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

ELENA HEATHERWICK FOR NEW STATESMAN
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The maid slaves: how wealthy visitors to Britain trap servants in their homes

Each year 17,000 domestic workers accompany wealthy families to the UK – helped by a special visa regime that campaigners call a “recipe for slavery”.

It was 6am on 15 August 2014. Amara should have escaped an hour earlier; she was running out of time. Had everything gone to plan it would have been easy to slip out of the house in the affluent Home Counties town of Ascot unnoticed, as her employers were away, but Amara had made a misjudgement. She had asked her fellow maid if she wanted to flee, too, and now her terrified colleague was threatening to call their boss, an Emirati diplomat, and inform on her.

A Facebook message popped up on her tablet: she had five minutes until her rescuer would give up and drive home, leaving her stranded. Amara would have to abandon her suitcase. She tucked her most precious possessions – a photocopy of her passport, her employment contract and her tablet – down the front of her pyjamas. Then she sneaked downstairs and out through the front door.

Her friend’s car was parked a few hundred metres down the road. Amara jumped in and they sped past the gated houses and through the tree-lined lanes of Ascot towards London, not quite 30 miles away. Amara felt a rush of elation, followed by the familiar pang of apprehension. After almost a year in captivity she was free, but she had nothing. No money, no plan, not even – and this was the small, humiliating detail she would always mention when she later told her story – a change of underwear. It was the end of ten months of “hell”, labouring under slave-like conditions as a domestic worker, and the start of a new ordeal as an undocumented migrant in the UK.

Amara is 40 years old and about 5ft tall. She used to be chubby but she never regained the weight she lost eating only her employer’s leftovers, and now her waist looks tiny in her belted trench coat. She dresses with care, her long hair set in soft 1950s waves one day and worn straight the next, with a smudge of grey eyeshadow and a slick of berry lipstick to match her handbag. Out of habit, and a residual fear of being caught and deported, she mostly speaks in a whisper. When we met in London in October, Amara asked that, for her safety, I give a false name and not reveal her nationality.

She grew up in south-east Asia, one of six siblings supported by money sent home each month by her mother, who had migrated to Macau, a wealthy special administrative region of China, to clean for rich families. After leaving school, she studied pharmacy at a prestigious private university, then transferred to a cheaper midwifery course when the fees became unaffordable. It was hard to find work as a midwife. It was often difficult to find any job, but sometimes she worked as a secretary. Her husband, a van driver, was often unemployed, too.

They had three children and lived with her in-laws to save money. Amara says they were neither rich nor poor, by which she means they could afford three meals a day but little else. When her son was about to turn 16, she realised that the only way she could afford to pay his college fees was to work abroad. (Her two daughters were 13 and six.) Amara’s mother warned her that the life of a domestic worker was brutal, but she shrugged off such concerns. “I said that, for me, if you just think of your children, everything will be easy. You can do anything for your children.” Now ­Amara concedes that she was only half right. Sometimes, thoughts of her children were the only thing that kept her going.

Things looked promising initially. She can’t remember exactly how much, but she had paid several thousand dollars to an ­employment agency for her medical clearances and to complete a training course in domestic work. She and her family were thrilled when she was offered a post at a royal palace in the United Arab Emirates, and even more so when her employers pushed back her start date by a month but paid her anyway. To celebrate her first monthly pay cheque of 1,600 dirhams (about £350), ­Amara took her children to their favourite restaurant, McDonald’s.

When she finally left her home country in September 2013, her husband and children accompanied her to the airport. The children were distracted by the promise of another McDonald’s meal on the way home, and Amara’s sadness at saying goodbye was tempered by the excitement of her first ever plane journey and the feeling that her plans were finally working out.

The flight landed in Dubai at 4am, and Amara and another maid were met by a driver. As soon as they were in the car, the driver took away their passports. Then he drove them to their temporary lodgings, where they were shown to a room with a double bed, a television and a small bathroom. There were security guards stationed at the entrance to the building who barred the two maids from going outside. Their lack of freedom seemed strange, but they were comfortable enough. Someone delivered three meals a day, and they spent their time watching television and thinking, over and over again, “We’re so lucky!”

After four days, Amara was taken to her employer’s home. It was not, as she’d been expecting from her contract, a royal household, but even so she’d never seen anywhere so grand. “It’s like a palace,” she says of her boss’s home. There were two vast rooms for entertaining, decorated with gold furnishings. Upstairs were five large bedroom suites, each with its own bathroom and reception area. A swimming pool was being dug outside. Amara thought the garden was enormous: whichever window she looked out of she could not see where the landscaped lawn ended and the rest of Dubai began. But she could not be certain – because for the ten months she lived with the family in the United Arab Emirates she was forbidden from going outside.

“Sometimes people think that if you’re living in a huge, nice house, even if you’re a household worker you’re lucky, because your employers are rich. But they don’t know what’s happening inside the house,” she told me.

Usually she worked from 6am until 1am or 2am. Even after she had gone to sleep, on the bare floor of the servants’ quarters, she would often be shouted for to fetch a glass of water or run some other errand, and so Amara started wearing her uniform through the night. Once a month, a driver was despatched to buy phone cards and the household staff were allowed to call their families to confirm that their salaries had been remitted; but otherwise she could not speak to her husband or children.

The abuse grew steadily worse, particularly after another servant was taken away by the police and sent home under mysterious circumstances. Her boss, whom Amara still calls “Madam”, started cutting down on the number of meals the remaining two maids were given, until eventually they received no food at all and had to scavenge the leftovers from the family’s dinners. Madam began cutting Amara’s salary as punishment for the smallest infractions, and after nine months she stopped paying her. When Madam’s husband was home he was a moderating influence and Madam would speak to Amara politely and without raising her voice, but he travelled often. In his absence, Madam’s moods grew increasingly volatile. She shouted at Amara, hit her and threw clothes and drinking glasses at her.

When Amara was told in the summer of 2014 that she was accompanying the ­family to the UK, she prayed that her visa would be rejected so that she would be able to stay behind and get some rest. But at the last minute her paperwork came through and Amara accompanied the family on a private jet to London.

***

In 2015, the UK granted 17,352 visas for domestic workers – cleaners, nannies, drivers, cooks, and so on – to accompany wealthy families visiting the UK. The largest number of domestic workers, more than 8,000, were originally from the Philippines, followed by Indians and Indonesians. According to the Home ­Office, roughly three-quarters of them were working for households from the Gulf, which often travel to Britain for business, shopping and medical treatment, or to escape the Middle East’s sweltering summer heat.

Until 2012, household staff were granted visa terms similar to those for other migrant workers: they were allowed to change employer, but not job sector; they could be accompanied by their partner or children; and after five years in the UK they were permitted to apply for indefinite leave to ­remain, meaning they could settle in Britain permanently.

But five years ago, the coalition government introduced new regulations for overseas domestic workers (ODWs), ostensibly to try to reduce net migration. A 2012 Home Office impact-assessment document mooted the idea of abolishing the ODW visa altogether, so that visiting families would have to recruit household staff from within the UK.

Families might want to bring their domestic staff with them for benign reasons, such as their children being attached to their nanny. But sometimes employers choose to hire servants overseas because British workers would never accept the gruelling conditions under which they work. This, at least, was the conclusion drawn by one employment tribunal in 2015, which ruled in favour of an Indian maid who took legal action against her bosses over religious discrimination, unfair dismissal and illegal working conditions. The tribunal concluded that the only reason the employers had made no effort to recruit a maid in Britain was that they “wanted a servant in the Indian style. They wanted someone who would be not merely of service but servile, who would not be aware of United Kingdom employment rights . . .”

The ODW visa was not scrapped; the Home Office document expressed concern that doing so could “deter wealthy visitors” to the UK. (The US and a number of European countries also have special visa schemes for domestic workers accompanying visiting families, but the rules vary.) Instead, under a new system introduced in April 2012, ODWs were permitted to stay in the UK for no longer than six months. They could not be accompanied by their immediate family or apply for indefinite leave to remain. And, crucially, they were prevented from changing employer.

For domestic workers employed by Gulf households the new rules were familiar: they mirrored the widely criticised kafala, or sponsorship, system, which is common among the oil-rich Arab states. Kafala, which prevents migrant workers from leaving abusive employers without losing the right to work, has contributed to the widespread abuse and exploitation of financially desperate labourers and domestic workers across the region. No migrant workers in the UK other than ODWs faced such restrictions. In October, I met Father Aodh O’Halpin, a missionary now based in London who has campaigned for domestic workers’ rights for decades. He described the UK’s ODW visa rules as “a recipe for slavery”.

The change of rules had an alarming and almost immediate effect. Research by Kalayaan, a small London-based charity that supports overseas domestic workers in the UK, suggests that rates of abuse shot up. Among workers who registered with the charity between 2012 and 2015, 81 per cent of those on the new tied visas were given no time off, against 66 per cent of those still on the old system. Two-thirds of workers on tied visas were barred from leaving the house freely (against 41 per cent with non-tied visas), more than 30 per cent were not paid for their work (against 11 per cent) and 14 per cent reported physical abuse (against 9 per cent). Kalayaan staff identified 64 per cent of the ODWs on tied visas as victims of trafficking, meaning that their employers forced or coerced them into coming to the UK with the intention of exploiting them.

Even so, those campaigning for domestic worker rights in 2015 had some cause for optimism. The new ODW visa had a negligible impact on migration numbers. This was unsurprising, as even at their peak in 2012 ODWs and their dependants accounted for just 0.7 per cent of net migration. More significantly, the Conservative government had pledged to give priority to the abolition of modern slavery and human trafficking. In March 2015 parliament passed the landmark Modern Slavery Act, and the government committed to an independent review of the ODW visa to determine if its immigration rules were compatible with efforts to tackle slavery.

The review, by James Ewins QC, was published in December 2015 and its findings were unambiguous. “The existence of a tie to a specific employer and the absence of a universal right to change employer and apply for extensions of the visa are incompatible with the reasonable protection of overseas domestic workers while in the UK,” he concluded. He recommended that household workers be allowed to change employers freely and extend their visas for up to two and a half years, a period he described as the “minimum” required. Abused domestic workers “need the freedom to change employment, which in turn requires that they stay for long enough to be able to find safe alternative employment”, Ewins wrote.

Yet the subsequent bill for the Immigration Act 2016 rejected many of Ewins’s recommendations. It granted ODWs the right to change employer, but did not allow them to extend their visa beyond six months. Campaigners argue that this concession is meaningless, because once abused workers have summoned up the courage and the means to leave their employers, most will find it impossible to find decent, short-term work before their visa expires.

I asked the Home Office to respond to these points. A spokesman said the government was introducing additional reforms to protect ODWs, including mandatory information sessions to inform workers of their rights, and pointed to special provisions and support for victims of slavery and human trafficking.

Under the new act, ODWs who are identified as having been enslaved or trafficked – a decision that follows a long and arduous process, known as the National Referral Mechanism (NRM) – can be granted a visa of up to two years, provided they can prove they are able to support themselves financially in the UK. Ewins’s report and rights campaigners have argued that this does not do enough to protect domestic workers.

For a start, many forms of abuse commonly experienced by household staff fall short of legal definitions of trafficking or slavery. “Do we need to be raped, to be beaten, to be starved to death to access protection?” Marissa Begonia, an overseas domestic worker from the Philippines and a rights campaigner, asked me.

Second, many abused domestic workers are fearful of seeking referral to the NRM. They know that if their claim is rejected they will be sent home. Emily-Anna Gibbs is a solicitor and co-founder of the independent Anti-Trafficking and Labour Exploitation Unit (ATLEU), and often represents domestic workers. She told me that the NRM “provides no escape clause for the thousands of overseas domestic workers who are trafficked and are faced with the choice: do I escape and take a load of risk ­going through the NRM, which I know very little about, getting legal advice which I fear I won’t understand and risking my livelihood? Do I take that risk? Or do I sit tight, suffer this exploitation, continue to do so because I have to pay the school fees for my kids’ education next month?” As a result, she believes, many domestic workers continue to suffer in secret.

All the advocacy groups and lawyers I spoke to agreed that the best way to protect domestic workers from being enslaved or trafficked, and the only way to empower them to flee abuse, is to allow them to extend their visas and switch employers freely. “It’s about the power relations: they can negotiate, because they can ultimately withdraw their labour,” said Kate Roberts, the head of the Human Trafficking Foundation. “If they can’t do that, there’s very little they can do to challenge any mistreatment, which can worsen until it reaches the point of exploitation – including slavery.”

***

At UK immigration control, Amara saw her passport for the last time. Her boss handed it to her in the customs queue, and then confiscated it again shortly afterwards. From the airport, she travelled with the family to the house in Ascot. No one told her where she was going, so she became disorientated. Madam’s ten-year-old asked Amara where she thought she was and then laughed when Amara replied: “London.” “We’re not in London, stupid. We’re in England,” the girl said.

In Ascot, Amara shared a bedroom with the other maid. The room, which had two single beds and an en suite shower, doubled as a laundry room and extra storage space for the family. Despite the slight improvement in her sleeping arrangements, Amara’s working conditions deteriorated. The family preferred staying in a central London hotel to being at their Ascot residence, so Amara would often clean the house in the morning before being driven to the hotel to wash and iron her bosses’ clothes, returning late at night. She was not paid, and still could not contact her family.

Madam’s behaviour became more menacing. She became convinced that Amara was a witch. “She says she got ill just because I looked at her food. She said, ‘You will pay for this. You will pay for everything you’ve done to me when we get back to Dubai,’” Amara told me. Afraid that Madam might seriously hurt, or even kill, her, she began planning her escape. She had been working for the family in England for 15 days and knew she had a week until they were due to return to the UAE.

Amara was able to run away thanks to a few bits of luck. The first was that before her household colleague in Dubai was sent home, she gave Amara her tablet computer and instructed her to hide it. The second was that Amara decided to risk asking one of Madam’s daughters for the wifi password at the Ascot house, even though she was “99.9 per cent certain” the teenager would not give it to her. The gamble paid off.

When her employers were staying in London it was not hard for Amara to leave the house, but with no money, no passport and no idea of where to go next she knew she couldn’t get far on her own. Her final stroke of good fortune was that she knew one person in the UK, an old friend from her home country who was working as an undocumented domestic worker in London and whom she contacted on Facebook. As Amara was still not sure where she lived, the friend instructed her to memorise the road signs when she was driven from London to her employer’s house, which she did.

After picking her up early that summer morning in 2014, the friend let Amara stay with her for a month, lent her clothes and helped her find part-time, casual work, often covering for other people’s sick leave or holidays.

Amara’s former employers appear not to have tried to track her down. A few months after leaving, she managed to get in touch with the maid who had worked with her in Ascot. She was surprised to hear from Amara, because she had been told by Madam that she was in prison. That woman is still working for the family in Dubai.

For over two years, Amara managed to scrape a living in London. As cleaning work was poorly paid and the hours unpredictable, she taught herself cake-making and sugarcraft by watching YouTube videos and began supplementing her income by selling cakes. She showed me pictures on her phone of some of her past creations: a Thomas the Tank Engine birthday cake; a sponge expertly decorated with an icing baby for a new arrival; another cake draped in a sweet Australian flag for a leaving party. Now that she is able to, she calls her husband and children daily and although, at ten, her youngest is too old for lullabies, Amara sings to her every night before she goes to bed. In her absence, her husband and her in-laws have been raising her children. She has not seen them since they waved goodbye to her at the airport, three and a half years ago.

Amara imposed a strict budget on herself, spending no more than £10 to £20 a week on food, toiletries and clothes, which allowed her to send roughly £200 a month back home. Her family had no idea how dearly Amara paid for these monthly remittances. To avoid upsetting or worrying them, she has never told them that she was abused, that she ran away from her employer, or that she is now undocumented.

Amara might have continued living underground in London indefinitely, ­devoting herself wholly to her family and hoping that with enough hard work she could distract herself from the gnawing fear of being caught and expelled from the UK. But a few weeks before we met, a shock event toppled her precarious new equilibrium. The boarding house in which her rescuer and friend was living was raided by the UK Border Agency, and her closest confidante was deported. Heartbroken and shaken, Amara realised she needed to address her legal status before she suffered the same misfortune.

***

Abused domestic servants do not fit the popular image of slavery. They sometimes arrive in the UK in private jets, and are chauffeured to elegant townhouses in Mayfair, diplomatic residences, sprawling country piles or five-star hotels. The domestic worker and campaigner Marissa Begonia described some of her experiences to me as being “caged in paradise”.

Domestic workers are often hidden in plain sight. Many of them gather every Sunday morning at the union offices of Unite in central London for a meeting of Justice for Domestic Workers, or J4DW – a campaign group that often starts its sessions with a singing and aerobics class to shake off another exhausting week’s work.

On the morning I attended, the first arrivals pushed the chairs and tables against the walls of a conference room, muttering about the bad habits of “corporates” as they efficiently cleared the dance floor of sugar sachets and scraps of notepaper. One woman rushed to change out of her uniform, having just finished an early-morning shift, and the others began stretching to upbeat pop music. The mood lifted quickly, rising to defiance when the group practised a song that I initially mistook as a straight rendition of Gloria Gaynor’s “I Will Survive”, until I caught the lyrics:

 

At first I was afraid, I was petrified

Hiding and running from it all, justice not on my side

But then I spent so many nights, thinking how they did me wrong

So I grew strong,

I learned how to move along.

Then I found you, a group of hope . . .

 

J4DW was founded in 2009 and is run by domestic workers, many of whom spend their only day off volunteering for the group. It is lobbying the government to change British visa regulations and offers its membership of more than 1,200 workers a range of support services, pointing them towards legal advice, providing courses in IT, English and employment rights, and occasionally organising rescue missions for those held captive by abusive employers.

Its weekly gatherings offer an opportunity for people living far from home, in a country whose language they might barely speak, to make friends. Even for those who are treated well by their employers, life is tough. Women spoke to me about unfaithful husbands and marriages strained by years spent apart, or their feelings of guilt and sadness at raising other people’s babies while their own children grew up without them.

Even so, the atmosphere at the meetings is warm, friendly and stubbornly optimistic. One woman cried as she shared the news of her recent cancer diagnosis, and a group closed around her to urge her to stay positive, to keep praying and to speak to another member who had proudly described herself to me earlier as a “Stage IV cancer survivor”. Amara first visited J4DW days after her friend was deported. “They gave me my confidence back,” she said.

Marissa Begonia, the 46-year-old mother-of-three who is also J4DW’s co-ordinator, seemed subdued when we first met. “I Will Survive” rehearsals could be heard ­taking place in the neighbouring room as she coached Sarah (not her real name) for a job interview. Together, they hunched over ­Begonia’s smartphone to plan the journey to the interview, then she instructed Sarah on how to negotiate reasonable working conditions by demanding holidays and days off, overtime pay, a daily rest period and a wage of at least £8 an hour.

Sarah, a Filipina, was staying temporarily with Begonia, having been rescued by a group of J4DW members from a house in Kensington, central London, a few weeks earlier. She is 36 years old but looks and sounds much younger, with a high, hesitant voice and a permanent uncertain smile. At a playground in Hyde Park she had met and befriended a J4DW member, who put her in touch with the group on Facebook after Sarah confided that she was earning just $400 (about £320) a month and working around the clock, with no days off. She had no winter clothes and because her employers rarely provided her with food, she subsisted mainly on coffee and the occasional biscuit. She described her travel to the UK from Dubai as a “suicide run”: her salary was too low to support her family, but what else could she do?

Despite her ordeal, Sarah believed that she was unlikely to be recognised as a victim of trafficking and did not want to be referred to the NRM in case her claim was rejected and she was deported. Her six-month visa would expire in two months, but she did not feel she could go back to the Philippines yet. She still needed to save enough capital for her siblings to start their own small business and for their children to go to college. As she saw it, her only option was to work in the UK illegally.

After Sarah left for her interview, Begonia sighed and told me that she was unlikely to heed her advice. She thought that Sarah, like many other ODWs, would be desperate to accept any work offered, and employers often realise that undocumented workers are unlikely to complain if they are exploited. Begonia was right. In the end, Sarah was offered £350 a week to work 15-hour days cooking, cleaning and looking after two children. She would have Sundays off, but would not receive holiday pay. Even if the employers, a Pakistani family living in London, stuck to the agreement and did not extend her working hours, she would in effect be paid £3.88 an hour (the minimum wage is £7.20). “I hope they don’t treat me like a robot,” Sarah said to me, when we met again a few hours after her interview.

J4DW’s members are almost all women, but they follow many different religions and are ethnically diverse. A large number are from the Philippines, but some are from other countries in south-east Asia, or sub-Saharan Africa. Some have been in the UK for years and now have British citizenship; others are working illegally. Many have harrowing stories to tell of abuse and ill-treatment, and although the details vary they are linked by a common thread: every woman had torn herself away from her loved ones in the hope of giving them a better life, and no amount of hardship had persuaded them to abandon that goal.

Begonia was no exception. She was exhausted. Sundays were her only full day off, and because her employers had a new baby she had started working 12-hour days. She would normally have contested this change, but her father had heart problems and while she had to worry about his medical bills she could not afford to risk her job.

She was used to having to pick her battles, even if that wasn’t something that came easily to her. She described herself as a “natural fighter”. She told me the story of how an employer in Hong Kong had attempted to sexually assault her. Begonia managed to escape to her room and barricaded herself in while she packed her belongings and wrote her resignation letter. Then she crept outside to hide all the kitchen knives bar one. “He’s big, and I’m so tiny. I give the resignation letter and my knife is like this,” she said, holding up an imaginary weapon. “I said, ‘Sir, I’m resigning with effect today because you’re a sex maniac.’”

Begonia first arrived in the UK in 2004, and five years later, having escaped from an abusive employer, she helped found J4DW. Her children now live with her in the UK and she has acquired British citizenship. She has been the group’s co-ordinator since 2012, and some of its members call her “auntie” as a mark of respect. She spends much of her time offering practical help for other workers, arranging donations of clothes for women in need, liaising with the police and angry ex-employers and, sometimes, hammering on strangers’ doors to extract servants trapped inside. She has also represented the group in parliament and at party conferences, and often speaks at forums for international workers. Begonia wants domestic workers to appreciate the bigger picture and to join her in seeking greater social and political recognition for those who are in their situation.

“We look after families, the building blocks of society,” she said, but people “don’t value domestic work as work and they don’t really respect domestic workers as workers”. She urges J4DW members to view their struggle as part of a broader fight against low pay and poverty in the UK. At one meeting she encouraged the women to see the recent Ken Loach film I, Daniel Blake to help them understand the problems faced by “vulnerable British workers”. “We are affected if British workers are affected,” she told the group.

As Begonia described her mission to me she grew more animated, her tiredness ­temporarily displaced by anger and frustration. Abused domestic workers have so few avenues for legal redress that J4DW can rarely offer much more than emergency ­assistance, moral support and help with finding new work.

She wants to give members of J4DW the confidence to join demonstrations and speak out in public, and many of them do – if they can. Yet domestic workers who have overstayed their visa, or who are stuck in exploitative jobs, cannot campaign for their own rights.

Begonia says that when she speaks in public she often reminds her audience of this, telling them: “I am a perfect example of how slavery could end. It has to end; it will end. But domestic workers need these rights. That’s what I had.”

***

The day after her friend’s boarding house was raided and she was deported, Amara visited Kalayaan. The charity determined that her trafficking case was sufficiently strong to refer her to the National Referral Mechanism. She is now waiting for a “conclusive grounds decision”, which would determine whether she can be formally recognised as a victim of trafficking and might thereby be eligible for a two-year visa. If her trafficking claim is rejected, she will have to leave the UK.

Amara does not know how long she will have to wait: according to Kate Roberts of the Human Trafficking Foundation, those referred to the NRM can be left waiting for anything between 45 days and several years for a decision. Nor does Amara know how good her chance of success is. The government does not publish data on the number of overseas domestic workers who are referred to the NRM and are formally recognised as victims of trafficking.

Amara has little grounds for hope that her former employers will ever be brought to justice. As diplomats, they are immune from criminal jurisdiction. In February 2015 a Filipina national identified in court documents as Ms C Reyes, who had been trafficked to the UK by Saudi diplomats, took her former employers to a tribunal, claiming racial discrimination, harassment and payment of less than the minimum wage. She lost the case. The Court of Appeal judgment acknowledged that “this may seem unfair to Ms Reyes”, but, it argued, “sometimes the apparent unfairness to an individual is outweighed by the harm that would be caused by a failure to give effect to diplomatic immunity in circumstances such as those that have arisen in this case”. (The case is under appeal at the Supreme Court, and will be heard in May.)

While she is under the NRM, Amara cannot be deported, which she considers a small relief. To distract herself from the agonising wait, she is spending as much time as possible at J4DW. She often participates in the singing and dancing sessions, and takes English and IT classes – anything to keep busy. When she speaks to her family on FaceTime every evening, her ten-year-old daughter becomes tearful and asks when she is going to come home. Amara warns her that it could be a little while yet.

“I’m praying the Home Office will give a positive conclusion so I can apply for a two-year visa,” she said. “I don’t want to stay here for ten years. What I want is to be here for two years, just so I can save. So at least I can have something when I get back to my house.”

Sophie McBain is an NS contributing writer

Sophie McBain is a freelance writer based in Cairo. She was previously an assistant editor at the New Statesman.

This article first appeared in the 09 February 2016 issue of the New Statesman, The May Doctrine