity.

Perhaps because we are in thrall to the ideology that helps to cause the problem, we turn to the market to try to solve it. Over the past few weeks, the discovery of a new American profession, the people-walker (taking human beings for walks), has caused a small sensation in the media. In Japan there is a fully fledged market for friendship: you can hire friends by the hour with whom to chat and eat and watch TV; or, more disturbingly, to pose for pictures that you can post on social media. They are rented as mourners at funerals and guests at weddings. A recent article describes how a fake friend was used to replace a sister with whom the bride had fallen out. What would the bride’s mother make of it? No problem: she had been rented, too. In September we learned that similar customs have been followed in Britain for some time: an early foray into business for the Home Secretary, Amber Rudd, involved offering to lease her posh friends to underpopulated weddings.



My own experience fits the current pattern: the high incidence of loneliness suffered by people between the ages of 18 and 34. I have sometimes been lonely before and after that period, but it was during those years that I was most afflicted. The worst episode struck when I returned to Britain after six years working in West Papua, Brazil and East Africa. In those parts I sometimes felt like a ghost, drifting through societies to which I did not belong. I was often socially isolated, but I seldom felt lonely, perhaps because the issues I was investigating were so absorbing and the work so frightening that I was swept along by adrenalin and a sense of purpose.

When I came home, however, I fell into a mineshaft. My university friends, with their proper jobs, expensive mortgages and settled, prematurely aged lives, had become incomprehensible to me, and the life I had been leading seemed incomprehensible to everyone. Though feeling like a ghost abroad was in some ways liberating – a psychic decluttering that permitted an intense process of discovery – feeling like a ghost at home was terrifying. I existed, people acknowledged me, greeted me cordially, but I just could not connect. Wherever I went, I heard my own voice bouncing back at me.

Eventually I made new friends. But I still feel scarred by that time, and fearful that such desolation may recur, particularly in old age. These days, my loneliest moments come immediately after I’ve given a talk, when I’m surrounded by people congratulating me or asking questions. I often experience a falling sensation: their voices seem to recede above my head. I think it arises from the nature of the contact: because I can’t speak to anyone for more than a few seconds, it feels like social media brought to life.

The word “sullen” evolved from the Old French solain, which means “lonely”. Loneliness is associated with an enhanced perception of social threat, so one of its paradoxical consequences is a tendency to shut yourself off from strangers. When I was lonely, I felt like lashing out at the society from which I perceived myself excluded, as if the problem lay with other people. To read any comment thread is, I feel, to witness this tendency: you find people who are plainly making efforts to connect, but who do so by insulting and abusing, alienating the rest of the thread with their evident misanthropy. Perhaps some people really are rugged individualists. But others – especially online – appear to use that persona as a rationale for involuntary isolation.

Whatever the reasons might be, it is as if a spell had been cast on us, transforming this ultrasocial species into a population of loners. Like a parasite enhancing the conditions for its own survival, loneliness impedes its own cure by breeding shame and shyness. The work of groups such as Age UK, Mind, Positive Ageing and the Campaign to End Loneliness is life-saving.

When I first wrote about this subject, and the article went viral, several publishers urged me to write a book on the theme. Three years sitting at my desk, studying isolation: what’s the second prize? But I found another way of working on the issue, a way that engages me with others, rather than removing me. With the brilliant musician Ewan McLennan, I have written a concept album (I wrote the first draft of the lyrics; he refined them and wrote the music). Our aim is to use it to help break the spell, with performances of both music and the spoken word designed to bring people together –which, we hope, will end with a party at the nearest pub.

By itself, our work can make only a tiny contribution to addressing the epidemic. But I hope that, both by helping people to acknowledge it and by using the power of music to create common sentiment, we can at least begin to identify the barriers that separate us from others, and to remember that we are not the selfish, ruthless beings we are told we are.

“Breaking the Spell of Loneliness” by Ewan McLennan and George Monbiot is out now. For a full list of forthcoming gigs visit: monbiot.com/music/

This article first appeared in the 20 October 2016 issue of the New Statesman, Brothers in blood