Treat with extreme caution

Homoeopathic medicine is founded on a bogus philosophy. Its continued use is a drain on NHS resource

Two years ago, a loose coalition of like-minded scientists wrote an open letter to chief executives of the National Health Service Trusts. The signatories simply stated that homoeopathy and other alternative therapies were unproven, and that the NHS should reserve its funds for treatments that had been shown to work. The letter marked an extraordinary downturn in the fortunes of homoeopathy in the UK over the following year, because the overwhelming majority of trusts either stopped sending patients to the four homoeopathic hospitals, or introduced measures to strictly limit referrals.

Consequently, the future of these hospitals is now in doubt. The Tunbridge Wells Homoeopathic Hospital is set to close next year and the Royal London Homoeopathic Hospital is likely to follow in its wake. Homoeo paths are now so worried about the collapse of their flagship hospitals that they are organising a march to deliver a petition to Downing Street on 22 June. Local campaign groups are being formed and patients are being urged to sign the petition.

Homoeopaths believe that the medical Establishment is crushing a valuable healing tradition that dates back more than two centuries and that still has much to offer patients. Homoeopaths are certainly passionate about the benefits of their treatment, but are their claims valid, or are they misguidedly promoting a bogus philosophy?

This is a question that I have been considering for the past two years, ever since I began co-authoring a book on the subject of alternative medicine with Professor Edzard Ernst. He was one of the signatories of the letter to the NHS trusts and is the world's first professor of complementary medicine. Before I present our conclusion, it is worth remembering why homoeo pathy has always existed beyond the borders of mainstream medicine.

Homoeopathy relies on two key principles, namely that like cures like, and that smaller doses deliver more powerful effects. In other words, if onions cause our eyes to stream, then a homoeopathic pill made from onion juice might be a potential cure for the eye irritation caused by hay fever. Crucially, the onion juice would need to be diluted repeatedly to produce the pill that can be administered to the patient, as homoeopaths believe that less is more.

Initially, this sounds attractive, and not dissimilar to the principle of vaccination, whereby a small amount of virus can be used to protect patients from viral infection. However, doctors use the principle of like cures like very selectively, whereas homoeopaths use it universally. Moreover, a vaccination always contains a measurable amount of active ingredient, whereas homoeopathic remedies are usually so dilute that they contain no active ingredient whatsoever.

A pill that contains no medicine is unlikely to be effective, but millions of patients swear by this treatment. From a scientific point of view, the obvious explanation is that any perceived benefit is purely a result of the placebo effect, because it is well established that any patient who believes in a remedy is likely to experience some improvement in their condition due to the psychological impact. Homoeopaths disagree, and claim that a "memory" of the homoeopathic ingredient has a profound physiological effect on the patient. So the key question is straightforward: is homoeopathy more than just a placebo treatment?

Fortunately, medical researchers have conducted more than 200 clinical trials to investigate the impact of homoeopathy on a whole range of conditions. Typically, one group of patients is given homoeopathic remedies and another group is given a known placebo, such as a sugar pill. Researchers then examine whether or not the homoeopathic group improves on average more than the placebo group. The overall conclusion from all this research is that homoeopathic remedies are indeed mere placebos.

In other words, their benefit is based on nothing more than wishful thinking. The latest and most definitive overview of the evidence was published in the Lancet in 2005 and was accompanied by an editorial entitled "The end of homoeopathy". It argued that ". . . doctors need to be bold and honest with their patients about homoeopathy's lack of benefit".

An unsound investment

However, even if homoeopathy is a placebo treatment, anybody working in health care will readily admit that the placebo effect can be a very powerful force for good. Therefore, it could be argued that homoeopaths should be allowed to flourish as they administer placebos that clearly appeal to patients. Despite the undoubted benefits of the placebo effect, however, there are numerous reasons why it is unjustifiable for the NHS to invest in homoeopathy.

First, it is important to recognise that money spent on homoeopathy means a lack of investment elsewhere in the NHS. It is estimated that the NHS spends £500m annually on alternative therapies, but instead of spending this money on unproven or disproven therapies it could be used to pay for 20,000 more nurses. Another way to appreciate the sum of money involved is to consider the recent refurbishment of the Royal Homoeopathic Hospital in London, which was completed in 2005 and cost £20m. The hospital is part of the University College London Hospitals NHS Foundation Trust, which contributed £10m to the refurbishment, even though it had to admit a deficit of £17.4m at the end of 2005. In other words, most of the overspend could have been avoided if the Trust had not spent so much money on refurbishing the spiritual home of homoeopathy.

Second, the placebo effect is real, but it can lull patients into a false sense of security by improving their sense of well-being without actually treating the underlying conditions. This might be all right for patients suffering from a cold or flu, which should clear up given time, but for more severe illnesses, homoeopathic treatment could lead to severe long-term problems. Because those who administer homoeopathic treatment are outside of conventional medicine and therefore largely unmonitored, it is impos sible to prove the damage caused by placebo. Never theless, there is plenty of anecdotal evidence to support this claim.

For example, in 2003 Professor Ernst was working with homoeopaths who were taking part in a study to see if they could treat asthma. Unknown to the professor or any of the other researchers, one of the homoeopaths had a brown spot on her arm, which was growing in size and changing in colour. Convinced that homoeopathy was genuinely effective, the homoeopath decided to treat it herself using her own remedies. Buoyed by the placebo effect, she continued her treatment for months, but the spot turned out to be a malignant melanoma. While she was still in the middle of treating asthma patients, the homoeopath died. Had she sought conventional treatment at an early stage, there would have been a 90 per cent chance that she would have survived for five years or more. By relying on homoeopathy, she had condemned herself to an inevitably early death.

The third problem is that anybody who is aware of the vast body of research and who still advises homoeopathy is misleading patients. In order to evoke the placebo effect, the patient has to be fooled into believing that homoeopathy is effective. In fact, bigger lies encourage bigger patient expectations and trigger bigger placebo effects, so exploiting the benefits of homoeopathy to the full would require homoeopaths to deliver the most fantastical justifications imaginable.

Over the past half-century, the trend has been towards a more open and honest relationship between doctor and patient, so homoeopaths who mislead patients flagrantly disregard ethical standards. Of course, many homoeopaths may be unaware of or may choose to disregard the vast body of scientific evidence against homoeo pathy, but arrogance and ignorance in health care are also unforgivable sins.

If it is justifiable for the manufacturers of homoeopathic remedies in effect to lie about the efficacy of their useless products in order to evoke a placebo benefit, then maybe the pharmaceutical companies could fairly argue that they ought to be allowed to sell sugar pills at high prices on the basis of the placebo effect as well. This would undermine the requirement for rigorous testing of drugs before they go on sale.

A fourth reason for spurning placebo-based medicines is that patients who use them for relatively mild conditions can later be led into dangerously inappropriate use of the same treatments. Imagine a patient with back pain who is referred to a homoeopath and who receives a moderate, short-term placebo effect. This might impress the patient, who then returns to the homoeopath for other advice. For example, it is known that homoeopaths offer alternatives to conventional vaccination - a 2002 survey of homoeopaths showed that only 3 per cent of them advised parents to give their baby the MMR vaccine. Hence, directing patients towards homoeo paths for back pain could encourage those patients not to have their children vaccinated against potentially dangerous diseases.

Killer cures

Such advice and treatment is irresponsible and dangerous. When I asked a young student to approach homoeopaths for advice on malaria prevention in 2006, ten out of ten homoeopaths were willing to sell their own remedies instead of telling the student to seek out expert advice and take the necessary drugs.

The student had explained that she would be spending ten weeks in West Africa; we had decided on this backstory because this region has the deadliest strain of malaria, which can kill within three days. Nevertheless, homoeopaths were willing to sell remedies that contained no active ingredient. Apparently, it was the memory of the ingredient that would protect the student, or, as one homoeopath put it: "The remedies should lower your susceptibility; because what they do is they make it so your energy - your living energy - doesn't have a kind of malaria-shaped hole in it. The malarial mosquitoes won't come along and fill that in. The remedies sort it out."

The homoeopathic industry likes to present itself as a caring, patient-centred alternative to conventional medicine, but in truth it offers disproven remedies and often makes scandalous and reckless claims. On World Aids Day 2007, the Society of Homoeopaths, which represents professional homoeopaths in the UK, organised an HIV/Aids symposium that promoted the outlandish ambitions of several speakers. For example, describing Harry van der Zee, editor of the International Journal for Classical Homoeo pathy, the society wrote: "Harry believes that, using the PC1 remedy, the Aids epidemic can be called to a halt, and that homoeopaths are the ones to do it."

There is one final reason for rejecting placebo-based medicines, perhaps the most important of all, which is that we do not actually need placebos to benefit from the placebo effect. A patient receiving proven treatments already receives the placebo effect, so to offer homoeopathy instead - which delivers only the placebo effect - would simply short-change the patient.

I do not expect that practising homoeopaths will accept any of my arguments above, because they are based on scientific evidence showing that homoeopathy is nothing more than a placebo. Even though this evidence is now indisputable, homoeopaths have, understandably, not shown any enthusiasm to acknowledge it.

For now, their campaign continues. Although it has not been updated for a while, the campaign website currently states that its petition has received only 382 signatures on paper, which means that there's a long way to go to reach the target of 250,000. But, of course, one of the central principles of homoeopathy is that less is more. Hence, in this case, a very small number of signatures may prove to be very effective. In fact, perhaps the Society of Homoeopaths should urge people to withdraw their names from the list, so that nobody at all signs the petition. Surely this would make it incredibly powerful and guaranteed to be effective.

"Trick or Treatment? Alternative Medicine on Trial" (Bantam Press, £16.99) by Simon Singh and Edzard Ernst is published on 21 April

Homoeopathy by numbers

3,000 registered homoeopaths in the UK

1 in 3 British people use alternative therapies such as homoeopathy

42% of GPs refer patients to homoeopaths

0 molecules of an active ingredient in a typical "30c" homoeopathic solution

$1m reward offered by James Randi for proof that homoeopathy works

This article first appeared in the 21 April 2008 issue of the New Statesman, Food crisis

Picture: SÉBASTIEN THIBAULT
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Jeremy Corbyn, Emmanuel Macron and the age of volatility

The rise of populism in Britain and France is the result of a restless “crowd electorate”. Both countries' future stability depends on their changing relationship with the EU.

Britain seems to have joined the rest of the democratic world in the volatility of its politics. Electorates are no longer armies, but crowds. Identities shaped by religion, class, region, ideology and tradition weaken. Conventional parties are hollowed out, and disoriented and angry voters turn to single-issue campaigns or insurgent populism. In every country this takes diverse forms shaped by political institutions and political cultures – Donald Trump and Bernie Sanders in America, Marine Le Pen and Emmanuel Macron in France, Beppe Grillo and the Five Star Movement in Italy, Nigel Farage’s Ukip and now Jeremy Corbyn’s Labour Party.

The trend, noticeable from the 1990s, was analysed in a now classic work by Peter Mair, Ruling the Void: the Hollowing of Western Democracy, which was published in 2013, two years after the author’s death. Elected governments had conceded powers to non-elected agencies such as the IMF, the World Bank, the World Trade Organisation (WTO), and above all the EU. Politicians had become professionals, largely detached from civil society and operating increasingly within these international institutions, “safe from the demands of voters”. Citizens were decreasingly willing to join professionalised political parties financed by large donors or public funds, or to identify strongly with them.

Membership fell across Europe and beyond, and among the sharpest falls were those in France and Britain, where levels of political participation had previously been high. Electoral turnout fell too.

As Mair saw it, “hand in hand with indifference goes inconsistency”, as low levels of participation were paralleled by rising levels of volatility. People who did vote for mainstream parties often changed allegiances at random, and made up their minds at the last minute in response to short-term factors. Others flooded into new movements, or even old ones that reinvented themselves as enemies of the system.

The political effects of the 2007-08 banking crisis are still being felt everywhere and subsequent policy failures have aggravated the discrediting of elites. Naturally, the most volatile element has been the young. Youthful radicalism is hardly new. In my youth, inspiration came from Mao, Che Guevara and even the Khmer Rouge. Now it comes from elderly white males such as Bernie Sanders, Jeremy Corbyn and Jean-Luc Mélenchon, who seem able to present old remedies as new revelations to those inevitably lacking political memory. Historians are perhaps tempted to seek precedents. My own choice is the 18th-century radical John Wilkes. His brilliantly provocative tactics made fools of successive governments and appealed to a largely London-based electorate.

Wilkes’s secret – apart from barefaced cheek – was that he was not seeking office. It has been liberating for Sanders, Corbyn and Mélenchon that they were not expected, and did not expect, to win, and hence were free to run election campaigns that were not programmes of government but protest movements aimed at generating maximum support and momentum. Brexit seems to have further liberated the British left. Only the hardest of Brexits would give free rein to a radical programme of nationalisation and support to industry, which would contravene EU legislation on equal competition and restrictions on state aids.

This kind of populism is a new phenomenon in modern British politics, because never has a major party entered a campaign with such an absolute conviction that it would lose. And never has the Labour Party been so dominated by the ideas and campaigning style of the hard Left: the ubiquitous rent-a-crowd, the conspiracy theories, the violence of language (especially online), the ruthless and immediate politicisation of national tragedies. This old recipe has been given unprecedented dynamism by social media. It is populism in its purest form: a movement purporting to represent “the many” against a corrupt and remote system.

Populism is unlikely to come to power in normal circumstances because of its evident risks. However, volatility is now “normal” and accidents happen.

The two most successful populists are Donald Trump and Emmanuel Macron. Both won only with the help of a chapter of accidents. The divisions in the Democratic Party, the peculiarities of the American voting system and the accusations directed at Hilary Clinton’s email system were crucial for Trump. The collapse of François Hollande’s Socialist presidency and the meltdown of the Parti Socialiste following Mélenchon’s populist challenge from the left, along with the “Penelopegate” scandal enveloping the conservative presidential favourite, François Fillon, have delivered both the presidency and a huge parliamentary majority to Macron. What might have resulted in Britain had the Grenfell Tower tragedy happened a few days before the poll?

***

Macron’s extraordinary victory in France, which some hail as a defeat of populism, is its most brilliant success. Macron came from outside politics, set up a new movement, and pledged to “renew” and “moralise” politics by recruiting half his party candidates from civil society and half from women, and excluding all with criminal records. His La République En Marche! has crushed the other parties. Unlike Trump, he has moved smoothly into power as if born to it.

The Fifth Republic is a “republican monarchy” and Macron seems to be pushing the system as far as it will go. His inauguration ceremonies equalled or exceeded the regal style of his loftiest predecessors, Charles de Gaulle, Valéry Giscard d’Estaing and François Mitterrand. He has been dubbed “Jupiter in the Elysée”, above the public fray, refusing to speak to journalists except in circumstances of his own choosing, and tightly muzzling his aides and ministers. Macron has ensconced himself in his palace with a tiny number of trusted young advisers – perhaps, as with Trump, a direct consequence of a populism that rejects established political elites. He has also begun an intensive centralisation and politicisation of the civil service, assuming the power to decide the reappointment or replacement of several hundred top officials.

However, Jupiter has an Achilles heel. The solidity of his support in the country is uncertain, and hence much depends on his cunning and charisma. This may seem paradoxical for the leader of a populist movement, but perhaps it is a fundamental feature of a politics that bypasses intermediaries and relies on the volatile support of the crowd-electorate: Trump, Macron, Corbyn, Farage, Mélenchon, Grillo – all one-man bands.


Emmanuel Macron’s success represents a populist eruption from the centre. Photo: Getty

In France’s recent legislative elections only 43 per cent of the electorate voted –probably the lowest turnout in a national election in its democratic history – due to uncertainty or suspicion. One survey puts the level of Macron’s positive support at only 11 per cent. His left-wing opponents have announced their intention of shifting the contest from the ballot box to the street, and Mélenchon has called for a “civic general strike”. Macron’s slick middle-class populism might have to confront the tough populism of the old left. I wouldn’t care to bet on the outcome.

How French and British politics develop in this time of volatility depends on the countries’ changing relationship with the European Union. France has chronic youth unemployment and its economic performance has long been sluggish. Some of its wounds are self-inflicted, but underlying them is the problem of the eurozone and the disparity of economic behaviour between France (and southern Europe) and Germany.

As long as the eurozone is managed as at present, this problem is insoluble. Germany is permanently in surplus and presses austerity on the laggards. France, while a less extreme case than Italy, needs Germany to agree to expand state borrowing by setting up eurobonds backed by the EU (that is, by Germany) and with an EU finance minister to control national budgets – hence, removing another core function of democratic governments. France’s future rests on Macron’s success. If his bold attempt to change France and the EU fails, it is hard to see where the country can go next.

Brexit may prove an easier prospect than that facing Macron, but its successful management – not least because of its centrality in the national debate – is equally crucial to our political stability. A crisis here could mean the wreckage of the Conservative Party, Jeremy Corbyn in Downing Street, turmoil in Northern Ireland and the breakaway of Scotland. Readers may regard some or all of these outcomes with favour.

***

Theresa May’s failure to secure a majority has revived doubts about how resolved the British really are. Labour’s side-stepping of the issue – accepting Brexit but not the Prime Minister’s version of it – was electorally clever but adds to the uncertainty. Adopting David Cameron’s approach to negotiation, Corbyn declares that “there is no such thing as ‘no deal’”. This inevitably encourages those in the EU who wish Brexit to be damaging enough to deter others: there have already been provocative statements from Jean-Claude Juncker and Guy Verhofstadt. Macron recently declared that “the door is always open” to Britain dropping Brexit; reversing national electoral choices is something the EU has past form on.

Quasi-Remainers of all parties are trying to strip the issue of everything except “jobs and the economy”, blithely denying the importance of democratic legitimacy, national sovereignty, immigration, strategic security and the future of the EU itself. Imagine the divisive effects on British politics and British society if a future government were forced to apologise for the referendum and asked to be readmitted to the EU: bitter recrimination, national humiliation, evaporation of international influence – all far beyond anything we are experiencing today

It would deliver a death blow to any attempt to reassert democratic choice over bureaucratic and financial power within Europe, and would mark the effective eclipse of national sovereignty for the foreseeable future. Nor would it make sense in the long run: the eurozone, if it is to survive, must create greater central control, which hardly anyone in Britain accepts; so we would in any case find ourselves on the outside.

The effort to restrict debate to “jobs and the economy” is based on reiteration of the dogma that Brexit threatens economic disaster. This revives the narrative created during the referendum campaign, whose most influential element was the official report produced by George Osborne’s Treasury. The IMF and the Organisation for Economic Co-operation and Development naturally followed Whitehall’s lead: that is how such bodies operate. The Treasury predicted that a “no deal” Brexit would cost around 7.5 per cent of GDP by 2030, an average loss of £6,600 per family. Even some Remainers were alarmed at what seemed a politicisation of the civil service. The former governor of the Bank of England Mervyn King has since described the report as “not an objective presentation of the facts”.

Nevertheless, the report had a huge impact on the referendum (most Remain voters said they were motivated mainly by economic fears) and its pessimism continues to overshadow the Brexit negotiations and provide grist to the mill of anti-Brexit groups in the UK and beyond: “we didn’t vote to become poorer”.

Significantly, the Treasury refuses to discuss with academics how it arrived at its forecast. However, a group of economists based in Cambridge, led by Graham Gudgin and Ken Coutts, has for the first time applied the standard scientific method of verification by trying to reproduce the Treasury’s results using the same economic models. Their findings, now accessible through Policy Exchange (“A Critique of Estimates of the Economic Impact of Brexit”), are startling.

Astonishingly (or perhaps not) the Treasury did not produce an estimate of the effects on UK trade of leaving the EU. Instead, it worked out the average importance of EU trade for all 28 member states, including the new eastern European states that do most of their trade within the EU. It also adopted a long time-scale, rather than focusing on the years since the creation of the euro – which have seen a slowing of intra-EU trade generally, and for the UK particularly.

This approach greatly magnifies the importance of EU trade for Britain, which is less than for any other EU country, and which has been declining in importance for years. Finally, the Treasury made the extraordinary assumption that if Britain did less trade with the EU, it would not be able to compensate significantly by embarking on more trade outside the EU – even though its non-EU trade has been growing and shows a favourable balance. In consequence of these methods, the Treasury prediction of the results of a “hard Brexit” was a considerable exaggeration.

Using the same methods as the Treasury, but applying data relating specifically to the UK rather than to the EU as a whole, the Cambridge researchers reach a very different conclusion. Even if it proved impossible to reach a free trade agreement and the UK reverted to trading under WTO rules (“falling off a cliff”, as some express it) there would be “only a minor loss” in overall GDP by 2030, as tariffs in 90 per cent of products have already been more than compensated for by the fall in a previously over-valued sterling. As for per capita GDP – that is, average living standards – they predict that this could actually rise if the rate of immigration were reduced.

So no deal is clearly better than a bad deal, including the “soft Brexit” advocated by Corbyn and others: to leave the single market but stay in the customs union. This would mean being unable to trade freely either inside or outside the EU or to influence EU policies from within.

In short, we have no reason to be frightened by the Brexit negotiations. Being inside or outside the EU has made no difference to our economic fortunes: our national wealth has increased at exactly the same rate as that of the US for the period since 1945. We are not facing economic disaster. It is not the case, as Nick Clegg recently asserted, that we face a choice between “painful concessions” and “economic disruption”.

Moreover, Britain is a major power independently of its ties with the EU. The international relations specialist and New Statesman contributing writer Brendan Simms estimates that it is the third power in the world after the US and China because of its wealth, size, “soft power”, military potency, and its relative internal cohesion and long-term political stability. A good relationship with Britain is important for the security, stability and prosperity of the whole European continent. Unless we play our hand extraordinarily badly in these negotiations, the outcome should reduce the potential of that volatile populism of which we are presently feeling the shock: volatility, after all, is a two-way process.

Peter Mair feared the democratic world was losing control of its political institutions, and thought it “not at all clear how that control might be regained”. Brexit should, as many of us hope, provide the beginning of an answer.

Robert Tombs is the author of “The English and their History” (Penguin) 

This article first appeared in the 21 April 2008 issue of the New Statesman, Food crisis