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

Getty
Show Hide image

Syria’s world war: how the West allowed Russian and Iran to take control

As the civil war rages on, Syria has become a theatre for great-power rivalry, with Russia and Iran turning cynical opportunism into high policy.

It is getting harder to make sense of Syria’s agony. In fact, unless a distressing photograph of a suffering child – most recently Omran Daqneesh in Aleppo – goes viral and reminds us all for a moment of the human cost, it is probably harder to get anyone to pay any attention at all. The situation is increasingly complicated, politically and morally. There is a shifting array of militias both supporting the regime and on the opposition sides, all with their own internal tensions. None of the external actors seems to be fighting with quite the same purpose as the others. No one is articulating a vision of what a post-conflict Syria should look like: perhaps because there isn’t one, except for the harsh, reductionist version offered by Islamists. The one thing that’s sure is that this conflict isn’t about the Sykes-Picot Agreement, whose hundredth anniversary fell in May, triggering a flood of sanctimonious commentary. The borders we see in the modern Middle East were the product not of a 1916 Anglo-French stitch-up, but of the Paris Peace Conference, the Treaties of Sèvres and Lausanne, the League of Nations mandates, subsequent interstate agreements in the 1920s and sometimes – as in the case of Saudi Arabia and much of the Persian Gulf, or Yemen – even later. Nor is it about Israel, whose own dilemmas seem ever less exceptional as we look at other communal conflicts across the region.

Russia in particular has made cynical ­opportunism into high policy. As a party to the conflict, it has managed in the past year to kill roughly 2,500 civilians, including over 200 children and 28 medical staff (more than Islamic State). But it is also apparently Washington’s preferred partner for peace. Russia has historically had predatory designs on Iran but the latter now lets it use one of its airbases, a dubiously constitutional act that Russia gleefully proclaims to the world, to the apparent disquiet of some in Iran. It is aligned with Bashar al-Assad but also with some Kurds. It co-ordinates tactically with Israel but fights alongside Hezbollah. Russia was previously hostile to Turkey, which opposes Assad but is now trying to halt the advance along the Syrian-Turkish border of the same Kurds whom his air force is bombing. Turkey is making eyes at Iran. And the Chinese have just offered extra training to Assad’s army.

The problem is not that borders are disappearing but that some states are fragmenting within these borders. This produces horrors such as Islamic State and other, publicly more cautious and sometimes divided, but still savage Salafi-jihadi groupings such as Jabhat al-Nusra (JaN) or Ahrar al-Sham (AaS). It also provides other states with an excuse to colonise the hollowed-out husks of their neighbours in ways that might prove far more enduring than the international settlements of the 1920s.

If you happen to be in the Israeli-occupied Golan (as I was recently) and drive up beyond Katzrin to the de facto border with Syria, you can see through field glasses the movement of armed groups associated with JaN or IS. The most significant of these, Liwa
Shuhada’ al-Yarmouk, occupies an enclave in southern Syria, to the south-west of the Golani town of Quneitra, whose main buildings were dynamited flat in the 1973 war. They are surrounded by elements of the Free Syrian Army (FSA) and other armed opposition groups, including JaN.

This is remarkable. This border was for four decades the quietest of all Israel’s frontiers with its enemies. When you ask senior Israelis – civilian and military – what this means for them, they shrug and say things like, “At least they are behaving themselves,” by which they mean, of course, that they are not attacking Israel. But if you probe, you discover a wider unease. This is only partly assuaged by the efforts Israel has made over the past three years to keep tabs on the situation by, for instance, offering medical treatment at Israeli hospitals to well over 1,000 wounded Syrians (by some accounts double that number), mostly opposition combatants. The treatment is delivered partly by Druze doctors whose historically irredentist community straddles the border.

If you go next to Jordan and talk to senior Jordanians, you will detect a similar unease. Some of it comes from the same concern about the threat from Salafi-jihadi groups – the murderous Abu Musab al-Zarqawi was Jordanian, after all – or the continued presence on Jordan’s northern border of increasing numbers of refugees whom the country simply cannot absorb. Some comes from greater Russian activity on the same border, most notably the recent air strikes on the FSA outpost at Tanf, halfway to al-Bukamal,
one of the major crossing points on Syria’s border with Iraq and, together with its counterpart in Iraq, al-Qaim, the nearest hub of Sunni jihadi insurgency. But in both countries there is a feeling that the conflict in Syria may ultimately produce a realignment of forces within Syria and Lebanon that will constitute a far more formidable threat to Israel than anything we see today.

***

This does not mean the continued killing in Syria does not matter. It does and it is shameful. The UN’s special envoy Staffan de Mistura said in April that the total number of deaths had reached approximately 400,000, mostly killed by regime action. Half of Syria’s entire population has fled or is internally displaced. For want of an alternative policy, the US administration has been casting around for ways of bringing influence to bear through Russia, which, alongside Iran, is the main external actor in the conflict. This influence remains focused on combating IS, JaN and other jointly designated armed Sunni Islamist organisations, an appalling group of people, but not the only ones by any means. We have had frequent reports of another proposed deal between the US and Russia under which the two countries together would designate areas where there is a confirmed JaN presence for joint or independent targeting – as well as continuing air operations (few of which have been Russian) against Islamic State. You might think that developments around Aleppo in recent weeks would make this less likely: but in Syria, conventional reasoning has ceased to apply.

In any case, the agreement would have little bearing on the operation of the Syrian air force, which would remain free to drop barrel bombs anywhere it liked – as long as it didn’t get in the way of joint Russian-US operations. It would not prevent any other sort of military activity by Assad’s forces – through artillery bombardments or ground-to-ground missiles, for example, which are already the regime’s principal tactics. Clearly it has had no impact on Russia’s current air operations, which redoubled in intensity after opposition gains in Aleppo in the past few weeks. And it would not obviously reduce support from the Gulf and Turkey for elements of the armed opposition.

The thwarted coup in Turkey will complicate matters further. President Recep Tayyip Erdogan had already been making overtures to Assad – who, when I was ambassador to Syria in 2007, publicly claimed that Turkey was Syria’s best friend in the region. Now resurgent with a newly providential purpose but also conscious of his and his government’s vulnerability, Erdogan may, after purging the army and security forces, decide to focus on the constitution, the economy, his internal enemies and the Kurds, who remain, in his view, the main threat to national security, both inside and outside Turkey. His visit last month to Moscow to repair relations with Vladimir Putin (who has been cultivating the Kurds to spite him), Prime Minister Yildirim’s warm words after Foreign Minister Javad Zarif’s visit to Istanbul in March, and the Turkish army’s support for the Arab/Turkmen intervention in the town of Jarabulus, previously a target of the largely Kurdish Syrian Democratic Forces, all point in the same direction. If that means supporting a militia – Nour al-Din al-Zenki, which filmed its men beheading a 12-year-old boy in Aleppo – too bad. As a result, the Turks’ commitment to the fight against IS (never entirely convincing) – or indeed, to any intervention in Syria that does not serve their own purposes – may weaken further, especially if there are more attacks inside Turkey like the suicide bombing of a wedding party in Gaziantep on 20 August.

There are reports that traces of nerve gas have been found once more in Syria. There have also been claims recently of the continued military use by the regime of phosphorus and incendiary thermite, and by both sides of other chemical substances.

I remember vividly the last week of August 2013, when Assad was going to be punished for stepping over that particular “red line”. I was in Riyadh at the time and involved in seeking, on behalf of the British government, senior engagement by the Saudis in an international response, which they were willing to give. The sense of frustration when the UK and US stepped back was palpable. It was palliated a little by the US-Russia deal to remove Syria’s stocks of chemical and biological weapons material and Assad’s agreement to sign the Chemical Weapons Convention. There have been numerous suggestions since then that this deal was never as clear or complete as proclaimed. But most people shrugged the objections off as the best being the enemy of the good. What was a barrel of chlorine between friends? It was a great international achievement and showed what could be achieved by not doing “stupid shit”.

If the nerve-gas and other reports are true – and a UN investigative report suggests they are – it maybe doesn’t look such a great achievement after all. It may even begin to look like an enabler for Assad – in the same way as all the subsequent little bargains with the Russians do and, indeed, the mother of all international achievements, the Iran nuclear deal. It will also represent yet another erosion of international norms, the very thing that we in the West say we value above all else.

***

As we approach the end of the second and final term of the Obama administration, experience extraordinary scenes at the Republican and Democratic conventions and await the decision of the American people on their new president in November, what does the balance sheet in Syria look like? Not so good – even for those who see Sunni Salafi-jihadi groups as the main enemy. It is true that Islamic State remains under severe pressure in parts of Syria and Iraq and has lost territory, most recently the strategically sited border towns of Manbij, al-Rai and now Jarabulus in Syria, doubtless reflecting an improved US-led military strategy. Yet IS has also shown considerable resilience. The 21 May audio statement by Abu Muhammad al-Adnani, its official spokesman, on the meaning of victory – now amplified by a recent editorial in its weekly Arabic newsletter, al-Naba’ – suggests that IS is preparing to regroup outside urban centres within Syria and Iraq if it loses Raqqa and Mosul – and to send shards of Islamist violence flying in countries across the world through the agency of true believers everywhere. JaN may just have announced a tactical disaffiliation (though significantly not a break) from al-Qaeda, but this is designed to enable the group to hide in plain sight. It continues to grow in strength in north-western Syria and is imbricating itself in the defence of Aleppo, at the heart of the armed opposition groups acceptable to the West. Past Russian air strikes have only reinforced its position: other armed groups are heavily involved in many of the same battles and it is hard to disentangle them. In any case, no one is going to stand idle as the Russians target one of the most effective groups of anti-Assad fighters.

The Geneva III peace talks on Syria have ground to a predictable halt, with the Russians using their willingness to shape the conflict to influence US policy, too. Meanwhile, the humanitarian situation remains appalling. Aleppo remains doubly besieged, in spite of the latest fighting and opposition success in reopening a narrow access point in the south-west of the city. The Russians, supported by Hezbollah and Iraqi Shia militiamen, are targeting the area and their offer of humanitarian corridors and pauses looks ever more bogus. The UN, whose own relationship with the regime has raised concerns, is warning of another disaster in the making as non-combatants in the deeply divided city become trapped between the hammer of Assad and his allies and the anvil of the armed opposition.

***

As we obsess about Sunni violence, Hezbollah continues to prosper. The Lebanese Shia militia has lost large numbers of men – as many as 2,000 since the start of the conflict. That is more than it lost against Israel between 1982 and 2000: there have been mutterings about this in the Shia community in Lebanon. Hezbollah fighters, too, may be starting to blame the Syrian army’s lack of offensive spirit for some of their casualties, if recent tweets from the Aleppo front line are correct.

They have lost senior commanders, notably (in May) Mustafa Badreddine, the successor to the infamous Imad Mughniyeh, as well as lesser figures such as Samir Kuntar, who beat a four-year-old girl to death on an Israeli beach in 1979. Mughniyeh’s own son was killed last year. And the war in Syria is costing them millions of dollars a month, at a time when their business wing is being squeezed by the US and the Gulf Co-operation Council (GCC) – a cost that Iran, under pressure of its own, is helping to meet. But Hezbollah, like the Iranians, can shrug off such losses. The gains it has made in operational capability – command and control, planning, logistics, complex battlefield management and so forth – and in terms of resupply from Iran make up for them. It has probably doubled its available military forces, to perhaps as many as 45,000 troops. It has rebuilt and improved its weapons stocks: in spite of Israeli interdiction efforts, it is believed to hold well over 100,000 short- and medium-range missiles, whose accuracy is much improved. It has become skilled at using UAVs. It is rumoured to have received air-defence systems via Iran. And, in the wider Levant, Russia’s delivery to Iran of the S-300 mobile air defence system this year, as well as Iran’s reported development of a copycat system, the Bavar-373, potentially gives Tehran the capacity to deny access to US and other aircraft, not just over Iran but over Iraq, parts of the Gulf and perhaps, in the future, Syria.

The Lebanese Shias have no serious political alternative, and no other community in their country can compete. As their armed militia’s presence in Syria corrodes the communal consent on which Lebanon’s own political system rests, their ambitions, like those of their patron and now partner Iran, may be growing.

***

When the conflict ends or stabilises, as one day it will, Hezbollah will almost certainly be militarily stronger, unless Assad loses. It is unlikely to believe in a federal solution in Syria any more than its analogues do in Iraq. Admittedly, it would be easier to achieve such a structure in Iraq, where federalism is enshrined in the constitution and already applies in the Kurdish north. But federalism is anathema to Assad. And in both places, a solution that places real power in the hands of a central authority dependent on Iran is almost certainly the preferred goal. If that entails managing continued low-level conflict with Sunni insurgent groups, so be it.

In the longer run, the big targets remain Israel, the US and its regional partners. Hezbollah and Iran have lost a huge amount of support in the wider Islamic Middle East because of their sectarian involvement in Lebanon, Syria and Iraq. This has not stopped them persistently trying to make mischief: indeed, it, and power games within Iran’s highly competitive governing elite, may be precisely why they do so. That in turn is one reason why the GCC states are now taking unprecedented action against them.

But Hezbollah can live with this. Assad has reinforced his hold on Damascus with its help and is likely to remain dependent on it for the foreseeable future. It has made the protection of the Shia shrines in Syria a religious mission. It is still trying to recruit sympathisers within the occupied Palestinian territories: the Israelis recently discovered a cache of Hezbollah explosives on their side of the border. More broadly, the public appearance in Quneitra of Mohammad Reza Naghdi, the commander of the Basij – a force brigaded under the Iranian Revolutionary Guard Corps (IRGC) – peering back through his own field glasses towards the watchers on the other side of the border, and the extraordinary report that the Iranian ambassador in Damascus has taken it upon himself to appoint a new head of the Assad regime’s National Defence Forces in the nearby Druze city of Suwayda, show clear intent. And if at some point in the not-too-distant future Hezbollah and Iran are able to launch new operations against or even inside Israel from secured positions in southern Syria, the picture might change again rapidly. With or without nerve gas.

In the end, the struggle against Sunni jihadis will be long and brutal. But there is an answer available if the region’s states – notably Iraq, which in my view is still just about salvageable if we focus properly on the endgame after Mosul – are prepared to reintegrate disaffected Sunnis effectively into their domestic political processes. An Iranian-backed victory for the Assad regime in Syria would make this far more difficult.

The consequences of this struggle that we face in the West are horrific but not a threat to our existence (unless we allow them to be so) and manageable with patient and better-resourced intelligence and police work, better communications and popular resilience.

The battle against Iran’s militiafication of states in the Middle East is less tractable. Iran itself is built on this model. Its deep security state uses it to suppress internal dissent and block reformists. It exported it decades ago to Lebanon. In Iraq, the Iranian-backed Shia militias that constitute the most significant part of al-Hashd al-Sha’abi (the “popular mobilisation”) recently claimed that they were brigaded by Prime Minister Abadi with the rest of Iraq’s official military and counterterrorism forces some months ago. Whatever Abadi’s intentions may have been, they will seek to exploit this to secure a role in any assault on Mosul, the most symbolically resonant Sunni city in Iraq.

The Kurds will, as always, be caught in the middle, trying to play off more powerful ­actors against each other, perhaps tempted to seek sponsorship from Iran and Russia, and surrounded by hostile Arab communities in a cycle of displacement and revenge.

In the absence of the US, all this allows an amplification of Iranian influence across the region that in some ways poses a more general threat to the Middle Eastern order – because it is part of a long-term, transnational design backed by a powerful state – than any other. If Iran can make its projection of power through zombie states and sectarian non-state actors a permanent feature of the landscape, it would be a great achievement, overturning a hundred years of a more or less stable (if unsatisfactory) interstate Arab acquis. This would also prepare the ground for new sorts of conflict within and between states and prove very hard to undo.

That is the source of tensions between Iran and the Sunni Gulf states, which has led the latter – disappointed in the US, rebuffed by Russia but welcomed by Israel – to seek support in surprising places. It is one of the factors in the war in Yemen, which has led to accusations that Saudi-led forces have unlawfully targeted civilians and contributed to the creation of another humanitarian catastrophe. Without political change at the centre, it may lead to Shia-on-Shia conflict over the spoils of a post-Mosul Iraqi state. It has led to war before between Israel, Hezbollah and, indeed, Hamas. It will do so again. Next time will probably be worse. The capacities of all sides have been strengthened. And, given the internationalisation of the Syrian conflict, it will prompt far more states and non-state actors to make unexpected alignments. This will be a new form of instability in the region.

The Middle East will be a huge challenge for whoever is elected the new president of the United States. The usual American approach to conflict management in the region, which rested on clear political resolve, may no longer work: if Russia now shapes the battle space in Syria, who will shape it in Gaza and northern Israel? It will be a challenge for the European Union, which is intimately affected by the collapse of Arab states. And it will be a challenge for a British government that wants to show it is not retreating from a world it helped to shape – only not through Sykes-Picot.

John Jenkins is the executive director of the International Institute for Strategic Studies – Middle East. He is a former British ambassador to Saudi Arabia, Libya, Iraq, Syria and Burma and a former consul general in Jerusalem

This article first appeared in the 01 September 2016 issue of the New Statesman, Syria's world war