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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The next Balkan wars

Europe is facing a new, potentially violent crisis as territorial and ethnic tensions reignite in the troubled south-east of the continent.

After some years of peace, the western Balkans are again descending into instability. Across the region, people are taking to the streets, demanding the resignation of governments. Thousands are fleeing abroad in search of jobs and opportunities. A violent strand of Wahhabism is taking hold among the region’s Muslim population. Perhaps most worryingly of all, the threat of disintegration is returning, as malcontent minorities try to divide their states.

Bosnia has long been the most dysfunctional state in the region, wasted by civil war in the 1990s and afflicted by ethnic divisions ever since. The Serbs and Croats have never abandoned their goal of separation. Milorad Dodik, the president of Republika Srpska (Bosnia’s Serbian “entity”), is being squeezed by political rivals at home and investigated by police in Sarajevo for alleged money laundering. To shore up his position, he has threatened a referendum on independence for Republika Srpska, scheduled for 2018.

Not far behind is Kosovo, an impoverished plateau in the Šar Mountains. It is unrecognised by half of the world, run by a corrupt elite and saddled with an embittered Serb minority. After years of resistance, Kosovo’s Serbs have recently extracted the right to territorial autonomy from the country’s notional EU supervisors. This has provoked a ferocious backlash from Albanian nationalists, who have attacked the parliament and held a series of violent street demonstrations.

Meanwhile, Macedonia is in chaos following the leaking of tapes that led to accusations that the former prime minister Nikola Gruevski had spied on the population and had been involved in corruption, electoral fraud and outright criminality. This has outraged the unhappy Albanian minority, which blames its leaders for upholding an illegitimate government instead of its community rights. In response, this group is demanding the federalisation of the state, auguring its potential disintegration. In the Balkans, it all eventually comes back to nationalism.

While local factors go some way to explaining the turmoil, however, they don’t tell us why the region as a whole is experiencing such instability, or why events are turning for the worse. The key to understanding the malaise is to recognise the Balkans’ position as a borderland between great powers. Throughout history, when one of these powers has wielded hegemony in the region, or a concert of powers has agreed a settled division, peace has generally prevailed. When no single power has been dominant or, worse, when powers have competed for control, chaos has invariably ensued. The Ottoman era marked the longest period of peace in modern times. But when the empire went into decline in the 19th century, nationalists across the Balkans seized the opportunity for independence – first the Greeks, then the Serbs and finally all the rest, helped by an opportunistic Russia, which sought to destabilise its Ottoman rival. 

Violence continued into the 20th century as the collapse of the European land empires untethered the region. The Balkan wars of the 1910s, in which emerging states such as Albania, Montenegro and Serbia fought to define their borders, were followed by two world wars, in which Austria, Germany, Italy and the Soviet Union all invaded the territory.

The western Balkans were finally pacified in the postwar period. Bulgaria and Romania passed to Soviet control and the two superpowers agreed to maintain a unified Yugoslavia as a strategic buffer between their respective spheres of influence. Wedged between Nato and the Warsaw Pact, with no room for manoeuvre, and a strongman, Tito, to maintain order at home, the locals put their enmities to one side.

With the end of the Cold War, the superpowers largely lost interest in the Balkans and released their grip on Yugoslavia. Romania and Bulgaria, free of ethnic entanglements, managed to find their balance. But the western Balkans were set adrift and violence returned as Serbs and others took up arms to forge a new order on the wreckage of the old multinational communist state.

Stability was eventually restored when the United States, which emerged as the undisputed superpower in the 1990s, imposed a new imperial settlement on the region. In Croatia, Washington helped the local army to crush the breakaway Republic of Serbian Krajina. In Bosnia, the US bombed Serbian positions, decisively tipping the balance of power in favour of the central government that had endured three years of military losses. In doing so, Washington was interested in promoting not only peace but also justice. After the brutality of the Serbian military campaign, with its terrorising and expulsion of other ethnic groups, basic morality determined that the Serbs be denied their wartime goal of independence from the rest of Bosnia.  

The result was the Dayton Agreement of 1995, a delicate compromise in which Serbs (and Croats) agreed to remain part of a unified Bosnian state. In return, the Serbs were given a self-governing entity – Republika Srpska – on half of the territory of Bosnia, while Croats gained limited self-government within a new Muslim-Croat federation.

Having dictated the terms of Dayton, the US, in effect, became its guarantor, supported by its European allies. It established a huge civilian presence on the ground, intended to steer Bosnia towards a durable peace. The Office of the High Representative adjudicated in ethnic disputes, clamped down on nationalist rhetoric and focused the locals on questions of social and economic reform rather than borders and territory. If politicians refused to co-operate, they were removed from their positions or presented with criminal charges. Nato troops on the ground did the enforcing.

***

When conflict broke out in Kosovo between Albanian separatists and their rulers in Belgrade in 1999, the US similarly imposed itself on the territory, using overwhelming force to expel the Serbian army, before setting up a civilian mission, Unmik, to steer a unified country towards a sustainable peace, as it had done in Bosnia.

With stability in both of these countries still fragile, nationalist conflicts elsewhere in the western Balkans could not be allowed to jeopardise Washington’s unfinished efforts at multi-ethnic state-building. When Macedonia’s unhappy Albanian minority launched a short-lived insurgency in 2001, the US clamped down on it with a settlement that forced Albanians to abandon the goal of separation in return for limited self-government. Macedonia held.

A similar logic applied to other states in the region. Through the 2000s, the US extended its presence in Albania, slowed down the secession of Montenegro and, with the fall of Slobodan Milosevic in 2000, implanted itself in Serbia, where it demanded democratic reform and Western integration in place of a discredited nationalism.

In this respect, the late 1990s and early 2000s can be seen as marking a restoration of order in the western Balkans after the chaos of the immediate post-Yugoslav period. With Washington at the helm, buttressed by European manpower and money, nationalists and separatists were disempowered and multi-ethnicity became the watchword. Many locals were frustrated with the American-led settlement, whether they were minorities such as Bosnian Serbs and Macedonian Albanians, who had ended up living in someone else’s state, or Bosniaks and Macedonians, who opposed the territorial concessions granted to violent minorities.

Confronted with overwhelming American power and the absence of any other power to whom they could appeal, there was little that the peoples of the western Balkans could do to change things. Turkey was content, concerned above all with peace on its land route to the markets of Europe. And Russia, while sympathetic to the plight of the Serbs, had no wish to encourage separatism in places such as Chechnya by questioning the new order in the Balkans.

However, this attempt at order was not to last. Matters went into reverse in the second half of the 2000s when the US withdrew its forces from the region to concentrate on more pressing issues elsewhere in the world. Its parting shot was to engineer the independence of Kosovo in 2008. With the last piece in the Balkan jigsaw in place – at least as Washington saw it – the US left it to the EU to finish the job of transforming the region’s turbulent states into prosperous and stable polities.

In tactical terms, the EU adopted a different approach to the US, replacing the hard power of the American military with the soft power of inducement – not least because, without an army, the EU had no real stick to wield. What it offered instead was a compact known as “conditionality”. For its part, Brussels agreed to admit the western Balkans into the EU, with all the benefits that this entailed – money, trade, freedom to travel and the chance for the locals to be reunited with their ethnic kin in a borderless Europe. And, for their part, the locals were expected to meet the conditions for entry to the EU, as the central Europeans had done before them.

Almost from the start, however, things failed to go to plan because the locals wouldn’t knuckle down to reform. By definition, the states of the western Balkans were eastern Europe’s laggards, blighted by the legacies of war as well as nostalgia for Yugoslav-style socialism and the absence of any tradition of democracy, liberalism or free markets.

Sometimes, the EU pushed issues that were important in a Western context, such as prison reform or gender rights, but just not a priority for the locals, who were more concerned with establishing the territory of the state, or changing the state they lived in. At other times, the required reforms cut across the interests of the elites who were making fortunes running a rentier economy.

***

The most resistant state was Bosnia, where the conflict never truly ended and where each ethnic group used the integration process to advance its core political goal: centralisation in the case of Bosniaks, separation in the case of the Serbs. Brussels would push an area of policy – the environment, say – and recommend a new agency to oversee compliance. Bosniaks would insist on one agency (at the central level) and Serbs would insist on two (at entity level, including one for Republika Srpska). Invariably, this was where the process got stuck.

So while the policy of conditionality was intended as the mechanism for stabilising the region, its effect was the opposite. In the absence of reform, the region remained stuck in political limbo, beyond the EU’s outer frontier. The EU began to lose control with the onset of the eurozone crisis, which brought the teleological project of building a European superstate to a halt. As firefighting and crisis management became the norm, the EU ceased to enlarge. With so many problems to solve, the last thing Europe needed was to admit a collection of corrupt, impoverished and ethnically divided states, all with potential veto powers and a treaty obligation to adopt the euro.

Indeed, many of the EU’s problems seemed to emanate from the Balkans. Most obviously, there was Greece’s mismanagement of its economy, which posed a mortal threat to the survival of the euro­zone and, by extension, the EU. But as Europe descended into recession, the issue of migration from Bulgaria and Romania also became a crucial political topic – and remains so today, as migrants and refugees from the chaos in the Middle East use the Balkans as a conduit to Europe.

In this context, no one was surprised when, in 2009, the German chancellor, Angela Merkel, publicly concluded that the EU needed to pause its policy of enlargement. All of this had an impact on the region, which interpreted it as Europe’s drawbridge closing. To all intents and purposes, the EU had reneged on its bargain with the western Balkans, which traded the prize of membership for good behaviour. All that remained was the prospect that one day, years in the future, after multiple reforms, the states of the region might join the EU, if it was in any position to enlarge and if it even still existed.

This changed the balance of risks and opportunities for those aspiring to join. Why continue with reform, especially when this implied serious economic pain? Was the EU even a desirable place to be? Greece’s example was hardly encouraging, nor that of Croatia, which squeezed its way into the EU in 2013 only to become the new sick man of Europe. Then the UK began to consider exit – hardly a vote of confidence.

Across the region, the reform process slowed even further. States such as Macedonia and Serbia shifted their focus towards the emerging economies of Turkey, Russia and China. Internal stability began to decline, aggravated by the recession that the EU exported to the region. Albania, Macedonia and others experienced mass demonstrations. Separatists began to renew their challenge to the American-imposed order, led by the Bosnian Serbs.

This is not to say there hasn’t been formal progress towards joining the EU. In the past couple of years, almost every country in the western Balkans has taken a step closer. Bosnia and Kosovo have been offered stabilisation and association agreements, the first step on the road to membership. Albania has been recognised as an official EU candidate. Serbia has opened membership negotiations. Montenegro, the most advanced country in the region, has closed several negotiating “chapters”. However, this bureaucratic progress does not necessarily reflect progress on the ground – in some cases, it signifies the opposite.

More precisely, the integration process has become a pretence that suits all sides. The EU can pretend the project of integration continues even as the eurozone and migration crises rage. And regional governments can pretend they are steering their countries towards a better future, for which they are richly rewarded by Brussels.

It is possible that a tiny country such as Montenegro will scrape into the EU on the back of this make-believe and Serbia will make some progress. But for other Balkan states, their journey towards Brussels will be more like that of Turkey, the eternal European aspirant. In reality, the western Balkans is once again losing its mooring.

***

 

The waning influence of the West has created an opening for new external powers, such as Russia, which has adopted a more active policy in the Balkans since the onset of the “new cold war”. Unquestionably, Russia is now a major influence on the region, especially in the Christian Orthodox countries of Serbia, Montenegro, Macedonia, Bulgaria and Greece. But its most significant involvement is in Bosnia.

In the past couple of years, Russia has feted Republika Srpska’s President Dodik, shielded Bosnian Serbs from accusations of genocide, called for an end to international supervision and, if media reports are correct, encouraged Bosnian Serbs to press their demands for independence.

Russia is not overtly trying to overturn the regional order. Instead, its aim is to bolster its alliances, deter the expansion of Nato and defend its economic interests in the Balkans. But regional disorder could still be the outcome. If Russia is cornered by the West over Ukraine, Moscow could trigger a serious regional crisis that embroils the EU and Nato, simply by giving a green light to the Bosnian Serbs.

A domino effect would then take hold. The departure of the Republika Srpska would open up the question of Serbia’s borders and encourage Kosovo’s Serbs to separate themselves completely from their country’s Albanian population. This would provoke Serbia’s Albanian minority, who live in an enclave adjacent to Kosovo, to make a similar break from Belgrade. Macedonia’s Albanians would then try to separate from their Slavic compatriots, fuelling the creation of a “Greater Albania”. Bosnian Croats would seek to integrate their territory with Croatia. And many in Montenegro would seek close relations with an expanded Serbian state. The West would undoubtedly refuse to recognise any of this to prevent the onset of violence but the facts on the ground would speak for themselves.

Any new Balkan conflict would draw in a wider cast of players. Russia would not sit by and let others determine the outcome of events; too much is at stake. The plight of Muslim Bosniaks and Albanians would draw in foreign jihadists, as happened in the wars of the 1990s – only in much greater numbers, given the upsurge in Islamism in Europe and the Middle East.

Meanwhile, several EU states would struggle to avoid entanglement. Croatia, which has recently adopted a more nationalist posture, would inevitably intervene in Bosnia on behalf of the Croat population. Bulgaria and Greece would take a keen interest in the fate of rump Macedonia after the departure of the Albanians.

All this leads to a sobering conclusion. As the EU loses its dominance in the Balkans, so the region’s unresolved nationalisms are returning to the surface on a bed of popular discontent. The Balkans have the potential to blow their problems back into Europe, entangling the EU in a new, potentially violent regional crisis. This may not happen tomorrow but, as the EU’s influence wanes, the day of reckoning draws ever closer.

Ideally, the EU would avert this possibility by fixing its internal problems, reviving the goal of enlargement and stabilising the region by means of integration, as has long been the plan. Yet, as matters stand, that looks like wishful thinking.

Timothy Less is the director of the Nova Europa political risk consultancy

This article first appeared in the 02 June 2016 issue of the New Statesman, How men got left behind