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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Death of a dictator

How Caesar’s murder set the template for political assassination.

The assassination of Julius Caesar on 15 March 44BC (“the ides of March” by the Roman system of dating) is the most famous political murder in history. Caesar had recently been made “dictator for life”, and he was killed in the name of “liberty” by a group of men he counted as friends and colleagues. In the aftermath, the assassins issued coins with a design specially chosen to celebrate the deed and press home the message: it featured the memorable date (“EID MAR”), a pair of daggers and the image of the small hat, “the cap of liberty”, regularly presented to Roman slaves when they were granted their freedom. This was liberation on a grander scale, freeing the Roman people from tyranny.

Several of the characters whose biographies feature in Plutarch’s Lives – Caesar, Brutus, Cicero, Antony, Pompey – had a role in the story of the murder. Julius Caesar was the victim, his dying moments vividly described by Plutarch. In this account, there were no famous last words, “Et tu Brute?” or whatever; after a futile attempt to fight back, Caesar pulled his toga over his head and took the 23 dagger blows that killed him. Brutus was the leading figure behind the assassination, a frankly messy business, as Plutarch makes clear (with several of the assassins “caught in friendly fire”, accidentally wounded by blows from their own side), and he was soon more or less forced to leave the city.

Cicero, the Roman politician, philosopher, poet, wit and orator, was not party to the plot but was very likely an eyewitness of the murder, and was straight away consulted by the assassins about what on Earth to do next (one of their main problems was that they had not thought ahead). Antony was Caesar’s right-hand man, gave the address at his funeral, and tried to take on the role of Caesar’s defender and successor – though he soon found an even more powerful rival for that position.

Pompey was already dead by 44BC. He had been killed four years earlier in a civil war, leading those Romans who had then been prepared to resort to pitched battles to resist the growing power of Caesar. But his shadow hung over the assassination. Caesar was murdered in an expensive new meeting hall whose building Pompey had funded, and he fell in front of a statue of Pompey, splattering it with his blood. It was as if Pompey was finally getting his revenge.

 

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The death of Caesar has provided the template for assassination ever since and has been the focus of debate on the rights and wrongs of political violence. In 1865, John Wilkes Booth used the word “ides” as the code word for the planned date of the assassination of President Lincoln. Shakespeare in Julius Caesar, largely drawing on an early translation of Plutarch’s biography, used the events of 44BC to reflect on the nature of political power, ideology and moral conscience. Others have seen the assassination as a useful reminder of the futility of such attempts at direct action. For what did it achieve? If the assassins had really wanted to quash the rise of one-man rule in Rome, if they had wanted to kill the tyranny as well as the tyrant, they were strikingly unsuccessful. More than a decade of civil war followed (a major theme in Plutarch’s biographies of Brutus and Antony), but the end result was that Caesar’s great-nephew – “Augustus”, as he was later known, and the man who rivalled Antony as Caesar’s heir – became the first Roman emperor. He established autocratic rule on a permanent basis. So much for the return of “liberty”.

In the long history of Rome – founded, as the Romans calculated it, around 750BC – the murder of Caesar, for all its later notoriety, was just one of many political crises, which became particularly intense and violent in the 2nd and 1st centuries BC. This was a period of expansion, political change, even revolution. There were vast Roman conquests overseas and, as a consequence, an enormous influx of wealth into the city. Gleaming marble from Greece, rather than local brick and stone, began to be used for temples and other public buildings in the city; slaves started to make up the majority of the workforce; and so many people flocked to Rome that its population topped a million, the only Western city of that size until London in the early 19th century.

But this age also saw repeated outbreaks of civil war at home, political disintegration, mass pogroms of citizens and the final fracture of what had once been a more or less democratic system of government. As a leading politician, Caesar was almost typical in coming to a violent end. None of the men I have mentioned died in their beds, nor fighting some “barbarian enemy”. They were killed in conflict with other Romans, by Roman hands, or on Roman orders. Pompey, for example, after losing in battle to Caesar, was decapitated by an Egyptian eunuch, ably assisted by a couple of Roman veteran soldiers; Cicero was put to death in 43BC in one of the pogroms, on Antony’s instructions, his head and hands later pinned up in the centre of Rome as macabre trophies for the crowds to leer and jeer at. A little over a decade later, Antony ended up killing himself after he lost in battle to Caesar’s great-nephew and successor.

The Romans described and fiercely debated the stresses and breakdown of their political system, trailing all kinds of explanations and possible solutions. For this period was also one of intellectual revolution in Rome, when the rich tradition of Roman literature began. Starting in the early 2nd century BC, Roman writers for the first time tried to tell the history of their city, to reflect on its problems and on how they thought it should be governed; and they used writing, too, for political attacks, insults in verse, self-advertisement in public, and personal letters in which they shared their aspirations, fears and suspicions.

When Plutarch in the early 2nd century AD was writing these biographies, he could base his narrative on plenty of contemporary material from the age of Caesar. Some of this we can still read, including Caesar’s one-sided account of his campaigns against the tribes of Gaul and later against Pompey (one of the very few eyewitness descriptions of ancient warfare to have come down to us) and volumes of Cicero’s political speeches, philosophical treatises and hundreds of his private letters, made public after his death by his loyal heirs. This writing helps us to understand what lay beneath all that chaos.

The rapid growth of the Roman empire was a crucial and destabilising factor. For us, why Rome grew in a few centuries from a small, moderately successful town in central Italy to one with control over more of Europe and the Mediterranean world than any state before or since is one of history’s big puzzles. Most modern observers put it down to some unfathomable combination of greed, a highly militaristic ideology, a dose of good luck and a happy knack of converting those they conquered into Roman citizens, and so into new soldiers for the Roman cause. The Romans were less puzzled on this score, pointing to the support of the gods, their piety and a succession of defensive rather than aggressive wars, in which they intervened to protect allies under threat. They were more troubled by the consequences of overseas growth for society and politics back home.

Despite their popular modern image, the Romans were not simply thoughtless and jingoistic imperialists. Some worried that the wealth and luxury that came with conquest overseas undermined what they saw as old-fashioned Roman austerity, a few about the cruelty of conquest (there was even
one, perhaps not entirely serious, proposal to put Caesar on trial for genocide during his conquest of Gaul). Others faced the question of how to adapt the traditional structures of Roman government to cope with new imperial demands. For how could you control and defend a vast empire, stretching from Spain to Syria, with a power structure and a system of military command developed to run nothing more than a small town?

That was one of the big issues behind the revolutionary changes of this period, and one of the factors that promoted the rise of dynasts such as Caesar. The political traditions of Rome, going at least as far back as the end of the 6th century BC, had been based on the principle that power was only ever held on a temporary basis and was always shared. The citizens as a whole elected the city’s officials, who combined both military and civilian duties, held office for just one year at a time, ideally not to be repeated, and never had fully independent decision-making power.

That there had always been not one but two consuls (the most senior of these annual officials) is a clear sign of that long-established commitment to power-sharing. But it was a principle ill suited to governing a far-flung empire and to fighting wars that might take place several months’ distance from Italy; you could hardly travel there and back in the regular year of office.

The Romans improvised various solutions to that problem: sending men out to the provinces, for example, after their year of office in Rome. But increasingly the Roman people voted more and more power into the hands of ambitious individual politicians on an almost permanent basis, even though those votes were often ­controversial and sometimes violently resisted.

 

 

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Caesar was not the first to challenge the traditional model of power-sharing. Despite leading the traditionalists against Caesar in 49BC, Pompey had, only 15 years or so earlier, been granted unlimited power for years on end across the whole of the eastern Mediterranean, first to deal with the pirates and human traffickers operating on the sea, then to deal with one of Rome’s remaining enemies in the East, King Mithridates of Pontus (in modern Turkey). Cicero was one of those who successfully spoke up, in a speech whose text we can still read, to quell the opposition to this grant, which was regarded as a dangerous step in the direction of one-man rule.

Even Brutus, despite his fine slogans on the subject of “liberty”, seems not to have been entirely immune from similar dreams of personal power. The coin celebrating Caesar’s assassination may have displayed the daggers and cap of liberty on one side. But on the other was an image of the head of Brutus. In Roman eyes, heads of living people on coins smacked of autocratic ambitions: Caesar was the first to risk such a display at Rome, Brutus the second.

So one side of the age of Caesar, richly documented in Plutarch’s Lives, was a series of “big men”, bankrolled by the vast profits that followed imperial conquests, competing for personal power. And that competition often came down to open fighting – whether in the streets of Rome, where there was no police force or any form of peacekeepers to maintain order, or across the empire more widely (the final battle in the Roman Civil War between Caesar and Pompey was fought in northern Greece, and Pompey was brutally finished off on the coast of Egypt). As the coin of Brutus hints, Caesar’s murder came too late to put the clock back to old-fashioned power-sharing. If Augustus had not established permanent one-man rule, Antony or some other rival would surely have done so.

Another important side of the period was the increasingly intense debates about what we would call “civil liberties”. How was it possible to protect the rights of the individual Roman citizen in this violent turmoil? How were the rights of citizenship to be balanced against the safety of the state? This came to a head almost 20 years before Caesar’s assassination, in 63BC. As Plutarch and others described it, Cicero was consul and believed that he had uncovered a terrorist plot, masterminded by a bankrupt and desperate aristocrat named Catiline, to eliminate some of the leading politicians, Cicero included, and to burn down much of the city. Once he had frightened Catiline out of Rome, Cicero rounded up those he believed were his accomplices and had them all executed without trial, even though they were Roman citizens and, as such, had a right to due legal process. “Vixere” (“They have lived” – that is, “They are dead”), he said in a particularly chilling euphemism, as he left the jail after super­vising their execution.

Not everyone at the time approved. Caesar was among those who stood up and objected. He was what we can still recognise as a classic populist, combining – as many have since – aspirations for dictatorship with a knack for popular rhetoric and an ability to appeal to the interests of the people (though, unlike some more recent examples of his kind, he also had a strong sense of popular justice). But in general Cicero was hailed as a hero who had saved the state from destruction.

The approval did not, however, last for long. Despite claiming the protection of an ancient equivalent of the Prevention of Terrorism Act, Cicero was banished into exile, on the charge of executing citizens without trial. He was recalled within a few months but, during his absence, his house had been demolished and a shrine to the goddess Liberty had pointedly been erected on the site.

The rights and wrongs of this case were debated ever after. How far, the Romans wondered, were elected officials allowed, or obliged, to transcend the law to save the state? We now debate very similar issues; how far the interests of homeland security make it legitimate to suspend the rights and protection that citizenship ought to ­offer, or how far we can stomach the idea of detention without trial, or summary deportation, if it prevents the “bad dudes” from doing us harm. That is why this is one of the Roman causes célèbres that speak to us most directly.

 

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The age of Caesar, then, was one of political murder, street violence, constant warfare both inside and outside Rome and fundamental disagreements about how the state should be run, how democracy and liberty might be preserved, while the demands of empire and security were met. It is impossible not to wonder what it was actually like to live through – and not just for the elite, rich and male political leaders who were the leading characters and celebrity victims in the conflicts and the focus of all ancient writers. What of the ordinary men and women who were not in the limelight? Did life for them go on much as before, while the big men and their armies fought it out? Or did the violence and bloodshed touch almost everyone?

It is hard to know and wrong to generalise. Just occasionally, Plutarch does take his eyes off those at the top of the pile and throw a fleeting glance at ordinary people carrying on with their lives more or less as usual in the chaos around them. We meet in passing Cicero’s wives and his daughter, Tullia who, like so many women in the Roman world, died from complications of childbirth, along with her infant son. We have a glimpse of an enterprising trader from northern Italy, a man called Peticius, who in 48BC just happened to be travelling in his ship along the coast of Greece when he spotted Pompey, on the run after his defeat by Caesar – and gave him a lift south.

Most engagingly of all, thanks to information he had picked up from his grandfather, Plutarch gives us a tiny but vivid insight into the practices “below stairs” in the kitchens of the palace in Alexandria that – to the horror of many Romans – Antony eventually came to share with Queen Cleopatra. Apparently, the cooks were so concerned about preparing the wild boar to perfection, whenever the company upstairs decided to eat, that they had eight boars roasting, each put on to cook at a different time, so that one would be sure to be just right when dinner was summoned (do the cooks at Mar-a-Lago or, for that matter, Balmoral have the same problem?). It is a nice image of ordinary people living in their own world and dealing in their own way with (and maybe laughing at) the capricious demands of the world leaders they served.

But not all were so lucky. One memorable story told by Plutarch, repeated and made even more famous by Shakespeare in Julius Caesar, tells the fate of an unfortunate poet called Cinna. This man was not quite as ordinary as Peticius or the cooks in Alexandria; he was a friend of Caesar but he was not in the political mainstream. A couple of days after the assassination, he went to the Forum to see his friend laid out for his funeral and fell in with a crowd of Caesar’s mourning and angry supporters. These men mistook the poet for a different Cinna, who had been one of the assassins, and so tore the poor man limb from limb.

The message of the story is clear. Assassinations have innocent victims, too. Simple cases of mistaken identity (and there must have been many of those at Rome, in the absence of any form of official ID) can leave a blameless bystander dead. Shakespeare’s plaintive line “I am Cinna the poet, I am Cinna the poet” is a haunting reminder of the many who must have been caught in the crossfire when the leaders of the Roman world clashed.

“The Age of Caesar: Five Roman Lives” by Plutarch, translated by Pamela Mensch and edited by James Romm, is newly published by W W Norton

This article first appeared in the 06 April 2017 issue of the New Statesman, Spring Double Issue

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