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

GARY WATERS
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After Brexit, should the Eurozone pursue full political union?

Is full political union of the eurozone the only way to stop the disintegration of Europe after Brexit?

The chaotic scenes in the Conservative and Labour Parties, widespread expressions of “Bregret”, confusion about what the future relationship between the European Union and United Kingdom will or should be, discussion of a second EU referendum or a “Brexit election” – all give the impression that the vote was somehow an accident. It is true there was a strong element of contingency to the outcome, which some have called “an establishment cock-up”. When in January 2013 he needlessly promised the referendum, David Cameron did not foresee that Boris Johnson would oppose him or that he would lose it. He could not have foreseen that a Labour leader would fail to mobilise the left-wing vote, and fail probably intentionally. The result was also determined by the unexpectedly brutal nature of the campaign, with wild claims on both sides, though those of some Leavers were by far the most egregious.

It is time, however, for those who wanted the UK to remain in the EU at least for now, of whom I was one, to accept reality. Britain did not decide to leave the EU in a fit of pique or absence of mind. Its departure reflects the deeper pattern of British history in Europe over the past few hundred years. It would certainly have left the EU at a later date, if the EU had not collapsed first.

The relationship between Britain and Europe can be summed up in two simple geopolitical propositions. First, that the EU was designed to deal with the German problem and the European Question, or, if one prefers, the German Question and the European problem, for they are two sides of the same coin. Second, the EU was not designed to deal with the British problem. Nobody claimed after 1945 that the UK had been such a danger to European peace that it required a supranational structure to embed and contain it. Nor did anyone argue that the UK, unlike most of the rest of continental Europe, had been so weak in the face of a threat from others that it needed the protection of a supranational body.

Britain and mainland Europe have thus been on quite separate paths for a long time. The central geopolitical fact on the continent was German power or potential power: demographic, economic and military. In the period before German unification this led to a system of conditional sovereignty in central Europe, designed to prevent another state – usually France – from using its resources to achieve hegemony, and to stop the Germans from developing such ambitions for themselves. It was based on the diffusion, not concentration of power. Things changed after German unification in 1871, which eventually unbalanced the European and global system. With great difficulty, Germany was subdued and a system of conditional sovereignty was reimposed on central Europe, the difference being that this time it was to be extended to the whole western half of the continent, which was also in mortal peril from Soviet communism.

The European integration project was thus a project of “dual containment”, designed to “embed” Germany and deter ­Stalin. It was also a strategy of “dual mobilisation”, in that it sought to draw on the energies of not only the western Europeans but also the Germans to fight communism, and certainly to stop fighting each other. This supranational project was strongly supported by the Americans and by parts of the British establishment, including Winston Churchill. The vision of a complete political union has not been realised, but the European Union has embarked on important supranational projects such as the euro, the Schengen travel area and common foreign and security policies.

In Britain, things developed very differently. Europe was at all times critically important. The question of England’s relationship to the continent dominated policy and politics for hundreds of years, from France in the 15th century through to the Westminster crisis in both of Britain’s leading parties today, which is primarily the product of disagreements over Europe. The main strategic and ideological threats have come from Europe.

In the 16th and 17th centuries there was the threat to Protestantism and parliamentary liberties from Philip II and Louis XIV’s absolutism and from Counter-Reformation Catholicism. In the 19th century, there was the challenge of Napoleon, followed by the confrontation between British liberalism and tsarist autocracy. In the 20th century, Britain saw off Germany in the First World War, resisted Nazism in the Second World War, and made a substantial contribution to Western measures to deter the Soviet Union during the Cold War.

***

Like many European states, Britain responded to these challenges by pursuing a policy of maintaining the “balance of power” across the continent, through alliances and payment of subsidies, to ensure that no single actor would be able to threaten Europe’s security. In constitutional terms, however, the British response to the European problem was very different. Faced with the danger from Louis XIV during the War of the Spanish Succession, in which the long-standing enmity between England and Scotland threatened to undermine the war effort against a common foe, the two countries entered into a complete political union in 1707. The state debts were merged, there would henceforth be only one army and foreign policy, and the new polity would be anchored in a common parliamentary representation at Westminster. This link between debt, defence and what then passed for democracy proved to be so powerful that it served as the basis for the American union in the late 18th century.

On the continent, in short, Europe was the problem and the European Union was the solution. In Britain, Europe was also the problem, but the United Kingdom was the solution. For this reason, the British have never seen the need to sacrifice their sov­ereignty in a supranational project. They have therefore co-operated with Europe on a largely intergovernmental, and not a supranational, basis.

That said, the modern European order – understood as the totality of economic, political and military relationships – that developed after 1945 was primarily an ­Anglo-American order. It was built on the Allied victory during the Second World War, which enabled the re-establishment of democracy on the continent. It depended wholly on the protective carapace provided by Nato, in which the UK was the second most important actor after the US, and by far the most powerful European one.

Since 1973, the United Kingdom has been part of the European integration project, and even though the relationship has often been turbulent, the British contribution there has been substantial. London was the principal sponsor of the single market and eastward enlargement of the EU.

To be sure, the United Kingdom stayed aloof from the crucial European projects: the euro, Schengen and any planned European army. It did so on two very cogent grounds. First, because involvement would have been incompatible with the independence of the UK, hard won over history with blood and treasure. Here, the conditional sovereignty of continental Europe clashed with the absolute sovereignty of the Westminster parliament.

Second, because the British government believed quite rightly that these federal projects required a political union. It was not, however, opposed to such an arrangement on the continent. It is true that London has long tried to keep the political bonds to Europe loose enough to enable continued UK membership without losing her sovereignty. But more recently, in an abandonment of the long-held principle of the balance of power, Chancellor Osborne, recognising the need to keep the eurozone stable, constantly pressed for closer fiscal and political integration across that area.

This gives the lie to the idea that Britain has been blocking progress in Europe. This is a firmly entrenched view in Brussels, expressed vehemently by the president of the European Commission, Jean-Claude Juncker. It was also expressed hilariously in the popular 1980s television series Yes Minister when Sir Humphrey told the minister, James Hacker, that Britain had only joined the European Economic Community to make a “pig’s breakfast of it from the inside”. The sad truth is that the EU does not need British help to do this. The continental Europeans have shown in the euro crisis, which has nothing to do with London, and in many other disasters, that they are quite capable of making a pig’s breakfast of it for themselves, unaided.

The problem, in other words, is not the United Kingdom, but the long-term weakness of continental Europe, which Brexit has brought home in the most painful way, and aggravated. Without the euro and migration crises, there would never have been a majority for Leave a fortnight ago, though there would probably have been a separation further down the line. The peoples of Europe sense this and so do the elites. They all know that whereas Grexit would be a judgement on Greece, Brexit was a judgement on the EU.

***

Unfortunately, the hope that the shock of Brexit will provoke profound reform in the European Union is based on a misunderstanding of the nature of national governments represented in the European Council and among Brussels elites. They need help but, like alcoholics, they also need to realise the utter wretchedness of their condition before they ask for it. Continental Europe, unfortunately, has much further to fall before it can rise again. At the moment, it is still in denial.

That should not stop Washington and London from trying to persuade the European Union, or at least the eurozone, to achieve a full political union on the model of Anglo-America. This could be an asymmetric union of “core Europe”, in which Germany took on the role played by England in the United Kingdom. Alternatively, it could be a more symmetric, larger union of the entire eurozone along American lines. Only by linking debt, defence and democracy as pioneered in the United States will Europe be able to stabilise the currency, deter Russia and address the democratic deficit against which electorates are rebelling. The alternative is either continued chaos, or a return to the nation state and the untethering of Germany from the continental order.

Whatever the solution in mainland Europe, the future attitude of the UK to the EU will determine the survival of this union, after Brexit even more than before it.

In this context, we urgently need to know the Brexit mainstream’s attitude to the ­European project. Farage, who resigned on 4 July as the leader of the UK Independence Party, may be containable but the full force of a new Brexit government will be a very different proposition. Theresa May hasn’t said much yet but, as a soft Remainer, she is unlikely to seek confrontation with the EU. In recent days, the once sulphurous Boris Johnson has been more conciliatory, even saying that the EU “was a noble idea for its time”, but he is no longer a candidate for the Tory leadership. Since the referendum result, Michael Gove has spoken of his hope that “we can build a new, stronger and more positive relationship with our European neighbours, based on free trade and friendly co-operation”. He has also, however, expressed a desire that Brexit should spark a “democratic liberation” of the continent. Gove now needs to explain what that means. If he has a Farage-style return to the national states and currencies in mind, the EU will resist him tooth and nail, and rightly so, as the European project is still the continent’s last, best hope on Earth. If, however, he means the establishment of a full parliamentary union of the eurozone to provide democratic legitimation for its decisions, then he is pointing the way out of the crisis. Of all people in British politics, Gove, a Scot who believes passionately in the UK, is perhaps best placed to make the argument for a multinational political union of the continent (without Britain). Yet he is unlikely to get the chance to do so, trailing as he is behind May and Andrea Leadsom, a hard Brexiteer, in the leadership contest.

***

Against this background, the big geopolitical question will be whether the UK and the EU, former partners hopeful of separating amicably, eventually become enemies. Right now, the two sides are at the ready but not in combat. Much will depend on who fires first, or is perceived to have done so. In this heated ­atmosphere, even a political sneeze could set off a massacre.

It goes without saying that both sides will lose from a confrontation. Critical to avoiding that is an understanding of the actual balance of forces. These are much less unfavourable to the UK than Brussels hawks and many British pessimists imagine. The claim by the Dutch prime minister, Mark Rutte, that “England has collapsed, politically, monetarily, constitutionally and economically” is wide of the mark. It is true that London is dwarfed by the economic might of the eurozone and the rest of the EU, and that it faces a period of considerable short-to-medium-term economic pressure. It is also true that the UK faces grave threats to its integrity in Scotland and, to a certain extent, in Northern Ireland.

That said, once a new government is formed, a highly coherent actor – the United Kingdom – will be facing a fatally divided ­coalition, which is already showing cracks not merely between the Commission and the European Council, but within the Council itself. Moreover, once started, the struggle will be won not by those who can inflict the most, but by those who can endure the most. The UK has repeatedly demonstrated a capacity to defend her sovereignty against all comers. Her political fundamentals are strong. Mainland Europe, by contrast, has repeatedly demonstrated its propensity to fragment. Its political fundamentals (sadly) are weak.

The threat to the unity of the United Kingdom is greatly exaggerated. Wales remains fully committed, and voted Leave by a similar margin to England. In Northern Ireland the divisions are principally between the two faith communities, and only in the second instance between one of those communities and the British state. There is no chance whatsoever of the province leaving the UK.

It is true that in Scotland the vote for Brexit has created a material change of circumstances, entitling the Scottish National Party-led government to demand a fresh referendum on independence. That said, independence only ever made sense in the benign European environment before the 2008 crash, the onset of the migration crisis and the Russian threat. At that time, the Irish “tiger” economy served as a model. Since the euro crisis, this is no longer the case. Even as late as the failed 2014 referendum, there would still have been EU members on both sides of the border. Now all is utterly changed. If it left the UK now, Scotland would immediately have a “hard” border with England, the country with which it does most of its trade. It is currently a net beneficiary of the Union economically; it would lose that money with independence, but, as a rich state within the rest of the EU, it would be required to contribute more to Brussels. The oil price is low. A Scottish vote for independence would therefore pose a much greater risk than Brexit does to England and, indeed, to Scotland, if the Scots choose remain part of the UK. Given that Scotland joined the UK in order to guard against European dangers, how likely is she to throw in her lot with a European Union in possibly terminal crisis by leaving the most successful union project Europe has produced so far: the United Kingdom?

Moreover, once fully engaged against a hostile continent, the full apparatus of the Foreign Office would be turned to making a (bigger still) “pig’s breakfast” of the EU. It would find allies on the mainland, pouring salt into Europe’s self-inflicted wounds and inflicting new ones. London would revert to devising an old “balance of power” policy for the continent.

Besides, one should not assume that Britain will be sent, as President Barack Obama threatened, “to the back of the queue”; his administration has since rowed back rapidly on those threats. Britain may be more dependent on the single market than vice versa, but many sectors, such as Germany’s car manufacturing industry, would be destroyed by a trade war. The Irish government, which is obliged by EU law to erect a hard border with any non-member-state that is not part of Schengen, will feel sharper and quicker pain than the UK. Eastern European governments, which look to Britain as a bulwark against Russia, will want to bury the hatchet quickly. Spain has already indicated that it will block Scotland’s admission in order not to create a precedent for Catalonia. None of these states, which together make up a majority in the EU, is likely to pursue a prolonged vendetta against London. In short, though there is widespread dismay, sadness and anger at the British decision, it would be wrong to deduce from that a willingness to place a long-term bet on victory by the EU over the UK.

Naturally, with the exception of a few Brussels blowhards, there is hardly anybody in the EU who is insane enough to want to add a struggle with the UK to the Union’s many other problems, none of which has gone away, and all of which are likely to escalate. The worry is that, given its well-documented incompetence, the EU will “sleepwalk” into such a confrontation. This would turn the UK into a positive Russia on the western flank of Europe, destabilising it from the outside and sucking it dry of its most positive and dynamic elements, even more than the UK already does now. It does not have to be this way.

Today, almost everything is up in the air, most obviously in mainland Europe. The only fixed point we have is that the UK has reasserted its complete sovereignty by leaving the EU. Everything else will have to be ordered around that fact.

Brendan Simms’s latest book is “Britain’s Europe: a Thousand Years of Conflict and Co-operation” (Allen Lane)

This article first appeared in the 07 July 2016 issue of the New Statesman, The Brexit bunglers