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

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The war on poaching

More than 1,100 rhinos were killed for their horns in Africa in 2016. Quasi-military conservation units are trying to stop the slaughter.

The Savé Valley Conservancy, 900 square miles of pristine wilderness in the Lowveld of south-eastern Zimbabwe, seems like a paradise.

Drive along its dirt tracks, past flat-topped acacias and vast-trunked baobab trees, and you scatter zebras and warthogs, impalas and wildebeest, kudus and waterbuck. Elephants lumber through the bush, leaving destruction in their wake. Giraffes placidly return your stares. Baboons cavort in the trees. A crowned eagle flies overhead with a rock rabbit in its talons. A pack of exquisitely patterned wild dogs lie on the warm red earth. There are lions and leopards, too, but out of sight.

My guide and I meet Bryce Clemence, the stocky, bearded outdoorsman who heads the conservancy’s Special Species Protection Unit (SSPU), by a muddy waterhole so that he can show us the most special of those species. He and a couple of his armed men lead us a few hundred yards into the bush before silently motioning us to stop. We wait, move on, stop again. Clemence points. Thirty yards away stands a two-tonne rhinoceros, a 15-year-old bull. It cannot see us, for rhinos have poor eyesight. It cannot smell us because we are downwind. But it senses our presence. Its ears revolve like miniature satellite dishes.

As we study this magnificent, primeval beast through our binoculars, one thing quickly becomes apparent. It has no horns. Normally it would have two, weighing seven kilos or more, but they have been removed in an effort to protect it. Rhino horn fetches around $60,000 a kilo in China and other east Asian countries, where it is considered an aphrodisiac and a cure for diverse ailments. This animal’s horns would have been worth more than $400,000 – a fortune in Zimbabwe, where the average household income is $62 a month and unemployment exceeds 90 per cent.

Sadly, not even de-horning works. Poachers will kill de-horned rhinos for any residual horn. In February 2015 they shot a six-month-old calf for just 30 grams of horn, Clemence tells me.

Savé Valley may look idyllic, but it is a front line in a war against rhino-poaching. More than 1,100 of the animals were killed across Africa in 2016, leaving barely 20,000 white rhinos, classified as “near threatened” by the International Union for Conservation of Nature, and 5,000 “critically endangered” black rhinos. What distinguishes Savé Valley is that it has begun to turn the tide, but only because it has access to the sort of funding that most African national parks can only dream of.

Clemence’s quasi-military operation consists of 35 highly trained men, all expert trackers, supremely fit and equipped with semi-automatic rifles and radios. Working in pairs, they do ten-day stints in the bush, monitoring the conservancy’s 168 rhinos from dawn to dark and endlessly searching for human tracks – or “spoor”.

They are supported by a canine unit whose two Belgian Malinois dogs can track at night and over rocks; a substantial network of paid informants in the surrounding communities and beyond; four 4x4 vehicles and 12 motorbikes; and nearly 100 armed scouts employed by the two-dozen private ranches that make up the conservancy.

Even that force is insufficient, Clemence says. The poaching gangs are growing more sophisticated. They now use high-powered hunting rifles with silencers to shoot the rhinos, and AK-47s to ward off the rangers. Sometimes the poachers use AK-47s against rhinos too: in 2014 one was hit 23 times.

They have begun using poison. One poacher was caught after laying oranges and cabbages laced with the pesticide Temik in the path of a rhino – Temik is nicknamed “Two-step” because that is how many steps an animal takes before dying. Another poacher planned to poison a waterhole, but was thwarted by an informer. “Poisoning is disgusting because it’s totally indiscriminate and has the potential to do massive harm,” Clemence says.

He has also caught poachers preparing to use the sedatives ketamine and xylazine. Having darted a rhino, they would then hack off its horns before it woke. They once hacked off the horns of a rhino that had been knocked out by a bullet and it woke with half its head missing. The creature survived for a week before Clemence’s unit found it. Vets had to put it down. “When you catch a poacher you want to beat him to death with a pick handle and very slowly break his bones, but you have to be professional,” says David Goosen, manager of the 230-square-mile Sango ranch, which forms part of the conservancy.

The odds are stacked against the SSPU in other ways, too. The poachers are paid well by the syndicates that run them – perhaps $5,000 each for a kilo of rhino horn. And even if caught, their chances of escaping punishment are high. Thanks to bribery or incompetence, just 3 per cent of prosecutions for rhino poaching in Zimbabwe end in convictions.

“You have to virtually catch them in the field red-handed, and even then they often get away with it,” Goosen says. “As soon as they get to the police station, a well-connected lawyer turns up, which means someone higher up is looking after their interests.” The maximum sentence for intent to kill a rhino is nine years for a first offence – less than for stealing cattle.

The SSPU is prevailing nonetheless. In the first three months of 2012, when Clemence arrived, the conservancy lost 14 rhinos. In 2015 it lost 12, last year three. It has also defeated Zimbabwe’s most notorious rhino-poaching gang.

Tavengwa Mazhongwe learned his craft from his older brother, “Big Sam”, who was killed poaching in 2009. Mazhongwe was responsible for at least 150 rhino killings, including many in Savé Valley. In December 2015 Clemence learned he was planning another attack and put his rangers on alert.

They found the gang’s spoor at 6.30 one morning, and tracked the four armed men in intense heat for nine hours. The gang took great care to cover their tracks, but late in the afternoon the rangers found them resting in a river bed. The rangers opened fire, killing one and seriously wounding a second. Mazhongwe and one other man escaped, but he was arrested near Harare two weeks later and given a record 35-year sentence for multiple offences. A judge had to acquit an officer in Zimbabwe’s Central Intelligence Organisation who drove the gang to the conservancy in a government vehicle because, he complained, the police did not dare investigate govenment officials. The rangers recovered an AK-47, a Mauser rifle with silencer, an axe, rubber gloves, a medical kit, tinned food and a phone-charger pack.

“You’ll never get to where you say ‘we’ve won’, but we have won in the sense that we’ve brought poaching down to a manageable level,” Clemence says. “We’ve taken out some of the most notorious syndicates. Victory will simply be breeding more than we’re losing and having sustainable numbers to pass to the next generation.” He hopes that the conservancy’s rhino population will reach 200 within two years, enabling it to relocate some animals to other parts of Zimbabwe where the battle is going less well.

The SSPU’s success comes down to skill, motivation, organisation and – above all – resources. The unit costs $400,000 a year, and is funded mainly by foreign NGOs such as Britain’s Tusk Trust. It receives practical support from the conservancy’s private ranches, some of whom – given the dearth of tourism – have to generate the necessary funds by permitting limited elephant and lion hunting for $20,000 an animal.

Zimbabwe’s national parks have no such resources. That is why private conservancies have 80 per cent of the country’s rhinos but 1.5 per cent of its land, while the parks have 15 per cent of the land but 20 per cent of the rhinos. Within a few years most of those parks will have no rhinos at all.

Martin Fletcher’s assignment in Zimbabwe was financed by the Pulitzer Center on Crisis Reporting

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