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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Tearing down the "caliphate": on the frontline against Islamic State in Mosul

Truck bombs and drone warfare in the fight to take back Iraq’s second city from Islamic State.

The battle to retake west Mosul began, for me, rattling around in an armoured Humvee with two Abaases. “I’m Abaas One. He’s Abaas Two,” the driver, Abaas Almsebawy, said in English with a broad smile, pointing to the gunner on top.

“I have killed two Da’esh,” Abaas Two said, using an Arabic acronym for the so-called Islamic State (IS). “Well, one for sure. The other one crawled away but he was bleeding badly. I was told he died.”

Abaas One was jealous of his gunner’s luck. He was shot twice by IS in the city of Ramadi, in central Iraq; he still had a bullet lodged in his back. “The doctor said it is my gift from Da’esh,” he told me and laughed.

Over the sound of gunfire and mortars, the two Abaases called out to each other, giving directions, spotting targets. The cry of “Abaaaaas!” was constantly in the air. One from Babylon, the other from Baghdad, they stretched out on a felt blanket inside the armoured vehicle during lulls in the fighting and fell asleep, oblivious to its discomforts and the IS mortars landing outside.

They had been involved in the fighting in the east of the city, which it had taken 100 days to recapture, in hard, street-by-street clashes and through an onslaught of IS car and truck bombs. Yet the battle to retake the west, which began on Sunday 19 February and is being led by Iraq’s Emergency Response Division (ERD) and counterterrorism forces, has proved different – and faster.

Abaas One, the driver, was exhilarated. As Iraqi army helicopters flew overhead and the air force strafed villages with machine-gun fire and rockets, he rolled on, part of an armoured assault on a front that stretched for miles. His Humvee was built for this kind of terrain, moving at speed across the desert towards villages, the airport and eventually the city of Mosul.

Something else was different about this battle, too. These men were not technically soldiers: they were policemen. Abaas One went into battle in a hooded top and a leather jacket. Stuck outside manning his gun, Abaas Two, like a fighter from another age, wore a greatcoat, small, circular spectacles and a woolly hat. One lean and broad-shouldered, the other bulky and round-faced, they were a contrast but a good fit.

The Abaases were part of Iraq’s elite ERD, which has led the charge into the west of the city, just as the country’s heralded “Golden Division”, the counterterrorism unit, had pushed into the east. The ERD, part of the ministry of interior, is the less experienced junior brother of the battle-hardened Golden Division but it was determined that west Mosul would be its prize. It made swift progress and, as it took back village after village from IS, troops posed for selfies with enemy corpses on the roadside.

The closer to Mosul you were, the more charred bodies you would see, lying along the route. Two in a ditch, killed by a mortar, and two on the road, the motorcycle they were travelling on cut in half by an air strike.

In command of the 1st Brigade was Colonel Falah al-Wabdan. In Ramadi in 2015, he and his men had been cut off and surrounded by IS forces and had escaped only when more troops came to their rescue.

As he stood on the ruins of a former palace that had belonged to one of Saddam Hussein’s brothers, he had a view of all of Mosul. “I will be very glad when I see my forces move forward,” he said. “Also [when I see that] my soldiers are all safe. And I will be even happier when we have killed IS. These people [IS] are like a disease in the body, and we are now removing it, day after day.”

From there, the Iraqi forces took the town of Abu Saif, and then, in a six-hour battle, what was left of Mosul’s airport. Its runways were in ruins and its terminal buildings reduced to rubble. Yet that was the last open ground before they reached the city. By the end of the week, Colonel Falah’s forces had breached the IS defences. Now they were heading into the dense and narrow streets of the city’s old town. Meanwhile, the elite Golden Division was the secondary force, having earlier been bogged down in heavy fighting.

The competition between the two rival divisions had helped to accelerate the advance. The ERD, however, had a secret weapon. “We need to ask your men to hold off, sir. We have helicopters in the air,” the US special forces officer told an Iraqi lieutenant colonel on the rooftop as the assault on Abu Saif was in full force.

The Iraqi mortar team in the orchard and olive grove below held fire. Then the mighty thud of coalition air strikes could be heard and, just two miles away, a huge, grey cloud rose above the town.

 

***

It is Iraqis who are doing most of the fighting and the dying in the battle against IS, but since the Pentagon relaxed its rules of engagement late last year more Americans are at or near the front lines. They are calling in air strikes and laying down fire from their MRAP (“mine-resistant ambush-protected”) vehicles. They are not in uniform but, despite being a covert force, they are conspicuous and still wear the Stars and Stripes on their helmets. When journalists, especially cameramen, approach, they turn their backs.

In and around Mosul, it is more common now to get stuck in a traffic jam of US vehicles: either artillery or route-clearance teams. The Pentagon will soon respond to President Donald Trump’s call for a new plan – an intensification of US efforts against IS – but on the ground around this city, the Americans are already much more engaged in the fight against the militants.

British special forces were also in the area, in small numbers. Unlike their American counterparts, they went unseen.

Also seemingly absent in the early part of the offensive were civilians. It was three days before I met one: a shepherd, Ali Sultan Ali, who told me that he had only stayed behind because he could not get his flock to safety, as a nearby bridge had been destroyed.

As his sheep grazed, Ali explained: “They continued to attack this area, and now we are three days sitting in our homes, unable to go out because of attack and mortars . . . All the people, they have left this area one after another. They went to the east of the city of Mosul and they rented houses there because there are too many attacks here.”

Almost 60,000 people have fled west Mosul. In this area, with its population of three-quarters of a million, the battle has the potential to become a humanitarian crisis. Camps for internally displaced people still have capacity, but they are filling up.

IS, with anywhere between 500 and a few thousand fighters inside Mosul, is again using the local population as cover. But coalition air strikes may be taking a heavy toll on civilians, too. Officially, the US-led force claims that 21 civilians have died as a result of its bombs since November, but an independent monitoring group, Airwars, suggests that as many as 370 have been killed by Western aircraft since the start of March.

After the airport was recaptured, the columns of desperate people heading south began to thicken. The children among them usually held a white flag – perhaps a clever distraction thought up by terrified parents for their long walk to safety. Near the airport, I met a man who was too distraught to give his name. He told me that his brother’s family – six people – had been killed in an air strike. With his eyes red from crying and a blanket over his shoulders, he stood by the roadside, pleading. “For God’s sake,” he said. “We need you to help us. We need a shovel to get the dead bodies out of the building, because there are still two bodies under that building.”

But the battle was reaching a new pitch around him, so he left for a camp to look for his brother, the only remaining member of his family, he told me.

When the ERD finally made it inside the city, the first thing I noticed was the fresh laundry hanging in the yard of a family house. Then I heard a huge explosion as an IS truck bomb slammed into one of the Iraqi Abrams tanks.

The tank trundled on regardless and, by nightfall, the ERD had a tiny foothold inside the city: the al-Josak neighbourhood.

 

***

 

Islamic State is steadily losing Mosul and in Iraq, at least, the end of the so-called caliphate is in sight. In Abu Saif, state forces found the corpses of foreign fighters and, hiding, an IS operative who was still alive.

“He’s Russian,” one officer told me, but the man might have been from one of the central Asian republics. There were dead Syrians on the battlefield, too, men from Deir az-Zour; and for the tens of thousands of foreign fighters who joined IS, Syria will likely be a last refuge.

There may be another reason for the faster pace of the assault in west Mosul. The Iraqi forces, having fought IS in Ramadi, Fallujah and east Mosul, are getting better at dealing with the militant group’s tactics.

Truck bombs took a huge toll on their men in eastern Mosul. It is hard to describe the force unleashed when one of these detonates near you. In an early assault on one village, IS sent out four truck bombs and one of them exploded a few hundred metres from where I was standing. The shock wave ripped around the building and shards of engine went flying over our heads. My mouth was full of dirt. The debris was scattered for what seemed like miles around – yet no one died.

The suicide attack driver may have been taken out by an Iraqi soldier firing a rocket-propelled grenade (RPG). Whenever they advance now, men stand ready with RPGs, specifically to tackle the threat of car bombs. And they are becoming better at “hasty defence”. An armoured bulldozer is always in the lead. When a new street is taken, defensive berms made of mud or rubble are built to halt any speeding car bombs.

The IS fighters are crafty. Iraqi forces took me to a house on a captured street. Its yard was covered and the front wall was gone. Parked in the front room was what looked like an ambulance. Hidden from surveillance aircraft, this was another truck bomb.

“It’s still live. I wouldn’t go any further,” a major warned me. Even the bomb disposal team said that it was too dangerous to touch. It was later destroyed from a very safe distance.

Although the group violently suppresses modernity, IS fighters are innovators. They have no air force but they can get their hands on drones, which are commercially available, and they have “weaponised” them. If the battle for east Mosul was the attack of the car bombs, the battle for the west began as a drone war.

For the men on the ground, IS drones are enormously disconcerting. During a gun battle in west Mosul, I stopped to speak to some troops taking cover behind a wall. As I asked a final question, the captain I was talking to cupped his ear and leaned forward because of a sudden eruption of gunfire. Then, just to my right, I felt a shock wave of a detonation that seemed to come from nowhere.

A member of the BBC team was hit, receiving a small blast injury to the arm. When we got back to the Humvee, the driver explained that there had been a drone above us. The gunfire was from Iraqi troops trying to bring it down. The detonation had not come from nowhere; it had come from directly overhead. As we drove out of there, I noticed that the gunner had closed the hatch. We were protected inside, but he was outside manning his weapon, looking for more drones.

“They drop MK19 40mm grenades from the drones to stop the movements forward. All the time, they will use four to five drones to attack one location,” Captain Ali Razak Nama of the federal police explained. “As you know, we can’t always see these drones with our eyes, but if we do see them we can attack the drones with our rifles. [But] when we go into the battle, we are not looking at the skies. We are looking ahead of us for car bombs, suicide attackers, IEDs or snipers.”

A unit of the Golden Division was hit 70 times in a single day by wave upon wave of IS drones. The operator managed to drop a grenade inside a Humvee from above; all four men inside, members of a bomb disposal unit, were killed. Dozens more were injured that day.

The sound of a drone, even one of their own, is enough to make the Iraqi forces hit the dirt and scramble under a vehicle. They are difficult to bring down. I once watched as snipers and heavy machine-gunners opened fire on some drones; they managed to strike one but still it flew on.

The IS fighters control them from motorcycles in an attempt to prevent the operators being tracked and killed. They switch frequencies in the hope that they will not be jammed. Yet as a coalition commander told me: “The enemy aren’t going to win by dropping grenades from the sky. So it is certainly not a game-changer.” Iraqi and coalition forces now appear to be having success in countering the threat. Just how, they will not say, but in recent days there has been a “very significant” drop in their use.

 

***

 

Mosul has been the biggest battle for Iraqi forces against Islamic State, but commander after commander said that others had been tougher. In Ramadi and in Fallujah, IS had a better grip. In Mosul, the local people have been quicker to turn away from the militants.

In the eastern part of the city, the bazaars are busy again and children have returned to school. Girls are receiving education for the first time in nearly three years, since IS captured the city. The so-called caliphate was declared on 29 June 2014 and, four days later the new “caliph” and IS leader, Abu Bakr al-Baghdadi, made his first and only filmed appearance, delivering a sermon at the city’s al-Nuri Mosque. Iraqi forces are now in sight of the mosque, with its Ottoman-era leaning minaret.

Mosul is Iraq’s second-largest city and has a cosmopolitan heritage, but Islamists had influence here for many years before IS arrived. As one Mosulawi told me, after neglect by the Iraqi capital, “There is discontent with Baghdad, not support for Isis.”

Al-Baghdadi is believed to have fled the city already. According to US and Iraqi commanders, he is hiding out in the desert. Shia militiamen and Iraqi army forces are attempting to seal off escape routes to the west, into Syria. Yet senior commanders accept that in a city Mosul’s size, it will be impossible to close all escape routes. Capturing al-Baghdadi is not a priority, they say.

There is also an acknowledgement that neither his death nor the loss of Mosul will be the end of Islamic State. But in Iraq, at least, it will destroy the caliphate.

Quentin Sommerville is the BBC’s Middle East correspondent

This article first appeared in the 16 March 2017 issue of the New Statesman, Brexit and the break-up of Britain