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

Photo: Hans-Christian Plambeck
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The learning machine: Angela Merkel

Her mentor Helmut Kohl called her his assassin. She is ruthless with those who betray her. She is also now being described as the leader of the free world. So, who is the German chancellor and what’s next for her?

World news these days is dominated by posturing tough guys – Vladimir ­Putin, Donald Trump, Recep Tayyip Erdogan. Amid all the pose and swagger, one politician stands out. Quiet and understated, she is now the West’s longest-serving leader. No tweets, no gossip, no hissy fits or saucy photos: this is Angela Merkel, chancellor of Germany since 2005, who will be seeking a fourth term in the elections this September. With the German economy strong and the refugee crisis abating, she is favourite to win once again.

Merkel’s unshowy style has made it easy to overlook her international prominence. But now, in the summer of 2017, with Trump’s United States turning in on itself, the transatlantic alliance in the balance, the European project in doubt, British politics upended and Russia at loggerheads with the West, Merkel has become the fulcrum of the international system. Not everyone likes her, but niemand kann um sie herum: nobody can get around her. Not Theresa May, not Trump – not even Putin.

This week, on 7 and 8 July, she hosts the G20 summit in Hamburg, where Trump will encounter Putin for the first time in a tête-à-tête stage-managed by Merkel. Yet Germany’s quiet strongwoman remains an enigma. Where did she come from? What motivates her? What does she want? And where is she going?

The eldest of three children, Angela Merkel was born in Hamburg, in the Federal Republic of Germany, in 1954. Her mother, Herlind, was an English teacher and her father, Horst Kasner, an official of the Lutheran Church. Soon after Merkel’s birth, her father responded to a call for more clergymen in the Soviet-controlled German Democratic Republic (GDR). He moved his family first to Quitzow in Brandenburg and then, three years later, to Templin, north of Berlin, where he took up a post at the local theological seminary. He joined the GDR’s state-controlled Federation of Evangelical Pastors, earning himself the nickname “Red Kasner” among his Western colleagues.

In East Germany the Kasners were both servants of their flock and members of an elite. They enjoyed the privileges of the state Church (which included access to Western newspapers and clothes) as well as parcels from relatives in the West. But they also lived under the persistent suspicion of the communist regime. Religious orga­nisations represented an alternative value system and were seen as potential vehicles of Western intelligence.

Merkel later recalled the GDR as a grey and confined place; she remains haunted by the first images she saw of the Berlin Wall. But she also says she enjoyed her childhood, and as a teenager she chose to adapt to the logic of the political situation. Her aim was to get on without being noticed. In this vein, despite being a vicar’s daughter and getting confirmed in the Church, she also chose to join the communist youth movement.

According to her teachers, Merkel was a ferociously motivated student, brilliant, tenacious and ambitious. She took no interest in clothes, fashion or school romances. Instead, there were three successive top performances in East Germany’s Russian language Olympiad. By the age of 15, she was the national champion in the language of the occupiers.

After moving to Leipzig University to study physics, she met and married a fellow scientist, Ulrich Merkel, but they were divorced in 1982. Subsequently she earned a doctorate in quantum chemistry in Berlin. During the 1980s she worked as a researcher at the Academy of Sciences in East Germany: the only woman in her field, a pattern that would be repeated throughout her life. It is worth stressing that Merkel was a theoretical scientist, not an experimentalist. She tackles problems methodically, running various scenarios, weighing up risks, trying to anticipate reactions and then making an informed choice. It’s an approach she has translated into politics, and calls Dinge vom Ende her denken: to think about things from the end result.

The young Merkel was self-conscious and reticent, though this was balanced by flashes of irony and self-deprecation. Seeking to rise in a man’s world, she turned these traits into her trademark style. Her attire reflects this. She is a woman who wears the same blazer, in more than 50 colours, always buttoned up, with flat, simple shoes. She never appears with a handbag. No showiness, no emotional display – no Thatcherite tantrums or cover stories for US Vogue.

This may seem an unpromising perfor­mative strategy for someone who aspires to make her way in public life, but it aligns Merkel with a deeply rooted trait of postwar West German political culture: a cult of sobriety in reaction to the disastrous seductions of Hitler’s charismatic leadership. She projects an untheatrical sincerity that millions find believable and reassuring. She often stands in the background – observing, learning and biding her time. She plays a long game, sitting out disputes until she is ready to make a decisive intervention.

***

Merkel entered politics as East Germany was collapsing; her rise was driven more by external forces than by her own actions. As street protests grew in late 1989, she did not join in. Instead, she gravitated to the liberal-conservative group Democratic Awakening, which was soon absorbed into the Allianz für Deutschland – an electoral coalition of centre-right parties led by the GDR wing of the Christian Democratic Union (CDU), West Germany’s governing party. In spring 1990, after the Allianz won the first free East German elections, Merkel was unexpectedly chosen to be the new government’s deputy spokeswoman. And so she found herself looking west, towards Chancellor Helmut Kohl, who by now was brokering the reunification of the two states.

In unified Germany’s first national elections in December 1990, Merkel gained a seat in the Bundestag as a CDU MP. Kohl immediately saw her as an asset in his first all-German cabinet – a clever 36-year-old woman, an Ossi (easterner) from a church family background with no Stasi ties. He appointed her minister for women and youth, the first female East German to hold any post in cabinet.

Within two years, Merkel had gone from being an obscure GDR research scientist in East Berlin to front-line government politics in Bonn. She used her ministerial opportunity quietly and effectively. She was no feminist – indeed, not particularly interested in her portfolio – but she had an instinct and appetite for power.

Though Kohl belittled Merkel by ­calling her mein Mädchen (“my girl”) from the East, he helped her ascend the ranks. In 1994 he made her the minister for the environment, nature conservation and nuclear safety, a role that gave her a higher international profile. Merkel convened the first UN Climate Change Conference in Berlin in 1995 and two years later led the negotiation of the Kyoto Protocol, the first and only binding global climate protection treaty to date. (She remains passionate about climate change, which is why she was unable to conceal her fury when last month Trump sabotaged a common G7 line on global warming.)

In government Merkel always seemed in a hurry, never made small talk, and ­often looked down on the “boys in the playground” – as she privately referred to her beer-drinking, ever-politicking male colleagues. She was feared for her directness and notorious for sacking those who opposed her or betrayed her trust. But she was also respected for her ability to distil a mass of information and admired for her self-­discipline and work ethic.

In the 1998 federal elections, Kohl was defeated by the young and dynamic Social Democrat (SPD) leader, Gerhard Schröder. Fourteen months later, still reeling from its defeat, the CDU was engulfed in a campaign finance scandal. Kohl was implicated but few in the party dared challenge him. Merkel, however, did, writing a cutting opinion piece in the Frankfurter Allgemeine Zeitung that urged the CDU to break with its old “war horse” Kohl. It did just that: and on 10 April 2000 the CDU elected her as the first female party leader in Germany. “I brought my killer close to me,” a bitter Kohl remarked later. “I put the snake on my arm.”

In the 2005 election the CDU secured a narrow victory, and Merkel formed her own government in coalition with the Social Democrats. The steely woman from East Germany was inaugurated as the Federal Republic’s first female chancellor.

***

Ever since the Second World War, “Europe” has been central to Germany’s identity and foreign policy. But unlike Kohl or West Germany’s first chancellor, Konrad Adenauer – men of the Rhineland, dedicated to reconciliation between Germany and its old enemy France – Merkel’s approach to the European project has not been particularly idealistic or historical. She came into the EU as an East German outsider who could not feel any special emotional bond either to the idea or to the institution.

From her pragmatic perspective, “Europe” secures peace and allows an integrated Germany to flourish economically. For this reason, the EU as a political and an economic entity must be repaired and held together. “If the euro fails, Europe fails,” she declared in 2011, at the peak of the Greek financial crisis. She went about ensuring the euro’s survival her own way. Sensitive to German public opinion, she had no desire to bail out Athens. Eventually, after long silences and many zigzags, she gave in to fellow EU leaders and Barack Obama, who warned that, without a financial rescue package, Greece would default on its debts and be forced out of the euro – pulling down the currency union and perhaps the EU, too. But Merkel insisted that in return for credits, Greece (and other weak southern European economies, such as Italy, Spain and Portugal) must accept German fiscal standards: thrift in public and private life and strict budgetary discipline, overseen by the EU.

The euro had been saved but at a cost to both sides. The austerity imposed on the debtors, especially Athens, created politically intolerable levels of unemployment. Germany was perceived as the bully of the continent. Cartoons in Greece showed Merkel’s face wearing Hitler’s moustache.

Despite early criticism at home, saving the euro ultimately earned Merkel strong public backing, because she had brought the crisis under control without too much damage to German living standards. In the process, a somewhat derogatory yet oddly affectionate new verb had been born – merkeln: to sit tight and say little. It rhymes with werkeln: to tinker. But in the end tinkering may not be such a bad thing.

The crucial role Merkel played in the Greece/euro saga made her acutely aware of her responsibilities as a German who was now, in effect, the leader of Europe. And it was in this dual position that she faced the refugee crisis in the autumn of 2015.

Confronted by a sudden mass migration into Europe after the collapse of the Arab spring and the Syria catastrophe, the EU failed to agree a unified response. Front-line states in the south-east, especially Greece and Hungary, were overwhelmed; big, rich states in the north-west, notably Britain, believed they were insulated against the human tide, and chose to stand aloof.

Motivated at first by compassion, Merkel pursued a different strategy. Dismissing demands from conservatives to close Germany’s borders, she announced in September 2015 that “Germany’s basic right to asylum has no upper limits”. She appealed to her fellow citizens, who had benefited hugely from international help after the Second World War, and urged them to welcome the needy of the 21st century, shunned by other Europeans. “If we now have to start apologising for the fact that we are showing a friendly face in an emergency situation, then this is not my country,” she said.

The “no upper limit” was swiftly interpreted as a “refugees welcome” message. Germany ended up with over 800,000 newcomers from the Middle East in 2015 – this in a country of 80 million which already had three million residents of Turkish origin. (It has been estimated that hundreds of thousands more from the Middle East, Africa and the Balkans entered the country illegally.) Many Germans responded positively by helping the refugees at reception centres. Yet conservatives in her party often saw Merkel as weak and reactive. Such criticism in turn bolstered the growth of right-wing populism.

During 2016, as reports of crime, rape and child marriages filled the tabloid newspapers, thousands of people gathered at anti-immigrant rallies. After the Berlin terrorist attack of December 2016 – when a failed Tunisian asylum-seeker crashed a hijacked lorry into a Christmas market, killing 12 people – Merkel’s approval rating dropped to 57 per cent, almost 20 points lower than before Europe’s migrant crisis erupted. Looking towards her re-election year, CNN predicted: “Angela Merkel may be the biggest loser of 2017.”

Her risk-taking over the refugees was more calculated than it appeared. Merkel had acted out of conviction, given her “Christian empathy”, as she put it, and her sensitivity to Germany’s Nazi guilt. There was also a distinctively East German element: when Hungary used razor wire to fence out migrants from the south, it brought back her darkest memories of the walled-in GDR.

More pragmatically, she felt confident that the German economy was robust enough to absorb the cost of hundreds of thousands of refugees and believed that there would be long-term benefits from an influx of young, skilled workers for a country whose population was projected to fall. Above all, she feared, as with the euro crisis of 2011, that the controversy over refugees could tear Europe apart unless Berlin showed strong leadership.

Merkel has a capacity to recognise mistakes and discreetly learn from them; some German commentators have nicknamed her “the learning machine”. There was no overt apology for her refugee gamble but a subtle shift of direction with one eye on the ballot box. Seeking to build a new consensus within her party, she told the CDU’s annual conference in December 2016, to loud applause: “A situation like the one in the late summer of 2015 cannot, should not, and must not, be repeated.”

She promised speedier asylum decisions, so that those who failed to qualify would be sent back more promptly. She also stressed that those migrants who stayed would not be permitted to develop a “parallel society” but be pushed towards full integration: “Our law takes precedence before tribal rules, codes of honour and sharia.”

Today, six months on, continental Europe is more stable after the far right’s defeat in the Netherlands and Emmanuel Macron’s presidential and parliamentary triumphs in France. And following significant CDU victories this spring in three regional elections, Merkel is strongly favoured to win another term as chancellor.

What’s more, with Britain exiting the EU, Merkel is keen to “relaunch” Europe. Calling for a “historic reconstruction of Europe”, she and Macron agreed in Berlin on 15 May to draw up a joint roadmap of how to deepen EU integration and make the eurozone more resilient. After her fraught relationship with the president’s lame-duck predecessor François Hollande, the Franco-German “couple” are back in business.

***

Dominant in Europe, resurgent at home, Merkel has also been operating on the global stage with growing confidence. Her greatest challenge here is the re-emergence of Russia as a would-be world power.

Merkel and Vladimir Putin (the de facto lord of the Kremlin for the past 17 years) share a long history in power – and go further back than that: he helped run the “dictatorship” under which she had grown up. In the back of Merkel’s mind Putin is still the KGB officer who spent five years in Dresden as a functionary of the occupying power.

These two leaders have held dozens of meetings and talked for hundreds of hours over the phone, conversing easily in German and Russian. Merkel has always sought to push Russia and Putin towards a relationship rooted in rules, principles and common interests – not one based on emotion or personal chemistry. Putin, in turn, has looked for a partner who would strike good economic and political deals and help keep his country at the international top table.

Putin had found such a partner in Merkel’s predecessor Gerhard Schröder. In 2005 they struck a deal for a gas pipeline from Russia to Germany through the Baltic Sea; as soon as Schröder left office, Putin installed him as chairman of the board of Gazprom, the Russian energy giant. In 2014 Schröder celebrated his 70th birthday with Putin in the Russian leader’s home town of St Petersburg, just weeks after the Russia-Ukraine crisis had erupted.

Merkel is repelled by alpha-male bonding (Kohl and Boris Yeltsin sweating it out in the sauna), not merely because she is a woman but as a matter of principle. And modish sympathy for Putin (Putinverstehertum) on the extremes of left and right in German politics is anathema to someone who has never underestimated Russian power. Indeed, Merkel has always seen through Putin. There was a telling moment soon after the 9/11 attacks when Putin addressed the Bundestag, pledging solidarity with the Americans and presenting his vision of Russia’s European destiny. German MPs were enthralled by his delivery – in fluent German – and by his apparently pro-Western message, and gave him a standing ovation. Merkel, too, stood up but she whispered to her neighbour that Putin’s German was that good “thanks to the Stasi”.

For his part, Putin introduced an element of mind games into their relationship. In 2006, when Merkel made her first official visit to Moscow, he gave her a stuffed toy dog. The Kremlin was aware through its intelligence channels that Merkel was nervous around dogs, having been bitten by one a decade earlier. The following year, during talks in the Black Sea resort of Sochi, Putin had his large black Labrador, Koni, run into the room while he and Merkel were sitting across from each other. Though she did not flinch, photos of the meeting show her looking awkward as the dog buried its head in her lap. Merkel soon got her own back, telling the media: “I understand why he has to do this – to prove he’s a man . . . He’s afraid of his own weakness. Russia has nothing, no successful politics or economy. All they have is this.”

Their personal edginess became central to world politics in 2014 after Russia annexed Crimea. For Merkel, Putin had now crossed a red line. Crimea had been part of Ukraine since 1954. Yet Putin claimed, after a referendum rubber-stamped the annexation, that the Russian inhabitants of the region were invoking the right to “self-determination” – just as the Germans did during reunification in 1990. This analogy did not go down well in Berlin. And relations with the West grew even worse after Putin presented the subsequent Russian intervention in eastern Ukraine as an assertion of his country’s rights as “an independent, active participant in international affairs”.

Merkel considered Russia’s actions a flagrant breach of international law. She rallied the EU, together with Barack Obama’s America, to impose sanctions on Russia, precipitating a financial crisis in Moscow. With the rouble losing almost half its value within two years and a collapse in the price of oil – on which Russia’s economy depends – the country slid into a recession.

The Ukraine situation remains deadlocked but Merkel’s position has evolved over the past couple of years. Initially, with Obama and David Cameron happy for her to take the lead, she tried, with French support, to broker a peace deal between Russia and Ukraine. This effort became harder to sustain after Russia extended military support to Bashar al-Assad in Syria. In response, Merkel began to toughen her stance. She reprimanded Putin for siding with Assad, stating: “I think we’re very close to war crimes.” Yet she also invited him to Berlin in October 2016 to resume dialogue and find a way out of the Ukraine quagmire.

After no progress was made in the Berlin talks, she insisted that dialogue had to be balanced by deterrence and committed German troops to Lithuania under Nato’s build-up in the Baltic states. Her position towards Russia hardened further after Donald Trump’s election win. The US president’s inability to provide steady global leadership and his unwillingness to reaffirm Washington’s unqualified commitment to Nato collective defence has forced her to fill the vacuum. This was clear when she met Putin at his summer residence in Sochi on 2 May – her first visit to Russia in two years.

By accepting the Russian leader’s invitation, Merkel risked seeming weak, but in the talks she refused to soften her positions. Putin did the same, of course, and so the summit yielded nothing on Ukraine or Syria – or, indeed, on anything at all.

However, Merkel unexpectedly blasted Putin in the press conference. Deliberately eschewing diplomatic comfort words such as “good” or “constructive”, she referred merely to their “extensive talks”, from which, she added sarcastically, “if nothing else, at least one learns something new”. As she spoke, Putin looked ­uncomfortable, staring at the ceiling or scrutinising the floor. She ended the press conference with a barbed but clear warning. When Putin was asked to comment on accusations of Russian meddling in recent Western elections, notably in the US and France, he replied indignantly: “We never interfere in the political life and the political processes of other countries.” Merkel said drily that she was well aware that “hybrid warfare plays a role in Russia’s military doctrine” and warned that her government “would act decisively if such moves were detected” when Germany went to the polls.

***

In Merkel’s valedictory address at the funeral of Helmut Schmidt in Nov­ember 2015, she described the former West German chancellor in words that mirrored her own approach to leadership. Schmidt, she said, was “convinced that a decision was only ripe once it had been thought through and infused with reason”. Perhaps mindful of her gamble over the refugees, she added that he had been willing “to pay the highest price, because he always factored the risk of failure into his actions – including even the risk of losing his chancellorship”.

She also praised Schmidt as an international statesman who in the 1970s already understood that the world was becoming “more open” and that this therefore demanded “greater global co-operation” on matters such as finance, security and climate in such forums as the G7 and G20.

Unlike Schmidt, however, Merkel has to operate as a woman in a man’s world. Her German nickname, Mutti der Nation, initially sounded somewhat deprecatory: Kohl’s little “girl” had grown up into Germany’s “mummy”. Sexist alpha-male politicians from Silvio Berlusconi to Donald Trump have found it hard to assimilate her into their patriarchal universe. And CDU traditionalists have long worried about whether the party’s Catholic, conservative, middle-class values were being undermined by a pinko, Protestant, Ossi woman.

Yet over time the more positive connotations of Mutti have filled the headlines: calm, good-hearted and dependable. Her courage in standing up for international ideals in an increasingly nationalistic era is widely acknowledged. Few dispute that she is now the most powerful defender of Western liberal values. Or, as the ­Washington Post put it, the “leader of the free world”. 

Kristina Spohr’s most recent books are “The Global Chancellor: Helmut Schmidt and the Reshaping of the International Order”; and, as co-editor, “Transcending the Cold War” (both Oxford University Press)

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