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

Edel Rodriguez for New Statesman
Show Hide image

Rehearsing for war

From the Middle East to North Korea, Donald Trump is reasserting US military strength and intensifying the rivalry among the great powers.

As Vice-President Mike Pence arrived in South Korea from Washington on Sunday, he announced that the “era of strategic patience”, in which the US sought to monitor and manage the nuclear threat from North Korea without pushing the matter for fear of escalation, was over. “President Trump has made it clear that the patience of the United States and our allies in this region has run out and we want to see change,” Pence declared. The heat under a crisis that had already been bubbling ominously was turned up another notch.

Much has been written in recent years about the stability provided by the post-1945 world order and the dangers of letting it crumble. The conflict in Korea provided the first big test of that order almost 70 years ago, but the difficulty was never really resolved. It remains the proverbial “wicked problem” in international affairs, “frozen” in an obsessively monitored and deeply uneasy stalemate, demarcated by the Demilitarised Zone: a line 160 miles long and roughly two and a half miles wide scored across the middle of the Korean Peninsula, drawn with superpower supervision in 1953. Partition has allowed a strong and ­successful state to flourish in the South while the North has survived in a state of ­arrested development.

The problem has been passed down from generation to generation because attempting to solve the issue risked opening a Pandora’s box. The risks included the unleashing of huge military force, potential world war and a refugee crisis on a scale that could severely destabilise even China. By the 1990s, it was clear that the North Korean regime had fastened upon another strategy for survival as the Cold War passed into history and its sponsors in Beijing and Moscow began to question the value of such an ally: the acquisition of nuclear warheads. Pyongyang has long had the firepower to flatten Seoul in a matter of hours. The mission since has been to develop its missile technology to carry that material as far as possible – certainly to Japan, but ideally also to the west coast of the United States.

The day after Pence’s announcement, the US and South Korea undertook a joint air and army exercise to ensure readiness in the event of an attack from the North. This followed a joint naval war game earlier in the week and the US decision to send a navy group led by the nuclear-powered aircraft carrier USS Carl Vinson, which Donald Trump described as an “armada”, to the region. No sooner had the fleet appeared than Japanese sources reported that it had been followed by Chinese and Russian submarines as it entered North Korean waters. Such are the great-power manoeuvres of the 21st century – whether on air, sea or land – in which the world’s most potent military machines shadow the moves of their competitors, and openly rehearse for war.

***

Asia has not had a major inter-state war since the 1970s but it is not immune from the tragedies of power politics that have beset other rapidly developing parts of the world. Across the region, military spending is rising fast as states jostle in anticipation of a changing balance of power.

The purpose of Pence’s Asia-Pacific tour is to offer reassurance to America’s allies in the region, which have been watching the rise of China, in particular, with trepidation. The stark change of tone emanating from the White House – and change of gear – has been noted. After years of steady consistency in US grand strategy, there is a sense of a building crisis and the Americans are being watched in anticipation of their next move more closely than they have been scrutinised in many years.

Before he left South Korea, Pence also visited Panmunjom, where the 1953 armistice was signed at the end of the Korean War, as well as Camp Bonifas, a UN military compound near the Demilitarised Zone, set up to monitor the ceasefire that followed. It is an eerie echo from the past that Pence’s own father served in the war that divided the country. Edward Pence was awarded the Bronze Star on 15 April 1953 for heroic service. The vice-president proudly displays the medal, and a photo of his father receiving it, in his office. He is no doubt aware of the costs of a conflict in which an estimated 36,000 of his countrymen were killed.

Just over a thousand British soldiers also lost their lives in the Korean War after being sent to fight in a joint UN force. But it was far more deadly still for the peoples of the Korean Peninsula, killing more than a million people, including 400,000 troops for the People’s Volunteer Army, among whom was Mao Anying, the eldest son of Chairman Mao, the leader of the Communist Party of China and protector of the North.

History throws up strange parallels. When the Korean War began in 1950 it was understood to be the first serious test of the international system established after the Second World War. It is striking just how many of the same ingredients remain, including the identity of some of the main protagonists. On 25 June 1950, a border conflict between North and South Korea escalated into full-scale war when Kim Il-sung’s Korean People’s Army – backed by China, and with the tacit support of the Soviet Union – invaded the Republic of Korea in the south, claiming that it represented the legitimate government of all Korea. This is a claim that the regime of his grandson Kim Jong-un has not abandoned to this day.

Two days after the invasion, on 27 June, the UN Security Council voted to send a joint force, under General Douglas MacArthur of the US, the former supreme commander of Allied forces in the south-west Pacific area, to protect the sovereignty of the South and repel the invaders. Much more was at stake than the question of territorial integrity or preserving international law. By bringing the Americans into confrontation with the Chinese – and with the Russians seen to be the steering hand in the background – the conflict had all the ingredients for rapid escalation.

From the start, there were concerns that the Americans might overdo the brinkmanship, even under the cautious leadership of Harry Truman. Fears that the self-confident MacArthur would exceed his brief were confirmed when the UN forces pushed back into North Korea in October. In response, the Chinese Communists, who believed that MacArthur had designs on China itself, flooded across the Yalu River in their tens of thousands.

It was in the autumn of 1950 that the danger of another world war, this one involving nuclear weapons, reached its peak. On 28 November, after a grave reverse for the UN forces, MacArthur stated that the advent of 200,000 Chinese had created “an entirely new war”, with much higher stakes than before. Suddenly, the prospect that the US might resort to using an atomic bomb against the North Koreans, or even the Chinese forces, seemed plausible.

While the nuclear scare passed, the war rumbled on towards an ugly stalemate over the next three years. A temporary solution of sorts was found with the 1953 armistice. But there was no resolution to Korea’s frozen war. In a way that no other totalitarian state has managed, the North zipped itself into a hermetically sealed chamber, preserving a three-generation dictatorship that is both comically anachronistic and frighteningly modern in its missile technology.

***

Some of this complicated backstory was explained to Donald Trump by China’s president, Xi Jinping, during his recent visit to the United States. Trump – who had been pressuring China to do more to deal with the North Korean regime – appears to have been receptive to what he heard.

“After listening for ten minutes,” he said, “I realised it’s not so easy.”

This is the first critical test of the “new era in great-power relations” which Xi has been floating for a number of years, but Trump has now decided to put to the test. According to Trump’s most recent tweets, Beijing has continued to work with the US on the North Korea problem. He has welcomed its contribution but insisted that America’s own willingness to deal with the problem does not depend on China. In other words, there is no master plan being played out here, even if – as seems credible – America did hack North Korea’s latest missile launch to make it a damp squib.

The Trump administration is not creating the conditions for a new long game, building a fresh multilateral consensus to contain the North Korean threat. Instead, with a newfound sense of momentum serving as a tail wind, it senses a moment to “solve” one of the longest-running and most treacherous problems in international affairs. It has decided, at the very least, to severely clip the wings of Kim Jong-un’s regime. And in doing so, it has set out to demonstrate that when America speaks, it speaks with effect.

Like much current presidential policy, “the Trump doctrine” is being made on the hoof. Much of the hyperactivity of the past month or so was not scripted but emerged in response to overt challenges – beginning in Damascus and panning to Pyongyang – to the United States and the “red lines” it has laid down in the past. One foundation stone of Trump’s approach to the world is firmly in place, however: the willingness to reassert US military power with swift and decisive effect. The idea that the “America First” slogan implied anything resembling isolationism is crumbling. The growing sense that it does imply unsentimental and unvarnished power politics in the name of the US interest rather than multilateral niceties is closer to the truth.

Under Barack Obama, the US sought to withdraw from those areas in which he felt that the US had overstretched itself under his predecessor. Obama opted for a more rapier-like and cost-effective form of power projection. He drew down from formal military operations in Iraq and Afghanistan, while presiding over a huge uptick in drone warfare, cyber capabilities and selective but deadly use of special operations. Much of the full range of US power was submerged in various “secret wars”, and the diplomatic compass was reset to pivot east. This was because, as a legacy of the 9/11 attacks, national security was geared towards the containment of an elusive and amorphous enemy – various offshoots of the global jihad movement – that operated on the periphery of America’s radar.

But the real metrics of great power are those now on display off the coast of North Korea. For all the advances in drone technology, the missiles that cause the gravest threats to humanity are those on the scale that the North Korean regime is attempting to build. Trump’s test was one that a president of the United States would have to face sooner rather than later.

Not since Ronald Reagan has the US been so willing to engage in naked displays of its own military potency in quick succession – and seek to gather diplomatic yields from them as swiftly as possible. The past fortnight brought a missile attack on an airbase manned by the Assad regime – changing the tenor of US-Russian relations overnight – and the dropping of the so-called Moab (“mother of all bombs”) on an Isis affiliate in Afghanistan. The latter was a far cry from the “clear, hold, build” counterinsurgency operations in vogue half a decade ago. But it did fit with a campaign promise by the new president that he would “bomb the shit out of Isis” should the opportunity arise.

Does this fit into a wider pattern or constitute a new approach? The Trump administration is eager to leverage any opening that might have been created. In Seoul, Pence wasted no time in joining the dots: “the world witnessed the strength and resolve of our new president in actions taken in Syria and Afghanistan”. North Korea, he continued, “would do well not to test his resolve, or the strength of the armed forces of the United States in this region”.

It is the generals who have increasingly set the tone for Trump’s foreign policy. During the 2016 election campaign, he promised to give the Pentagon more leeway than it had under Obama to focus on “winning”. The new national security adviser, H R McMaster, and the defence secretary, General James Mattis, are now the steering hands.

Neither man has followed the rather crass and short-sighted fashion for running down diplomacy. Mattis once said that if the state department budget was cut, he would need more ammunition. McMaster is an urbane thinker who knows that the use of force must always be carefully calibrated and is just one tool in a continuum of factors. In this respect, it is a problem that so many jobs in the state department remain unfilled. Now that muscle has been flexed, the experienced negotiators and diplomats should be flooding through the door.

***

The policy of “strategic patience” was based on an understandable calculation. But, in hindsight, it does appear that North Korea has suffered from neglect. Mitchell B Reiss, one of the most experienced diplomats who led efforts on North Korea in the 1990s, notes that, despite unprecedented co-operation between the US and China in recent weeks, including open threats of economic pressure and military action, they were still unable to prevent North Korea from testing ballistic missiles on 16 April. Even though the missiles exploded immediately after lift off, “The failure of Washington and Beijing to stop the test in the first place has important implications for the Trump administration’s future policy options and for stability in north-east Asia.”

In Reiss’s view, it is “highly unlikely that the North can be cajoled, threatened or given incentives to surrender its nuclear weapons”. The uncomfortable truth is that “short of regime change, which could inflame the entire Korean Peninsula in war”, the US cannot halt the North’s nuclear weapons programme. But that does not mean there are no options. Slowing the pace and raising the costs would be “prudent steps”. More, too, could be done, Reiss says, to “interdict imports of sensitive technologies, to sanction Chinese and other nationals who act as purchasing agents for the nuclear and missile programmes, and to punish Chinese banks that help finance these programmes through so-called secondary sanctions”.

In the end, so much comes down to US-China relations. Could this be the basis for a reset and a new accommodation between Beijing and Washington? How much further is China willing to go to use its leverage on the North, which depends on it for energy and food? And how patient will the Trump administration be if its new strategy does not yield tangible results of the sort that are sometimes elusive in the long and often open-ended game of deterrence? 

John Bew is a New Statesman contributing writer and the author of “Realpolitik: a History” (Oxford University Press)

John Bew is a New Statesman contributing writer. His most recent book, Realpolitik: A History, is published by Oxford University Press.

This article first appeared in the 20 April 2017 issue of the New Statesman, May's gamble

0800 7318496