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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Donald Trump and the age of rage

What the rise of Trump tells us about our failing politics.

I met Donald Trump at a party in midtown Manhattan hosted by Dominick Dunne, the novelist and Vanity Fair journalist. It was October 1999 and the party was being held to celebrate the launch of Dunne’s new book, The Way We Lived Then, which is about old Hollywood (the title is a nod to Anthony Trollope).

Trump wasn’t there to talk to people, of course, but to be photographed, an ambition at which he fully succeeded, significantly helped by the presence of his striking new girlfriend, Melania Knauss (now his third wife). Trump’s urgent need to be noticed manifested itself as a kind of weird social radiance. What is interesting, from my point of view, is that I’ve forgotten the other guests at that party, many of equal ­celebrity, far greater achievement and much more ­interest. Trump registers with people, including, to my surprise, with me.

Those strands of Trump’s personality have served his presidential ambitions well. He leaves an impression, his central point of difference from the amorphous Beltway professionals whom he ridicules. “Ghastly” or “vulgar” aren’t really criticisms in Trump’s world-view; “forgettable”, however, is the bottom of the moral scale. This instantly creates asymmetries for his opponents: it is difficult to inflict reputational damage on a politician who neither needs nor craves respectability.

But personal magnetism – I cannot bring myself to type “charisma” – does not explain the Trump phenomenon. He is the most spectacular beneficiary of something far wider and more international: the perception that politics as we know it is failing. Running against Washington is as old as Washington, but never has it looked quite like this.

How do you like anti-politics now? For it is anti-politics – the contempt for the “establishment” and the convenient flight from serious debate about how it could better exercise power – that has taken Donald Trump to within striking distance of a shot at the White House. And as the search for the right person or plan to stop him becomes frantic (the responsibility is America’s, the concern is global), we should ask the wider questions. What if intelligent people – pundits and voters alike – had stood up more bravely for the political mainstream, pointing out the necessity of compromise, pragmatism and disappointment? Strands of the Republican Party now regret the visceral attacks they sanctioned against President Obama. The party unleashed a demotic rage that subsequently turned against its own establishment. The analogy applies far beyond the Republican Party: is anti-politics a parlour game that has got out of control?

Ironically, the ascent of the establishment as a focus of hatred and political anger has coincided with the decline of the establishment as an instrument of power. Think of the weakness of the establishment currently governing the Republicans in America. It has proved notably useless at doing all the things establishments are supposed to do: manipulate power behind the scenes, undermine mavericks and keep the show on the road.

This failure seems especially out of character for the Republicans. Even allowing for the insanity of its Tea Party strands, you would have expected the GOP – if its “establishment” was what we imagined it to be – to have snuffed out this Trump nonsense, probably during a grouse shoot in South Carolina, or over a few holes of golf at Augusta National in Georgia. Isn’t power what these people do? No longer, it seems, except in our imagination. So why are we so sure that the establishment, which can’t even cough up a decent candidate, is the power pulling the strings? I am beginning to wonder if the establishment’s new role, far from the exercise of unchecked power, is to provide a convenient palliative sideshow. So long as we insist that the establishment is messing up the world, then we won’t have to face up to tangible and worsening political problems and our reluctance to debate them seriously.

***

Donald Trump is both the em­bodiment of political failure and the result of political failure – or perceived political failure. He represents political failure because he has accelerated the descent of political discourse: “They’re rapists, build walls, ban Muslims.” He is the result of political failure because he taps in to a deep, subliminal anger: the conviction that “the system” has betrayed and abandoned the people.

Why do so many people feel this way, to the extent that even Trump (and other preposterous candidates) become palatable? Despite widespread political correctness, there is one group that it is perfectly legitimate to despise: politicians. When I worked for a newspaper, I was surprised one day to hear a reporter, usually so fair and mild-mannered, describe her hatred and contempt for politicians – “the worst people, just disgusting”. This is the kind of comment you hear from normally civilised and balanced people, who usually don’t know any politicians personally, but feel quite certain of the truth of their conviction.

In Britain, the parliamentary expenses scandal, though indefensible, was not the cause of this contempt, but rather its consequence. Given the strength of the underlying hatred, an appropriate story was always going to come along that allowed our contempt to be channelled into ridicule. I’ve seen news stories operate along the same lines in professional sport. When a manager or team has become unpopular with the fans, an event or “error” will act as a lightning rod for general ill-feeling. Usually the tipping point is quite routine; people get away with much worse when their stock is high.

Why are politicians and the “establishment” so despised? The new populism is partly a delayed consequence of the end of deference, in part fuelled by the emergence, especially on social media, of a strong, hard-edged and almost daily picture of “the will of the people”. Maybe this is what real democracy looks like?

Economics is also central to the “age of rage”. In the loosest terms – except among the very poorest – even “late capitalism” has continued to raise absolute living standards, albeit increasingly slowly. But few people judge their wealth according to absolute living standards. Wealth is perceived as relative to something else: relative to the past, relative to others (especially those inside “the establishment”) and, crucially, relative to individuals’ own expectations.

By those criteria, most people feel much poorer. The political class itself is the target of these economic frustrations, exacerbated by the financial crisis, even though politics is far from a complete explanation.

Second, there is a sense that politics has “failed” at ground level. This has two deep causes, which, taken together, create a significant credibility gap. First, as politics has been professionalised, its practitioners have become better at knowing what to say to get elected. Whatever their other failings, none of us can doubt that politicians spend more time than ever working out what the electorate wants, and devote greater energy towards trying to suggest that they know how to deliver it.

Having professionalised electoral messaging, politicians simultaneously professionalised avoiding controversy once in power. The degeneration of the political interview into unlistenable banalities is only one side of the coin. The flipside is the gaffe-hungry media, encouraged by an anti-politics sentiment in the electorate. The “gotcha” culture of debate doesn’t make politicians accountable, it makes them evasive.

The continual threat of being “caught out” saying the wrong thing – or saying ­anything – coexists with the perpetual expectation that politicians will be saying something at all times. We have drifted towards the assumption that politicians will speak in public non-stop, yet without taking any risks: the definition of a boring conversation. Trump’s ghastly voice seems fresh to so many people because he isn’t schooled in this tradition.

Professional political strategy clings to the notion that any vacuum creates space for an opposition advance. I think they’re wrong, and that it is impossible for politicians to have interesting and important things to say on the hour, every day. My view, in contrast, is that politicians devalue their own words by printing too many of them. But would they do it if the electorate didn’t expect it?

***

The ultra-professionalisation of politics has coincided with a huge crunch on the state’s capacity to expand. A simplistic history of politics in the second half of the 20th century would show parties winning power by handing out an ever-expanding range of goodies. Today, however, that ­arrangement is pincered from three sides: an ageing population, burgeoning expectations, and the weight of existing commitments to taxpayers, such as pensions. So, the central challenge facing overstretched liberal democracies is obvious: people want more services and benefits than they want to pay for. (Evidence that voters prefer not to focus on this contradiction lies in the remarkable success of Bernie Sanders, who promises more of everything without explaining how to pay for it. Both the Trump and the Sanders campaigns channel political disenchantment, but they exploit the feeling in opposite ways.)

For governments, however, a credibility deficit accumulates over the long term. And even quite effective administrations, as a result, leave the impression of significant underachievement. In other words, just when politicians have professionalised the art of saying the “right” thing, they have found it harder than ever to get things done in office. As with living standards, it is this deficit – the gap between political promises and governmental performance – that is causing problems, not the performance alone. Are today’s governments really worse than some of those gone? If so, when exactly were these exceptional governments of the past? These questions, intriguing as they are, do not figure in how people think.

How can the political class narrow the credibility gap? The tempting answer is to suggest providing the kind of sparkling, error-free government that has never existed and never will exist. The other problem, revising improbable expectations, at least might be achieved. In the ultra-professional era, political parties have suffered from a kind of prisoner’s dilemma: if, despite the long-term problem of credibility, they don’t play the media-friendly game of promises and button-pushing, someone else will.

After all, what does the alternative look like? “You can’t have this, lower your expectations, things are going to be hard”: it’s easy to see why politicians don’t relish saying these things, even when they’re true. The whole process that has led to today’s political disenchantment is all too rational: rational politicians coming up with rational avoidance strategies for problems that may not be soluble. Haven’t we, the electorate, played a part in that process, too?

Domestic frustrations are compounded by threats emanating from abroad. Hyper-terrorism, globalisation and migration on an unprecedented scale are huge problems and challenges with no obvious solutions. Donald Trump has exploited fears on both counts with crass answers. How much harder it is to turn complex approaches to the two problems into easy soundbites.

When I was living in New York in the late 1990s, the Clintons seemed to represent a great deal of what was wrong with politics. Ethically they hovered somewhere between dodgy and outright corrupt. Their personal relationship seemed an extension of political lobbying, more an alliance than a marriage; politically they told us how much they cared, rather than showing it. Bill had the partially redeeming quality of charm. Hillary had a talking-clock voice and predictable opinions – her 1996 book, It Takes a Village, was beyond parody – without Bill’s knowing wink.

And now? If she is up against Trump in November, I will happily stuff envelopes and campaign for her. Whatever it takes. The nature of my U-turn says everything about Trump: nothing about Hillary, whose reputation has become even more tarnished and whose political voice is more jaded. If she must be the future, we can be in no doubt about the impoverishment of the choice.

There is a view that a win for Hillary, and the restoration of competent (but cynical) middle-ground politics, will show the hollowness of anti-politics as a movement – a frenzy that won’t survive the cold rationality of the ballot box. This opinion holds that it is parties that have gone nuts, not the people. “This is not the revolt of the public against the party leadership,” argued Philip Collins in the Times. “It is the revolt of the party activists against the public.”

Yet the view that a Hillary win will see predictable centrism safely restored feels wide of the mark. I doubt a simple reprisal of Clinton-Blairism (which Daniel Finkelstein defined as the idea that it is “possible to do everything without upsetting anybody”) can get us out of this hole. Trump taps in to something frightening. If it’s defeated this time, it will still come back, even if the man will not. Until the deficit of political credibility is reduced, the demotic potential of the populist “outsider” will remain.

And next time I’m pretty sure it will be someone nastier than Donald Trump. The need is to find a better Hillary Clinton. That will only get harder if intelligent people go on paying lip-service to anti-politics. There are always establishments. The important question is how good they are.

Ed Smith is a contributing writer for the New Statesman

Ed Smith is a journalist and author, most recently of Luck. He is a former professional cricketer and played for both Middlesex and England.

This article first appeared in the 14 April 2016 issue of the New Statesman, The making of a monster