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

AKG-IMAGES/ULLSTEIN BILD
Show Hide image

A nervous breakdown in the body politic

Are we too complacent in thinking that the toxic brew of paranoia and populism that brought Hitler to power will never be repeated?

The conventional wisdom holds that “all that is necessary for the triumph of evil is that good men do nothing”, in Edmund Burke’s familiar phrase; but this is at best a half-truth. Studying the biography of a moral monster triumphantly unleashed on the political and international stage points us to another perspective, no less important. What is necessary for the triumph of evil is that the ground should have been thoroughly prepared by countless small or not-so-small acts of petty malice, unthinking prejudice and collusion. Burke’s axiom, though it represents a powerful challenge to apathy, risks crediting evil with too much of a life of its own: out there, there are evil agencies, hostile to “us”, and we (good men and women) must mobilise to resist.

No doubt; but mobilising intelligently demands being willing to ask what habits and assumptions, as well as what chances and conditions, have made possible the risk of evil triumphing. And that leads us into deep waters, to a recognition of how what we tolerate or ignore or underestimate opens the way for disaster, the ways in which we are at least half-consciously complicit. If this is not to be the silly we-are-all-guilty response that has rightly been so much mocked, nor an absolution for the direct agents of great horrors, it needs a careful and unsparing scrutiny of the processes by which cultures become corruptible, vulnerable to the agendas of damaged and obsessional individuals.

This can be uncomfortable. It raises the awkward issue of what philosophers have learned to call “moral luck” – the fact that some people with immense potential for evil don’t actualise it, because the circumstances don’t present them with the chance, and that some others who might have spent their lives in blameless normality end up supervising transports to Auschwitz. Or, to take a sharply contemporary example, that one Muslim youth from a disturbed or challenging background becomes a suicide bomber but another from exactly the same background doesn’t. It is as though there were a sort of diabolical mirror image for the biblical Parable of the Sower: some seeds grow and some don’t, depending on the ground they fall on, or what chance external stimulus touches them at critical moments.

If what interests us is simply how to assign individuals rapidly and definitively to the categories of sheep and goats, saved and damned, this is offensively frustrating. But if we recognise that evil is in important respects a shared enterprise, we may be prompted to look harder at those patterns of behaviour and interaction that – in the worst cases – give permission to those who are most capable of extreme destructiveness, and to examine our personal, political and social life in the light of this.

***

It would be possible to argue that the anti-Semitism of a lot of German culture – as of European Christian culture overall – was never (at least in the modern period) genocidal and obsessed with absolute racial purity; limited but real possibilities of integration were taken for granted, converts to Christianity were not disadvantaged merely because of their race, and so on. Yet the truth is that this cultural hinterland offered a foothold to the mania of Adolf Hitler; that it gave him just enough of the permission he needed to identify his society’s problems with this clearly definable “alien” presence. In his new book, Hitler: the Ascent, Volker Ullrich compellingly tells us once again that no one could have been under any illusion about Hitler’s general intentions towards the Jews from his very first appearance as a political figure, even if the detailed planning of genocide (lucidly traced in the late David Cesarani’s recent, encyclopaedic Final Solution) took some time to solidify. Yet so much of the German public heard Hitler’s language as the slightly exaggerated version of a familiar trope and felt able to treat it as at worst an embarrassing overstatement of a common, even a common-sense, view. One of the most disturbing things about this story is the failure of so many (inside and outside Germany) to grasp that Hitler meant what he said; and this failure in turn reinforced the delusion of those who thought they could use and then sideline Hitler.

To say that Hitler “meant what he said”, however, can be misleading. It is one of the repeated and focal themes in Ullrich’s book that Hitler was a brazen, almost compulsive liar – or, perhaps better, a compulsive and inventive actor, devising a huge range of dramatic roles for himself: frustrated artist, creative patron, philosopher-king (there is a fine chapter on the intellectual and artistic circle he assembled frequently at his Berchtesgaden residence), workers’ friend, martyr for his people (he constantly insinuated that he believed himself doomed to a tragic and premature death), military or economic messiah and a good deal else besides. His notorious outbursts of hysterical rage seem to have been skilfully orchestrated as instruments of intimidation (though this did not exactly indicate that he was otherwise predictable). Ullrich devotes a fair measure of attention to the literal staging of National Socialism, the architectural gigantism of Albert Speer which gave the Führer the sophisticated theatre he craved. In all sorts of ways, Hitler’s regime was a profoundly theatrical exercise, from the great public displays at Nuremberg and the replanning of Berlin to the various private fantasies enacted by him and his close associates (Göring above all), and from the emotional roller coaster he created for his circle to the dangerously accelerated rate of military-industrial expansion with which he concealed the void at the centre of the German economy.

Theatre both presupposes and creates a public. In the anxiety and despair of post-Versailles Germany, there was a ready audience for the high drama of Nazism, including its scapegoating of demonic enemies within and without. And in turn, the shrill pitch of Hitler’s quasi-liturgies normalised a whole set of bizarre and fantastic constructions of reality. A N Wilson’s challenging novel Winnie and Wolf, a fantasia on Hitler’s relations with Winifred Wagner, culminates in a scene at the end of the war where refugees and destitute citizens in Bayreuth raid the wardrobe of the opera house and wander the streets dressed in moth-eaten costumes; it is an unforgettable metaphor for one of the effects of Hitlerian theatre. Ullrich leaves his readers contemplating the picture of a vast collective drama centred on a personality that was not – as some biographers have suggested – something of a cipher, but that of a fantasist on a grand scale, endowed with a huge literal and metaphorical budget for staging his work.

All of this prompts questions about how it is that apparently sophisticated political systems succumb to corporate nervous breakdowns. It is anything but an academic question in a contemporary world where theatrical politics, tribal scapegoating and variegated confusions about the rule of law are increasingly in evidence. On this last point, it is still shocking to realise how rapidly post-Versailles Germany came to regard violent public conflict between heavily armed militias as almost routine, and this is an important background to the embittered negotiations later on around the relation between Hitler’s Sturmabteilung and the official organs of state coercion. Ullrich’s insightful account of a de facto civil war in Bavaria in the early 1920s makes it mercilessly plain that any pretensions to a state monopoly of coercion in Germany in this period were empty.

Yet the idea of such a state monopoly is in fact essential to anything that could be called a legitimate democracy. In effect, the polity of the Third Reich “privatised” coer­cion: again and again in Ullrich’s book, in the struggles for power before 1933, we see Nazi politicians successfully bidding for control of the mechanisms of public order in the German regions, and more or less franchising public order to their own agencies. A classical democratic political philosophy would argue that the state alone has the right to use force because the state is the guarantor of every community’s and every individual’s access to redress for injury or injustice. If state coercion becomes a tool for any one element in the social complex, it loses legitimacy. It is bound up with the rule of law, which is about something more than mere majority consent. One way of reading the rise of Hitler and National Socialism is as the steady and consistent normalising of illegitimate or partisan force, undermining any concept of an independent guarantee of lawfulness in society. It is the deliberate dissolution of the idea of a Rechtsstaat, a law-governed state order that can be recognised by citizens as organised for their common and individual good. Rule by decree, the common pattern of Nazi governmental practice, worked in harness with law enforcement by a force that was essentially a toxic hybrid, combining what was left of an independent police operation with a highly organised party militia system.

So, one of the general imperatives with which Hitler’s story might leave us is the need to keep a clear sense of what the proper work of the state involves. Arguments about the ideal “size” of the state are often spectacularly indifferent to the basic question of what the irreducible functions of state authority are – and so to the question of what cannot be franchised or delegated to non-state actors (it is extraordinary that we have in the UK apparently accepted without much debate the idea that prison security can be sold off to private interests). This is not the same as saying that privatisation in general leads to fascism; the issues around the limits to state direction of an economy are complex. However, a refusal to ask some fundamental questions about the limits of “franchising” corrodes the idea of real democratic legitimacy – the legitimacy that arises from an assurance to every citizen that, whatever their convictions or their purchasing power, the state is there to secure their access to justice. And, connected with this, there are issues about how we legislate: what are the proper processes of scrutiny for legislation, and how is populist and short-view legislation avoided? The Third Reich offers a masterclass in executive tyranny, and we need not only robust and intelligent counter-models, but a clear political theory to make sense of and defend those models.

***

Theatre has always been an aspect of the political. But there are different kinds of theatre. In ancient Athens, the annual Dionysia festival included the performance of tragedies that forced members of the audience to acknowledge the fragility of the political order and encouraged them to meditate on the divine interventions that set a boundary to vendetta and strife. Classical tragedy is, as political theatre, the exact opposite of Hitlerian drama, which repeatedly asserted the solid power of the Reich, the overcoming of weakness and division by the sheer, innate force of popular will as expressed through the Führer.

Contemporary political theatre is not – outside the more nakedly totalitarian states – a matter of Albert Speer-like spectacle and affirmation of a quasi-divine leader; but it is increasingly the product of a populist-oriented market, the parading of celebrities for popular approval, with limited possibilities for deep public discussion of policies advanced, and an assumption that politicians will be, above all, performers. It is not – to warn once again against cliché and exaggeration – that celebrity culture in politics is a short route to fascism. But a political theatre that never deals with the fragility of the context in which law and civility operate, that never admits the internal flaws and conflicts of a society, and never allows some corporate opening-up to the possibilities of reconciliation and reparation, is one that exploits, rather than resolves our anxieties. And, as such, it makes us politically weaker, more confused and fragmented.

The extraordinary mixture of farce and menace in Donald Trump’s campaign is a potent distillation of all this: a political theatre, divorced from realism, patience and human solidarity, bringing to the surface the buried poisons of a whole system and threatening its entire viability and rationality. But it is an extreme version of the way in which modern technology-and-image-driven communication intensifies the risks that beset the ideals of legitimate democracy.

And – think of Trump once again – one of the most seductively available tricks of such a theatre is the rhetoric of what could be called triumphant victimhood: we are menaced by such and such a group (Jews, mig­rants, Muslims, Freemasons, international business, Zionism, Marxism . . .), which has exerted its vast but covert influence to destroy us; but our native strength has brought us through and, given clear leadership, will soon, once and for all, guarantee our safety from these nightmare aliens.

***

This is a rhetoric that depends on ideas of collective guilt or collective malignity: plots ascribed to the agency of some dangerous minority are brandished in order to tarnish the name of entire communities. The dark legacy of much popular Christian language about collective Jewish guilt for the death of Jesus could be translated without much difficulty into talk about the responsibility of Jews for the violence and poverty afflicting Germans in the 1920s. (Shadows of the same myths still affect the way in which – as recent reports suggest – sinister, vague talk about Zionism and assumptions of a collective Jewish guilt for the actions of various Israeli politicians can become part of a climate that condones anti-Semitic bullying, or text messages saying “Hitler had a point”, on university campuses.)

Granted that there is no shortage of other candidates for demonic otherness in Europe and the United States (witness Trump’s language about Muslims and Mexicans), the specific and abiding lesson of Nazi anti-Semitism is the twofold recognition of the ease with which actually disadvantaged communities can be cast in the role of all-powerful subverters, and the way in which the path to violent exclusion of one kind or another can be prepared by cultures of casual bigotry and collective anxiety or self-pity, dramatised by high-temperature styles of media communication.

Marie Luise Knott’s recent short book Unlearning With Hannah Arendt (2014) revisits the controversy over Arendt’s notorious characterisation of the mindset of Nazism as “the banality of evil”, and brilliantly shows how her point is to do with the erosion in Hitlerian Germany of the capacity to think, to understand one’s agency as answerable to more than public pressure and fashion, to hold to notions of honour and dignity independent of status, convention or influence – but also, ultimately, the erosion of a sense of the ridiculous. The victory of public cliché and stereotype is, in Arendt’s terms, a protection against reality, “against the claim on our thinking attention that all events and facts make by virtue of their existence”, as she memorably wrote in The Life of the Mind. Hitler was committed to the destruction of anything that challenged the simple self-identity and self-justification of the race and the nation; hence, as Ullrich shows in an acutely argued chapter of Hitler: a Biography, the Führer’s venom against the churches, despite their (generally) embarrassingly lukewarm resistance to the horrors of the Reich. The problem was that the churches’ rationale entailed just that accountability to more than power and political self-identity that Nazi philosophy treated as absolute. They had grounds for thinking Nazism not only evil, but absurd. Perhaps, then, one of the more unexpected questions we are left with by a study of political nightmare such as Ullrich’s excellent book is how we find the resources for identifying the absurd as well as for clarifying the grounds of law and honour.

The threats now faced by “developed” democracy are not those of the 1920s and 1930s; whatever rough beasts are on their way are unlikely to have the exact features of Hitler’s distinctive blend of criminality and melodrama. But this does not mean that we shouldn’t be looking as hard as we can at the lessons to be learned from the collapse of political legality, the collective panics and myths, the acceptance of delusional and violent public theatre that characterised Hitler’s Germany. For evil to triumph, what is necessary is for societies to stop thinking, to stop developing an eye for the absurd as well as the corrupt in language and action, public or private.

Hitler: a Biography – Volume I: Ascent by Volker Ullrich is published by the Bodley Head

Rowan Williams is an Anglican prelate, theologian and poet, who was Archbishop of Canterbury from 2002 to 2012. He writes on books for the New Statesman

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