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 life of Pi

How the gaming prodigy David Braben and his friends invented a tiny £15 device that became the biggest-selling British computer.

If you had visited David Braben’s room at Jesus College, Cambridge in 1983 you would have found an unusual scene. Sure, it was just as cramped, muddled and tinged with the fragrance of generations of undergraduates as that of any other student. But while Braben’s neighbours lined their walls with textbooks and Hollywood posters, the shelves in his room supported cascades of cabling and copper wire. And there in the centre of the desk, amid a shanty town of screws and pliers, an Acorn Atom computer hummed.

Braben knew its insides better than his own. Such was the extent of his frequent and intrusive tinkering that he left the machine’s casing permanently off, leaving the circuitry exposed, like that of a battle-wrecked android. One winter’s day that year, he and a friend, Ian Bell, stood in front of the Atom’s chunky monitor. Braben moved his hand towards the keyboard and, with a tap, executed a Big Bang.

Elite, as Braben and Bell’s universe would later be named, was an ambitious computer simulation of endless rolling galaxies, waiting to be explored via a digital spaceship. To grow such vastness from such rudimentary technology, Braben had to pull off the equivalent of a numerical conjuring trick. Rather than manually plotting cosmic systems by typing star and planet co-ordinates into a database, he used the Fibonacci sequence, which starts with “0” and “1”, and continues the sequence by adding the two preceding numbers. This mathematical curiosity governs a variety of natural phenomena, such as the arrangement of leaves on a tree or the pattern of the florets in a flower, making it the ideal formula to spawn a seed from which virtual galaxies could be generated.

The game offered breadth and depth. You toured the universe in a spaceship, represented on screen by a few scant white lines, free to mine resources, dogfight with pirates or even become a galactic marauder yourself, preying on the cargo ships that sailed along trade routes. While most arcade games of the time brought players into their reality for a few brief minutes before kicking them out again, penniless and defeated, Elite worked at a different pace. Players could spend hours touring its innumerable systems. Braben’s contemporaries were astonished. “We stood around wide-eyed; these were feats of coding we had thought impossible on the low-powered machines of the day,” Jack Lang, a university friend of Braben’s, told me.

Braben and Bell’s invention became a sensation. Elite sold out of its initial run of 50,000 copies in less than two weeks, and went on to sell 600,000 copies across 17 different computer formats, making millionaires of its young creators. The game also inspired a generation of so-called Britsoft programmers who, over the next decade, would make Britain a leading hub for computer-game development, and produce, in Tomb RaiderGrand Theft Auto and Championship Manager, a clutch of enviable and world-renowned names.

 

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Twenty years later, when he was running Frontier Developments, one of the most successful games companies in the UK, Braben noticed a trend. Each time his company advertised a job in programming, ­fewer candidates would apply. “I was expecting the number of applicants to rise because we’d had some positive press,” he told me when I visited him at the Frontier offices in Cambridge.

Braben, who, in his black hoodie, looks significantly younger than his 53 years, runs Frontier from a spacious, glass-fronted office. Nearby, scores of artists, designers and programmers tap and toil in orderly phalanxes of computers. The company, which in 2016 turned over £21.4m, employs more than 300 staff.

“But at that time we found that we were having to hire from abroad,” Braben told me. He called some directors at other British games companies and found that they had the same problem. Then he called the University of Birmingham, where he sat on the advisory board. “They, too, were in crisis: applicants to the computer science course had dropped off a cliff,” he said. “It made no sense to me.”

At the time, Braben was running focus tests with children on one of the company’s games, and he sneaked an additional question into his survey: “What is the most boring lesson at school?” The response left him bewildered – ICT (information and communications technology). “You would think computing would be the most exciting lesson for a child at school, wouldn’t you?” he said.

He called a local schoolteacher. “The issue became immediately obvious: the curriculum was teaching children nothing more than how to use Word and Excel. Programming had been removed from lessons and, in most cases, ICT was being taught by people who were computer-illiterate.” The teacher told him that students would run riot in class. Some children had discovered that by deleting a few critical files from Windows they could ensure that the computer would fail to switch on the next time the machine was rebooted.

“Schools were having to employ people just to repair this vandalism,” Braben said. The drop-off in applicants to computer science courses at universities and for positions in development studios was, he concluded, a result of years of classroom neglect. The Britsoft industry, it seemed, was in danger of collapsing from the bottom up.

Braben wrote to Margaret Hodge, then an education minister in Tony Blair’s Labour government. “I thought they were keen on education,” he recalled. “But when we met, Hodge told me that they were already teaching computer studies. She accused me of special pleading for my industry.” (Hodge has said, through a spokeswoman, that she “does not recall this meeting”.)

Braben told Hodge that she didn’t need to take his word for it; she could simply speak to a few teachers. “It was so frustrating,” he said. “Government was pouring all of this money into things that weren’t necessarily making a difference to getting kids into computer science. I was just trying to point out that the games industry was a huge asset that could be used to inspire kids. Kids like to learn to program if it’s framed around making games.”

This was Braben’s own childhood experience. His father worked for the Cabinet Office researching nuclear physics, and the family moved around, living in Cheshire in Stockton Heath, near Warrington, then briefly in Italy and finally in Epping, in the eastern suburbs of London. All the while Braben was designing games for him and his two younger siblings to play. One of the first was a modified version of battleships, played in the back garden using pieces pilfered from other board games, and based on nautical battles from the Second World War that he had read about in history books.

After he persuaded his parents to buy him the Acorn Atom, Braben progressed to designing computer games. For one of them, he drew a map of the northern hemisphere as viewed from space. He then taped the map to the computer screen and traced the outline of the countries in code. In the resulting game, players assumed either the role of the Americans or the Russians, tasked with sending nuclear bombs arcing across the screen in an attempt to destroy their opponent’s main cities. The winner was rewarded with a rudimentary computer version of their side’s national anthem.

Braben, who attended Buckhurst Hill County High, a grammar school in Chigwell, Essex, was a natural programmer, talented at maths and physics. But the computer on which he learned his basic programming skills, the Acorn Atom – the precursor of the BBC Micro, which would soon be found in many school ICT rooms – made it easy for him.

“It came with everything you needed in the box,” he said. “People say these days that design software costs only around £100, but that’s a huge amount for a kid. The amazing thing was that, with the Acorn and the BBC Micro and many of those other early machines, you had everything you needed to learn how to program anything you could imagine right from the get-go.”

Braben’s talent extended to entrepreneurship. When he was 17, he wrote to a games publisher saying that he believed his games to be as good as theirs. A week later three men in suits showed up at his parents’ house; he was worried about taking his computer to their office on public transport, so they offered to come to him. Astonished at what the boy had managed to achieve with the hardware, they offered him a job on the spot. Braben pretended to mull the offer over for a few days, before refusing the position in favour of studying natural sciences at Cambridge.

It was the memory of these formative experiences to which he returned when he was cold-shouldered by the government. He called Lang, by then an entrepreneur in Cambridge, who said the university there was also struggling to attract computer science applicants. The pair discussed ways to get the subject taught in the classroom, and a plan formed. If they could find a way to teach programming outside the school system, perhaps the schools would follow.

Initially Lang and Braben considered designing a programming course using bespoke software. The problem was that schools and libraries around the country used different versions of Windows. Finding a one-size-fits-all solution for students to compile and run their games proved impossible. Instead, Lang suggested the idea of a budget computer, one that would allow children the freedom to tinker, customise and break things, and then restore it all at the touch of a button.

“It struck me that probably the best way these days for a young student to learn how to program is to buy an old BBC Micro off eBay,” Braben said. “That’s a bit of an admission, isn’t it? It’s also fundamentally capped by the number of BBC Micros that are still working in the world, so it’s not a general solution. But it’s such a good way of learning. It encourages you to experiment. Rebooting a PC can easily damage the software. With the BBC Micro you could do all kinds of outrageous things and then just reset it. The hardware was tough, too.”

It is possible to destroy a BBC Micro, Braben said, but very difficult. So the idea was to build a computer that reflected the Micro’s sturdiness and simplicity: a machine for all-comers, practically indestructible in form, and universal in function. In 2003 Braben, Lang and four of their friends – Pete Lomas, Alan Mycroft, Robert Mullins and Eben Upton (“slightly eccentric guys from Cambridge”, as Braben puts it) – met at a computer lab at the university and, from a shopping list of components, began to price up a microcomputer.

“We knew how cheap components were becoming because of the rise of mobile phones,” Braben said. “But when we came up with the final price we couldn’t believe how low it was.” The group estimated it would be possible to build a home computer with a single USB port and an HDMI (high-definition multimedia interface) connector – which enables the device to be connected to a compatible screen – for £15.

 

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The six men named their invention the Raspberry Pi. “Fruit seemed good; Raspberry particularly good because it’s a bit of a thumb-nose at the convention. We added Pi to make it sound a bit mathematical,” said Braben. They formed the Raspberry Pi Foundation, a charity aiming to “promote the study of computer science and related topics . . . and put the fun back into learning computing”. It was almost a decade before their vision for the micro-budget microcomputer would become a reality.

“We decided that we needed support from a large organisation,” Braben said. “We started speaking to the BBC and spent a few years discussing the project with them as potential partners.” The group even offered to give the corporation the software design free of charge. But the strong initial interest led to a series of interminable meetings, where nobody from the BBC seemed willing to be the one to make the final decision.

“The final meeting I had with the BBC really annoyed me,” he said. “They told me that I needed to seek sign-off from a group that had already signed off on the project, simply because there had been a reorganisation in that group. We were going around in circles. That’s when I realised it wasn’t going to work.”

Immediately after the meeting, a furious Braben strode to the White City office of Rory Cellan-Jones, the BBC’s technology correspondent. Cellan-Jones knew of Braben from reading Francis Spufford’s 2003 book, Backroom Boys, a biography of various British inventors in which Braben and Bell featured prominently.

“When Braben contacted me under the illusion that I was somebody at the BBC with some semblance of power, rather than an infantryman, I was delighted,” Cellan-Jones told me. Yet he was at a loss as to what he could do to help the inventor standing in front of him with a Raspberry Pi in his hand. “I thought to myself: well, there’s nothing I can do with this. I can’t get a crew to film something like that.”

Sensing Braben’s despair, Cellan-Jones suggested that he film a short video on his phone there and then; he would post it to his BBC blog and announce the Raspberry Pi to the world. Doing so might, Cellan-Jones reasoned, force the BBC’s hand. At the very least it would help to gauge public interest in the device.

In a nearby corridor, Braben held the device up to the camera and explained what it was and why it might be important. “It was short and simple,” he recalled. At lunchtime on 5 May 2011, Cellan-Jones posted the video and a story about the computer to his blog. “It’s not much bigger than your finger, it looks like a leftover from an electronics factory, but its makers believe their £15 computer could help a new generation discover programming,” he wrote.

The story went viral, receiving a quarter of a million hits that day. “I was surprised and delighted,” Cellan-Jones said. “It was a great idea from the start. But I encounter lots of great ideas. You get to the stage where you start to believe that nothing will work. Then, every now and again, someone turns up with a rocket ship to Mars.”

Despite the interest, the BBC, as Braben puts it, kept coming up with reasons why the corporation shouldn’t back it. So the six members of the foundation decided to fund the first 10,000 units out of their own pockets. On 29 February 2012, at 5am, Braben began a day of media appearances, first on BBC Worldwide, then on Radio 4’s Today programme. An hour later, the website where the public could order one of the first Raspberry Pis went live. Within five seconds it had sold out.

Unable to keep up with the demand, the website sold far more units than the team had components for. “It went very well indeed,” Braben said.

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Since then, the rise of Raspberry Pi has been inexorable, with more than seven million units sold. This fully customisable and programmable computer, no larger than a credit card and only slightly thicker, can be used for everything from controlling the lights in your garage to learning how to become a software developer. In Syria it has been used to create local radio transmitters, able to broadcast messages to towns within a range of up to six kilometres, disseminating information about nearby skirmishes and essential supplies.

The Pi computer has been used to take weather balloons to the edge of space – its four AA batteries draw just enough current to stop the device from freezing – enabling schoolchildren to send teddy bears into the stratosphere to take photographs of the curvature of the planet. It can even broadcast its position by GPS, enabling those children to locate the device when it floats back to Earth. It doesn’t matter too much if it is lost, because it costs as little as £5 in its most basic form. This year, the foundation gave away a basic Raspberry Pi on the front of the MagPi, an affiliated magazine that teaches readers how, among other things, to program a football game from scratch.

Hundreds of thousands of young people have attended the foundation’s educational programmes. In 2015 Raspberry Pi entered into a collaboration with Code Club, an organisation created as a response to “the collective failure to prepare young people for life and work in a world that is shaped by digital technologies”. Code Club now runs more than 3,800 clubs in the UK and over 1,000 more in 70 other countries. Staffed by volunteers, the clubs provide nine-t0-11-year-olds with the opportunity to make things using computers. Roughly 44,000 young people regularly attend Code Clubs in the UK alone; some 40 per cent of these youngsters are girls.

Braben’s plan to get British schoolchildren learning how to program has been even more fruitful. Since Raspberry Pi’s launch, applications for computer science degrees have increased by a factor of six. Data from Cambridge Assessment, the exams and research group, shows a significant increase in numbers of children choosing to study ICT at GCSE level, with a 17 per cent year-on-year rise in 2015.

There have been other beneficial side effects. Thanks to the buzz generated by the Raspberry Pi, and pressure from the foundation as well as Google, Microsoft and others, the government has put computer science back on the national curriculum.

“We’re seeing a huge growth in engagement with computer science in the UK, and Raspberry Pi has been a big part of that movement,” said Philip Colligan, the chief executive of the Raspberry Pi Foundation. “It came along at just the right moment and provided a physical manifestation of the idea that kids should be learning how to make things with computers, not just how to consume.”

Cellan-Jones agrees that the timing of the device’s launch was perfect. “It was certainly part of a wide movement to change how ICT was taught in schools, but of all those efforts I think it played the most important part. By having a physical object it made it tangible.”

Braben believes that the Raspberry Pi and its many imitators are dispelling the mystique that has grown around technology, driven in part, he says, by Apple’s closed systems. It is almost impossible, for example, to remove the cover of an iPhone to see how it works.

“When I was growing up, if my hi-fi was buzzing I’d take the lid off and maybe put some Blu-Tack in to stop the buzzing,” he said. “At some point, this collective fear crept in.”

For Braben, who has two stepchildren, now going on 13 and 18, it’s important for children not to be afraid of the technology on which they rely. “You only need one person in ten to actually study computer science. But for everyone else, having some understanding about, say, what goes on in your phone is incredibly helpful.

“In so many walks of life, whether you’re a builder using power tools or an accountant using accounting software, you are forever being presented with and relying upon technology. Understanding a little about what’s going on, rather than being afraid and embarrassed, is crucial.”

So, too, is having fun along the way. Braben has since returned to the stars of his youth by way of Elite: Dangerous. This sequel to the game that made him his fortune was released in late 2015. Rather than turn to algorithms to scatter the universe with stars and planets, this time the Frontier team re-created our own galaxy.

The digital sky for the revamped game includes every known star present in our own, their positions drawn from the numerous publicly available sky maps, each of which can be visited in the game using a spaceship. Altogether, the game is comprised of 400 billion stars, their planetary systems – and moons – all, like the insides of the computers on which they run, waiting to be explored.

This article first appeared in the 02 February 2017 issue of the New Statesman, American carnage