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Refutation of Creationist Memes

Neurologica Blog - 3 hours 7 min ago

The term “meme” was coined by Richard Dawkins to refer to a unit of thought, behavior, or style that spreads through a culture, as if it were a living thing like a virus. That term has also been co-opted to refer to a social media construct that usually takes the form of a picture with a pithy phrase. Memes (of the social media variety, which is how I will use the term from here out) can be humorous and when well done can convey an important idea in a pithy and witty fashion.

We often will spread skeptical memes on the SGU’s Facebook page, and so I have been paying attention to them more recently. Creating a really good meme is challenging, and often I see memes that don’t quite work. The main challenge is conveying the proper nuance in a short phrase (Twitter carries the same limitation). Meaty skeptical ideas don’t often lend themselves to the number of words that can easily fit on one small picture. But often they can convey a core idea very well.

Of course, people of every ideological persuasion use memes to convey their message. Recently I have come across a number of creationist memes, and like all such nonsense they demonstrate only that creationists really do not understand evolution. Each meme conveys a profound misunderstanding, and it occurred to me that each creationist meme therefore presents a teaching moment. So here they are, with my analysis, a random assortment of creationist memes. If you come across others feel free to link to them in the comments and I will add them to the list.

Creationist Meme #1 – Chimp-Pig Hybrid

We’ll start with an easy one (from Evolution’s Family Tree): This is an excellent example of a straw man logical fallacy – attacking a weak argument that is easy to refute (or ridicule) but that does not actually represent the position of your opponents. The notion that humans resulted from a pig-chimp mating is a real idea proposed by Eugene McCarthy.

McCarthy, however, is not a “leading geneticist” but a crank. His proposal was soundly criticized by the scientific community, who did not take it seriously for a moment. Chimps and pigs are simply too distant evolutionarily to produce viable fertile offspring, and there is no real indication of porcine characteristics in humans. McCarthy is speculating wildly from superficial similarities between humans and pigs in a classic example of crank science.

Using this crank idea, rejected by actual evolutionary scientists, to criticize evolutionary theory is like criticizing planetary astronomy because of the wacky ideas of Immanuel Velikovsky.

Creationist Meme #2: Phylogeny

Here is a more serious meme (also from Evolution’s Family Tree) that conveys a misunderstanding about the science of evolutionary theory. First, I want to note the use of terminology here. The creator of this meme uses the term “evolutionism” instead of “evolution” or “evolutionary theory.” The implication here is that belief in evolutionary theory is an ideology, rather than a scientific position, a claim that is demonstrably wrong.

They also claim that phylogenetic trees such as the one presented here are presented by evolutionary scientists as “evidence.” They are not. They are a diagram that organizes our current scientific understanding of the evolutionary relationship among a group of species, which can either be extinct, extant, or both. These trees are based upon evidence, but they are not the evidence themselves.

This is such a basic misunderstanding that I have to wonder if the creator of this meme really knows that phylogenetic trees are not presented as evidence but could not resist using that claim as a propaganda dig. Either way, it is either dishonest, or profoundly ignorant.

More importantly, however, the meme completely misunderstands the purpose and meaning of phylogenetic trees. In the example here, the diagram is showing the evolutionary relationship among a group of extant (living) fish (that is why the lines all end at the top, which represents the present). Such a diagram may be derived entirely from genetic and morphological analysis of living species. In other words – the data being summarized here has nothing to do with fish ancestors and only has to do with relationships of modern fish.

Also, the diagram is clearly a schematic. The lines represent only the order in which phylogenetic branchings occurred, not actual evolutionary lineage. This diagram is not meant to represent common ancestors, that is not the data being shown.

Even when phylogenetic trees show extinct species from fossil evidence and attempt to capture evolutionary pathways (and not just branching order), it is rare for scientists to think that they have discovered a literal common ancestor to later species. Speciation events (the branching points in the tree) tend to occur in small populations and can occur in a few thousand years, which is a geological blink of an eye. It would be statistically very unlikely for a fossil to represent an actual common ancestor population. The fossil record samples mainly from large stable populations, which likely miss the actual branching points.

Further still, the meme clearly misunderstands the concept of transitional fossils (and claims they don’t exist). All species are, in fact, transitional in that they represent an evolutionary connection between other species. When we look at extinct species from their fossil remains, we see creatures that fit well into the evolutionary pattern of life. Because they fit somewhere into this web of evolutionary connections, they are transitional.  Even a fossil species that is at the end of an evolutionary dead end is still part of a larger group that is transitional between other groups. What we don’t find in the fossil record are creatures that fit nowhere in the evolutionary history of life – no true anomalies or non-transitional species.

Creationist Meme #3: The Walk of Progress

This meme is based on the common creationist claim that there are no transitional fossils. As I explained in #2, this claim grossly misunderstands what is meant by transitional, and also simply misrepresents the state of fossil evidence. In fact, there are billions of fossils sitting in museums throughout the world.

The meme takes for granted the “march of progress” icon of evolution, even though this is considered an old image that does not accurately represent evolutionary history. Evolutionary change over time does not generally occur in a linear fashion (there can be exceptions). Human history, for example, is a complex branching bush of speciation. There is also no direction in evolution. A modern hominid phylogenetic tree is much more complex than this simple image.

The primary misconception of this meme, however, is to confuse the common ancestor of chimps and humans with chimps. The meme points to the most ape-like creature in the diagram and proclaims “there are millions of these.” There aren’t. In fact, there are none. We have not discovered a creature that can be considered a common ancestor between chimps and humans. That period of time is not well represented currently in the fossil record.

If the creator of the image thought that picture was a chimp, then they are asking – why are there millions of chimps and humans (currently living species) when there are so few extinct hominids? This may have something to do with the fact that they are extinct.

A much better way to look at the evidence is this: Evolutionary theory predicted that all living creatures are actually related, which means that in the past there must have been creatures that were part way between any two closest living creatures. It seems that chimps are our closest cousins, therefore evolutionary theory predicts we will find fossils of creatures that are morphologicaly part way between humans and chimps.

This prediction proved true. There are now thousands of fossils of hominids, filling in the space between humans and chimps, with some branching off in their own direction, while others are clearly human ancestors. If evolution were not true, there would be no particular reason for any of these fossils to exist. It is interesting to see how motivated reasoning can allow someone to twist reality, and easily verifiable facts, into a particular narrative.

Conclusion

Creationist memes demonstrate that creationists do not have even a basic working understanding of evolutionary theory, or they ignore that understanding in order to score cheap propaganda points. One might argue that these memes are straw men and do not represent common creationist thought, but the fact is that they do. These types of claims are mainstream creationism.

Send me any more creationist memes that you find and I will take them down one-by-one.

Categories: Medicine

Update on Cholesterol and Statins

Science Based Medicine - 8 hours 20 min ago

The statin hypothesis is that statins reduce cardiac risk more than can be explained by the reduction in LDL cholesterol. That hypothesis has been overturned by a new study.

 

The consensus of mainstream medicine is that a high blood level of LDL cholesterol is a major risk factor for cardiovascular disease and that lowering high levels can help with prevention and treatment. Statins have been proven effective for lowering cholesterol levels and for decreasing cardiovascular and all-cause mortality. I recently wrote about the new guidelines for statin therapy.

Currently half of American men between the ages of 65 and 74 are taking statins, and 71 percent of adults with heart disease and 54 percent of adults with high cholesterol take a cholesterol-lowering drug.

There is still a fringe group of a few maverick “cholesterol skeptics” who think lowering cholesterol is useless or counterproductive.  But the evidence shows they are wrong.

Statins are beneficial, but some have questioned whether their benefits are due to their ability to lower cholesterol or to their anti-inflammatory effects. Or to both. There are two competing hypotheses, the LDL hypothesis and the statin hypothesis. A new study in The New England Journal of Medicine sheds some light on that controversy and tips the balance in favor of the LDL hypothesis.

The LDL hypothesis assumes that lowering LDL by any means will improve outcomes. It is supported by a lot of evidence. In the Cholesterol Treatment Trialists’ (CTT) study, a meta-analysis of studies involving over 90,000 subjects, they found that a reduction of 1 mmol per liter reduced the annual incidence of cardiovascular events by a fifth.

The statin hypothesis is that the improved outcomes seen with statins are due to other biologic effects unrelated to their cholesterol-lowering ability, in particular to their anti-inflammatory effects. There is also some supporting evidence for that hypothesis, such as the JUPITER trial, which showed that patients with low levels of LDL cholesterol but high levels of the inflammatory marker CRP benefited from taking statins. Previous studies showed no difference when other cholesterol-lowering drugs were added to statins.

The new statin study

The IMPROVE-IT trial was a large, well-designed, double-blind, randomized trial involving 18,144 patients over age 50 who had been hospitalized within the previous 10 days for a heart attack or high-risk unstable angina. Both groups got 40 mg of simvastatin; one group also got 10 mg of ezetimibe, a drug that lowers cholesterol by a different mechanism, reducing intestinal absorption. The combined group had significantly lower LDL cholesterol levels (53.2 mg vs. 69.9 mg) as well as significantly lower triglycerides, HDL, apolipoprotein B, and high-sensitivity C-reactive protein. The combined group also had significantly fewer cardiovascular events.

The absolute benefit was modest, with only a 2 percentage point difference in major cardiovascular events. There was no difference in all-cause death rates, adverse effects, or cancer. There was a high drop-out rate: 7% a year and 42% overall.

The event rate reduction was exactly what was predicted by the CTT analysis. An accompanying editorial  concluded:

Overall, IMPROVE-IT provides us with important information on the value of lowering LDL cholesterol levels, regardless of the agent used. These data help emphasize the primacy of LDL cholesterol lowering as a strategy to prevent coronary heart disease. Perhaps the LDL hypothesis should now be considered the “LDL principle.”

Other new cholesterol-lowering drugs

PCSK9 inhibitors have been in the news. They are monoclonal antibodies that target and inactivate a specific protein in the liver (proprotein convertase subtilisin kexin). In 3 recent trials reported in the NEJM, they lowered LDL dramatically, to the lowest levels ever seen in a lipid-lowering trial, and patients were 50% less likely to have a heart attack or stroke or develop heart failure over the 1-year period of the trial.

But they are not yet on the market, and the news is not all good. They must be injected every 2-4 weeks, they may be priced at $7000 to $12,000 for a year’s treatment, and they may cause neurocognitive side effects. They might become a viable option if only for selected high-risk patients who are unable to take statins or whose response to statins is inadequate. Time will tell.

Lower LDL cholesterol any way you can

For patients at high risk of cardiovascular events, current evidence supports the strategy of reducing LDL cholesterol levels. The initial approach involves reducing other modifiable risk factors as much as possible (smoking cessation, blood pressure control, healthy diet, weight loss, exercise, etc.). If risk remains high, the next step is statin therapy. If statins don’t reduce LDL cholesterol sufficiently, the addition of another cholesterol-lowering medication may offer additional protection. If statins are not tolerated, other medications that lower cholesterol can be expected to reduce risk. The potential role of the new PCSK9 inhibitors is not yet clear.

 

 

Categories: Medicine, Skepticism

The New Seralini Study

Neurologica Blog - Mon, 07/06/2015 - 07:47

Seralini, author of the infamous study alleging to show increased rates of tumors in rats fed GM food, the one that was retracted by the journal and then later republished in a separate journal, has published another controversial study.

The study, published in PLOSone, looks at the feed that is fed to lab rodents, the kinds used in GM research. They found:

All diets were contaminated with pesticides (1-6 out of 262 measured), heavy metals (2-3 out of 4, mostly lead and cadmium), PCDD/Fs (1-13 out of 17) and PCBs (5-15 out of 18). Out of 22 GMOs tested for, Roundup-tolerant GMOs were the most frequently detected, constituting up to 48% of the diet.

The implication is that all prior research looking at GMO and pesticide toxicity is now called into question because the control rodents would also have been fed a diet that contains some GMO, pesticides, and also heavy metal contaminants. The concept here is valid – control groups need to be proper controls. If you are testing the effects of a pesticide on rats, and the control rats are also getting the pesticide in their food, then the comparison is compromised. This would dilute out the effects of the test substance by increasing the background rate of tumors and other negative outcomes, the “noise” in the study. This would further mean that studies would have to be more powerful (contain more subjects in each group) in order to detect the diluted signal.

Although the logic of their paper is sound, the devil is always in the details. How much pesticides and other contaminants did they find? They found 1-6 pesticides out of the 262 they tested for in each feed studied. This does not sound impressive. Further, they did not demonstrate that the small amounts detected were biologically relevant. The dose makes the toxin, and trace contaminants are almost ubiquitous, but are well below biologically active levels.

What they did not demonstrate is that there is any difference between lab rodents fed the foods they tested vs a control without any pesticide, heavy metal, or GMO contaminants. That, of course, is the ultimate question, and without that data they are just speculating.

Also consider that until 20 years ago there was no GMO feed. Therefore we have historical controls prior to the use of GMO, and any original GMO safety testing would by necessity have had no GMO in the control feed. There also does not appear to have been any significant change in the baseline rate of tumors and other effect from prior to the introduction of GMO varieties to after.

Seralini’s latest efforts are already being highly criticized by scientists around the world. The Genetic Literacy Project summarizes many of them here. One point that several scientists repeat is that Seralini used recommended limits on daily intake as his threshold for toxicity, but he used the limits for humans. Typically a 100 fold buffer is added when determining safety levels for humans. The more scientifically appropriate level to use would have been the no observed effect level (NOEL). Therefore the levels he detected in the food was still likely far below that which would cause any effect.

The GLP also points out that in the original version of the paper, sent to the media two weeks prior to publication, Seralini did not disclose a major conflict of interest that was later added to the published version (likely because PLOSone required it). The study was partly funded by a company, Sevene, that produces and sells homeopathic potions. This in itself is odd – any scientist allying themselves with a company whose product is pure pseudoscience is showing poor judgement, in my opinion. But worse – Sevene sells a homeopathic detox treatment for the pesticides glyphosate and atrazine. This is a clear conflict of interest, as they have a stake in the outcome of this study.

Conclusion

In science data is king, but data is only as good as the methods used to collect it. We can evaluate those methods by reading the formal presentation that is published in the technical literature, but this still does not give us a complete picture. As I have discussed many times here, there is a great deal that goes on behind the scenes of a scientific study that may not be reflected in the final paper. For this reason some journal editors are considering requiring submissions to include raw data and any notebooks used during the study, to get a peak behind the scenes and help root out fraud or just sloppy technique.

This all means that the reputation of the researcher, their team, and their lab is important, as are full disclosure of any potential conflicts of interest. This is also why independent replication is critical.

It is not uncommon for one researcher or team, or a small group of researchers, to be out of step with the rest of the scientific community. Often these researchers have a particular ideology that they seem to be promoting through their research. There are, for example, anti-vaccine researchers who seem to be the only ones to come up with data calling into question the safety of vaccines. The same is true for the safety of cell phones, or wifi.

Seralini has earned a reputation as being a scientific outlier in this sense. The quality of his studies are generally highly criticized, his results questionable, and his conclusions tend to go beyond the evidence he presents and to have a decidedly anti-GMO theme. It is therefore difficult to have faith in any of his studies.

Even putting his reputation aside, the quality of this latest study, as published, has major flaws and is simply not compelling. That will not stop anti-GMO activists from exploiting it to dismiss GMO safety studies, which seems to be the intent.

Categories: Medicine

The war in California over nonmedical exemptions to school vaccine mandates, part 2

Science Based Medicine - Mon, 07/06/2015 - 03:05

Last week, in the run-up to the 4th of July holiday weekend, something happened that I truly never expected to see. SB 277 became law in the state of California when Governor Jerry Brown signed it. In a nutshell, beginning with the 2016-17 school year, the new law eliminates nonmedical exemptions to school vaccine mandates. When last I wrote about SB 277 for this blog three weeks ago, I explained why I thought it was unlikely that SB 277 would ever become law, so that California could join West Virginia and Mississippi as the only states that do not permit religious or personal belief exemptions to school vaccine mandates. Basically, it was because California is not Mississippi or West Virginia. It’s a hotbed of antivaccine activism. Although statewide vaccination rates are high, there are a number of areas where antivaccine and vaccine-averse parents have led to low vaccine uptake with resultant outbreaks of vaccine-preventable diseases. Most recently, a large outbreak centered at Disneyland served as the catalyst that made it politically possible for a bill like SB 277 even to be seriously considered by the California legislature. Even so, given that California is home to a number of antivaccine celebrities such as Rob Schneider, Alicia Silverstone, Bill Maher, Charlie Sheen, Mayim Bialik, and Jim Carrey, antivaccine pediatricians such as “Dr. Jay” Gordon and “Dr. Bob” Sears, and many of the activists at the antivaccine crank blogs Age of Autism and The Thinking Moms’ Revolution, I was not optimistic.

I was mistaken in my pessimism, and I’m happy about that. I’m grateful to all those who didn’t see passing this law as an impossible task, such as Senator Richard Pan and Ben Allen, and who worked tirelessly to see it through, as some of our regular readers did. I was also pleasantly surprised that Governor Jerry Brown didn’t betray California children by watering down the bill with a signing statement, as he did three years ago when an earlier bill (AB 2109) was passed to make it more difficult for parents to obtain personal belief exemptions to school vaccine mandates.

So now that SB 277 is law in California, what now?

The backlash

The first issue that will not go away is that antivaccine activists are very, very angry. Already, they are threatening to mount a recall campaign against Sen. Pan, complete with a Recall Pan website. Let’s just put it this way. I don’t get the feeling that this campaign will have much traction. Nor do I think that efforts to overturn the law through a referendum are likely to go very far, particularly if antivaccine activists keep trotting out Andrew Wakefield and Tony Muhammed of the Nation of Islam to speak at their rallies.

Its penchant for publicly featuring discredited scientists and religious cranks aside, the antivaccine movement, although small, is if anything very vocal and quite unafraid to go into full conspiracy mode. For instance, the aforementioned Jim Carrey unleashed a flurry of Tweets after the Governor signed SB 277, calling the law fascist, repeating old antivaccine tropes I like to refer to as the “toxins” and “pharma shill” gambits:

Greed trumps reason again as Gov Brown moves closer to signing vaccine law in Cali. Sorry kids. It's just business. ;^[

— Jim Carrey (@JimCarrey) June 27, 2015

And then:

California Gov says yes to poisoning more children with mercury and aluminum in manditory vaccines. This corporate fascist must be stopped.

— Jim Carrey (@JimCarrey) July 1, 2015

Next:

They say mercury in fish is dangerous but forcing all of our children to be injected with mercury in thimerosol is no risk. Make sense?

— Jim Carrey (@JimCarrey) July 1, 2015

Plus:

I am not anti-vaccine. I am anti-thimerosal, anti-mercury. They have taken some of the mercury laden thimerosal out of vaccines. NOT ALL!

— Jim Carrey (@JimCarrey) July 1, 2015

Concluding with:

I repeat! I AM PRO-VACCINE/ANTI-NEUROTOXIN, as is Robert Kennedy Jr. Please read the following article and book http://t.co/GTr9lReaXO

— Jim Carrey (@JimCarrey) July 1, 2015

There were others, but you get the idea. As I said at the time, to Carrey, apparently Dumb and Dumber is more than just a movie he made with Jeff Daniels. It’s a way of life. Also, either Jenny McCarthy had a more permanent affect on him than previously thought (I always thought he went antivax because he was in love with her), or he was always antivax, which is part of why McCarthy was originally attracted to him in the first place. Whatever the case, Carrey got so carried away (so to speak) that in one of his Tweets he posted a photo of an autistic boy named Alex Echols without his mother’s permission to illustrate his point of children being “poisoned.” In response, Alex’s mother complained on Instagram and Twitter thusly:

@JimCarrey Please remove this photo of my son. You do not have permission to use his image.

— Karen Echols (@karen_echols) July 2, 2015

The reason Echols was so unhappy was because her child’s autism was a result of tuberous sclerosis and couldn’t even semi-plausibly be linked to vaccines, as she pointed out on her Instagram account. Carrey ultimately was forced to apologize. Even though Carrey went too far and had to apologize, Reuben over at The Poxes Blog was correct to point out that Carrey’s Twitter meltdown was the perfect microcosm of how the antivaccine movement thinks, if thinking it can be called, by pointing out that “if Jim Carrey is not anti-vaccine, he is just as weird as all the other anti-vaccine cult members who claim to not be anti-vaccine but can’t endorse one single vaccine. Then they run off yelling, “Parental choice! Parental choice!”

Rather like Sandy Fleming, an antivaccine mother who was recently profiled in Los Angeles Magazine:

Why do you oppose SB 277?
Because we don’t have a situation or a pandemic that warrants the government forcing parents to make medical decisions. Being able to make decisions between you and your doctor is a right we have had for all of our lives, and it’s so important. Think about being able to decide with your doctor how you’ll be treated for cancer or a simple flu. There’s never been a one-size-fits-all medicine. This bill breaks the parent-doctor conversation. Don’t even bother reading warning labels, you don’t have an option in this case.

This all sounds reasonable on the surface, but I can’t help but note when reading quotes from parents like Fleming: It’s always about parental rights to them, never about the child’s right to proper medical care that protects them from preventable diseases. Indeed, Rand Paul himself made this argument explicit when he said:

The state doesn’t own the children. Parents own the children, and it is an issue of freedom.

In this, antivaccine activists are very much like the parents who refuse chemotherapy for their child with cancer, who also routinely invoke “parental rights.” In their opposition to SB 277 (or any law that makes it even just slightly more difficult to obtain a personal belief exemption to school vaccine mandates) antivaccine parents like Fleming routinely invoke their rights over those of their children. Actually, they go farther than that. They invoke their rights over not only those of their children, but over those of other people’s children with whom their children will come into contact at school. In this, “health freedom” is simply a dog whistle for the antivaccine movement which, translated, really means, “I invoke the ‘freedom’ to do whatever I want with my children, regardless of the consequences.”

Don’t believe me? Take a look at the reaction to the antivaccine movement to the death of a woman with a compromised immune system from the measles. On Thursday, the Washington State Department of Health announced that a issued this press release:

OLYMPIA – The death of a Clallam County woman this spring was due to an undetected measles infection that was discovered at autopsy.

The woman was most likely exposed to measles at a local medical facility during a recent outbreak in Clallam County. She was there at the same time as a person who later developed a rash and was contagious for measles. The woman had several other health conditions and was on medications that contributed to a suppressed immune system. She didn’t have some of the common symptoms of measles such as a rash, so the infection wasn’t discovered until after her death. The cause of death was pneumonia due to measles.

This is a horrible tragedy that I’ve been fearing for a long time, and it’s finally happened. The measles has claimed its first victim in the latest series of outbreaks. Indeed, this was the first measles death recorded in the US in 12 years.

I knew right away what antivaccinationists were going to say. They were going to say that they’re sorry, that this is horrible. Then they would make excuses, adding that this woman was immunosuppressed and that’s why she died. They’ll claim that measles is a benign disease. Of course, that’s only partially true. The mortality rate from measles in otherwise healthy individuals is quite low (approximately 1 to 2 per 1,000), but it’s not zero. Complications like pneumonia are by no means uncommon. Less common, but still to be feared, are complications such as encephalitis (again, approximately 1 in 1,000) or, even worse, the uniformly deadly complication of subacute sclerosing panencephalitis (SSPE). This is a rare but fatal disease of the central nervous system that results from a measles virus infection acquired earlier in life, usually developing 7 to 10 years after a person has measles, even though the person seems to have fully recovered from the illness. Elsewhere in the world, measles is far deadlier. It’s also incredibly infectious, caused by one of the most easily transmissible viruses known to medical science. Moreover, the measles virus itself is temporarily immunosuppressive, and vaccinating against the measles protects against more than just the measles.

But how could this woman have gotten so sick and died before it was realized that she had the measles? After all, the measles is nothing if not recognizable (at least to those who’ve seen it before), thanks to a characteristic rash caused by the disease. Here’s why:

It’s not surprising that the woman had no obvious measles symptoms; people with compromised immune systems often don’t develop a rash when infected with the virus, said Paul Offit, chief of infectious disease at Children’s Hospital of Philadelphia.

The woman’s death was a preventable, but predictable, consequence of falling vaccination rates, said Peter Hotez, president of the Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development in Houston.

As noted over at io9, rashless measles is rare, but far from unheard of. An overreview of measles warns:

Among immunocompromised persons, diffuse progressive pneumonitis caused by the measles virus is the most common cause of death [97–104]. These patients may first have typical measles with pneumonia, or they may have a nonspecific illness without rash followed by pneumonitis without a rash. In general, signs of pneumonitis develop in the 2 weeks after the first onset of symptoms [90, 96, 105]. Other patients have had reappearance of rash and pneumonitis after long intervals following “classical” measles [97, 106].

In other words, if you’re immunocompromised, you might not know you have the measles until you develop severe viral pneumonitis due to the measles virus. Make no mistake, in immunocompromised patients with the measles, pneumonitis is the most common cause of death.

This woman’s death was not tied to the Disneyland measles outbreak, but Clallam County had a small outbreak of measles earlier this year, which is not surprising given that Washington has been a hotbed of low vaccine uptake and antivaccine activity, to the point that the legislature moved to make it more difficult to obtain nonmedical exemptions. Clallam County has not been immune to parents declining to protect their children from vaccine-preventable diseases by claiming personal belief exemptions.

The bottom line is that there was an outbreak a few months ago in Clallam County, and, even though it wasn’t linked to the Disneyland measles outbreak (health officials report that it was a different strain of the measles), it almost certainly was linked to low vaccine uptake in areas of the county. That is why the antivaccine movement is dangerous.

Not surprisingly, the usual suspects are quick to claim that low vaccine uptake had nothing to do with why this woman died, that this death was not preventable. First up, there’s Dr. Jay Gordon, our favorite “I’m not antivaccine” antivaccine pediatrician, responding to questions on Twitter:

Yes, that’s Dr. Jay telling someone that this unfortunate woman’s death was not preventable! Not preventable? Nonsense! MMR is very effective at preventing measles, and if MMR uptake is adequately high, herd immunity will protect people who are unfortunate enough to be immunosuppressed. Dr. Jay is basically trying to pass the buck and duck responsibility.

Meanwhile, Dr. Bob Sears, master of the antivaccine dog whistle, is furiously trying to distance the Disneyland measles outbreak from this woman’s death:

MEASLES DEATH NOT LINKED TO DISNEYLAND OUTBREAK, ACCORDING TO ABC NEWS AND WASHINGTON STATE HEALTH DEPT SPOKESMAN

Here is an update from ABC News. Again, our condolences to the family.
According to the last line in the story, this case was NOT linked to the Disneyland outbreak. We don’t yet know what that means. It may have been a measles strain from somewhere else? We don’t know yet. Vaccine strains can also be picked up by immunocompromised people, as this woman was. But be have no facts about that whatsoever.

Again, our heartfelt condolences to the family.

That’s nice. You can almost hear Dr. Bob backing away and saying, “Don’t blame me!.” Even worse, he is trying to blame this woman’s death on viral shedding from vaccinated people, which is simply not justified, as secondary transmission of the vaccine strain of measles has not been observed. Of course, it doesn’t matter that this outbreak was due to a different strain of measles virus. It really doesn’t. What matters is MMR uptake. The reason it’s low in certain affluent areas is, at least in part, due to the fear mongering spread by Dr. Bob’s and Dr. Jay’s patients, some of whom are quite active in the antivaccine movement. (Remember, Dr. Jay was Jenny McCarthy’s son’s pediatrician back when she was transforming herself into a “warrior mother” going to war against vaccines.) It’s low because irresponsible pediatricians like Dr. Jay and Dr. Bob are sympathetic to the views of antivaccine parents, to the point where they not infrequently parrot antivaccine talking points. Indeed, Dr. Jay, relying on his “30 years of clinical experience,” has been known to insist that vaccines cause autism even as he admits that there’s no good evidence to support that belief.

If you want despicable, though, check out this comment by someone named Jen Glover Bishop:

If pneumonia was the cause of death then measles is a non issue. Pneumonia is a complication that can occur after the common cold in an immune compromised person. Anything would have led to pneumonia in a person like that. Life is not illness proof.

This is sort of true. Even if it were totally true, there’s one big difference between the common cold and the measles. We can’t prevent the common cold easily. We can prevent the measles. With a vaccine. And antivaccinationists do everything to deny and minimize their contribution to outbreaks. If you really want to see how low they can go, check out this comment by Christina Wright:

honestly, i call bullshit on this story. i’m sorry if it’s actually true, but its just way too vague and really sketchy that someone just so happens to die from measles as people are starting to wake up about all these bills being introduced. this is a scare tactic to whip the public back into shape. hello pharma pays $$$$$$ for marketing, thats all this is…a marketing strategy to set the tone of what’s to come.

Yes, it’s time for the conspiracy theories to come out. Same as it ever was. Of course, if conspiracy theories aren’t enough, then there’s always outright denying the importance of this story—and even that it’s legitimate—as Colleen Cron Oleksinski does:

With ALL due respect, why is this making national news? People die everyday without national recognition, why is this any different? By the way, Im not buying it either.

Oleksinski was answered by a chorus of Hallelujahs like this:

Setting the stage. They wasted no time. This is tragic absolutely. And what did they say, she passed in the spring? Did they wait this long to have an autopsy? Bring this out now, two days after CA signs BS277 and it is from a different state…perfect to infect the whole country with PANic and misinformation. Federal bill…I can’t wait.

And:

It’s making the news so that the sheep will once again become paralyzed with fear…and they won’t put up a fight when forced vaccinations come to their state.

And:

Getting the fear nice and deep to then roll out adult mandatory vaccines!

You get the idea. it’s not our fault, and this poor woman’s death is nothing more than a conspiracy by big pharma and the government to pave the way for jack booted thugs wielding syringes to force children and adults to be vaccinated. It’s a fantastical, paranoid delusion, but it’s what they believe, even at the expense of denying the human tragedy that’s just occurred. What do you expect from people who routinely compare SB 277 to the Fugitive Slave Act and the Holocaust?

This is what we’re up against in trying to build on the success of the pro-SB 277 forces in California and introduce similar laws in other states.

SB 277’s one big weakness

SB 277 is a major improvement in the law regulating vaccination and vaccine exemptions in California that protects children from infectious disease. However, it is not perfect, and we do not know how it will work in practice yet when it goes into effect next year because the California Department of Public Health has not yet issued regulations. For example, a question came up for me reading Gov. Brown’s signing message:

The Legislature, after considerable debate, specifically amended SB 277 to exempt a child from immunizations whenever the child’s physician concludes that there are “circumstances, including but not limited to, family medical history, for which the physician does not recommend vaccination.”

Thus, SB 277, while requiring that school children be vaccinated, explicitly provides an exception when a physician believes that circumstances — in the judgment and sound discretion of the physician — so warrant.

What does this mean? I went and took a look at the text of the bill as passed, specifically, Section 5:

SEC. 5. Section 120370 of the Health and Safety Code is amended to read:

120370. (a) If the parent or guardian files with the governing authority a written statement by a licensed physician to the effect that the physical condition of the child is such, or medical circumstances relating to the child are such, that immunization is not considered safe, indicating the specific nature and probable duration of the medical condition or circumstances, including, but not limited to, family medical history, for which the physician does not recommend immunization, that child shall be exempt from the requirements of Chapter 1 (commencing with Section 120325, but excluding Section 120380) and Sections 120400, 120405, 120410, and 120415 to the extent indicated by the physician’s statement.

It’s hard not to wonder whether this means that antivaccine pediatricians in California, like Dr. Bob Sears and Dr. Jay Gordon, are already putting money down on a new Lamborghini. No, that’s not my joke; I stole it from someone on Twitter:

@gorskon @MyHealthyBabies @JayGordonMDFAAP No doubt some CA doctors will profit from this. I hear Bob just ordered a new Lamborghini.

— Greg Hinson (@ackdoc) June 30, 2015

That might be going too far, but it does bring up a point. The biggest weakness in SB 277 is that it appears to leave it pretty much up to a child’s pediatrician regarding whether an exemption to the school vaccine mandate is medically indicated. In that, it is similar to the Mississippi law. In contrast, in West Virginia, it isn’t just the word of the child’s physician that matters; all requests for medical exemptions are reviewed by an Immunization Officer, who determines if they are appropriate “based upon the most recent guidance from the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) with respect to medical contraindications or precautions for each vaccine.” In other words, SB 277 does not appear to have any oversight regarding what reasons doctors invoke to issue medical exemptions, and, indeed, in his signing statement Gov. Brown explicitly mentioned that feature of the law as the reason why he was willing to sign it.

On the surface, this provision would indeed seem to be a godsend to antivaccine pediatricians, who will likely see their business boom in the wake of SB 277 as parents, no longer able to obtain nonmedical exemptions, start looking for medical exemptions in much the same way parents in states that allow religious exemptions but not personal belief exemptions suddenly found religion and used it as a justification for not vaccinating. Resistance to vaccination will flow wherever it can. I’m just happy that, in this case at least, only letters from a physician will be valid for obtaining a medical exemption. One can only imagine what would happen if letters from naturopaths and chiropractors, who, unfortunately, are licensed “health care professionals” in the state of California, were permitted. This was the case for AB 2109, where naturopaths were listed as one of the medical professions whose members could counsel parents on the benefits and risks of vaccinating and sign their personal belief exemption.

Be that as it may, there is clearly wide latitude given to California physicians on this issue. Indeed, Dr. Jay himself wrote yesterday:

Governor Brown signed this law because of the strong medical exemption provisions. He recognized that parents with reasonable medical objections—as opposed to personal or religious objections—must still have access to exemptions for their children.

Consult with a physician who knows your child and your family.

No one should scare you into or out of vaccinating.

This is the sort of thing that irritates me about Dr. Jay. He knows that the parents of some of his patients are antivaccine activists. How could he not? He was the pediatrician who took care of Jenny McCarthy’s son Evan back when she was emerging as America’s foremost antivaccine celebrity activist. Does he ever, in the privacy of his office, suggest to these parents that maybe—just maybe—it’s not such a good idea to spread misinformation demonizing vaccines as toxin-laden poisons causing autism, autoimmune diseases, neurodevelopmental disorders, SIDS, and even shaken baby syndrome? Only he and his patients’ parents know for sure, but I sure doubt it. Certainly, he rarely, if ever, publicly calls out anyone on “his side” for promoting such misinformation. Instead, he falls back on a vague false equivalency that paints pro- and anti-vaccine activists both as irrationally trying to frighten people to their position, as he did above. Of course, even if that were true, there would still be a big difference. What pro-vaccine activists say about the dangers of vaccine-preventable diseases is true. What antivaccine activists say about the dangers of vaccine is almost always untrue. In fact, Dr. Jay himself engaged in such fear mongering just a few months ago when he declared that The MMR is not controversial because of Wakefield, and I haven’t forgotten his many articles for The Huffington Post dating back a decade and appearances on TV that spread misinformation and fear about vaccines, invoked the “toxins” gambit, and likened vaccine manufacturers to tobacco companies.

His protestations otherwise (which, to be fair, I really think he sincerely believes, thanks to massive cognitive dissonance), we know what side Dr. Jay is on.

But back to Twitter. There was an exchange just last week in which Dr. Jay asserted:

@unhealthytruth Medical exemptions will be solely at the discretion of doctors. #SB277 Families unable to choose their MDs will have issues

— Jay Gordon, MD, FAAP (@JayGordonMDFAAP) June 30, 2015

Dr. Jay replied about “family history” in SB 277 and was asked:

.@jaygordonmdfaap Tell me how YOU as a PEDIATRICIAN would apply that. Be specific. #SB277

— David Gorski (@gorskon) June 30, 2015

He was therefore asked how he, as a pediatrician, would decide whether to recommend a medical exemption to school vaccine mandates, now that SB 277 basically gives him the power to do that. At first, he said, simply, “Nope”:

@gorskon Nope.

— Jay Gordon, MD, FAAP (@JayGordonMDFAAP) June 30, 2015

After some prodding, he did get one thing right:

@geekpharm: @gorskon @JayGordonMDFAAP if I say I'm worried the mercury will cause autism, would you give my kids a medical exemption?”__No

— Jay Gordon, MD, FAAP (@JayGordonMDFAAP) June 30, 2015

Which is a relief.

However, elsewhere, he remained maddeningly vague, going on about “family history” of reactions to vaccines, even though he admits that the AAP does not consider this a contraindication. He sparred with a couple of doctors, who asked him what specific medical conditions he’d consider a contraindication to vaccination. Oddly enough, he didn’t mention any of the contraindications that no one disagrees about, such as the accepted contrindication that children with severe immunosuppression (such as due to chemotherapy or illnesses that compromise the immune system) should not receive attenuated live virus vaccines. It would have been so easy to say that, because such a contraindication is on firm medical ground. But instead, Dr. Jay went here:

-2- Just the usual health care situation: If your doctor talks with you and respects your judgement your child will get needed exemptions

— Jay Gordon, MD, FAAP (@JayGordonMDFAAP) June 30, 2015

And:

-3- If not, some families w very reasonable requests for medical exemption will be turned down. "No shots, no school."

— Jay Gordon, MD, FAAP (@JayGordonMDFAAP) June 30, 2015

And:

@davidjuurlink @gorskon An adverse reaction to previous vaccine in patient or sibling is one good example.

— Jay Gordon, MD, FAAP (@JayGordonMDFAAP) June 30, 2015

So what does this mean? The cynic in me thinks it might mean this:

.@MyHealthyBabies I suspect @JayGordonMDFAAP's "medical criteria" for exemption under #SB277 will be "Mommy and Daddy want it."

— David Gorski (@gorskon) June 30, 2015

Certainly, for some physicians, that will be the main criterion. The question will come when it is parents who have a perfectly healthy child with no generally accepted contraindications to vaccination (such as immunosuppression) or even typical “contraindications” promoted by the antivaccine movement, such as a sibling who had an adverse reaction to vaccination, a sibling with autism, the child having autism himself, and the like. How far will pediatricians like Dr. Jay go to give their patients’ parents what they want? It will be a fascinating question, something to keep an eye on as SB 277 is implemented next year. One thing that I expect to happen is for dubious laboratories, like Doctors Data, to come up with more (and ever more bogus) panels of laboratory tests purported to predict “sensitivity” to adverse reactions from vaccines. Just you watch.

One comforting observation is that there doesn’t seem to be much of a problem with pediatricians writing up dubious recommendations for medical exemptions in Mississippi, whose law doesn’t require review of doctors’ requests for medical exemptions for their patients by an Immunization Officer. But Mississippi is not California, and the law has been in place there for many years. People are used to it. Also, California is one of the great paradises for the many “alternative” practitioners there, including physicians who have gone to the dark side, making the supply of physicians willing—shall we say?—to stretch the boundaries of indications for a medical exemption to vaccines likely much greater in California than it is in Mississippi.

Perhaps the most effective means of making sure that doctors sympathetic to antivaccine parents don’t come up with excessively creative rationales for recommending medical exemptions is vigilance by the state medical board, the federal government, and insurance companies. For instance, one quality metric that is being increasingly examined among pediatricians is the percentage of children who are up-to-date on the recommended vaccines. Pediatricians who fall short on that measure because they issue way more medical exemptions than average could well come under scrutiny. At the very least, they might be risk losing pay-for-performance bonuses. (Not all antivaccine-sympathetic pediatricians are in concierge practices that do not belong to any insurance plans, like Dr. Jay and Dr. Bob.) Unfortunately, state medical boards tend to be toothless; so I have little hope that complaints about a physician to the Medical Board of California about physicians issuing dubious medical exemptions will have much of an impact.

Don’t think that my pointing out this weakness in SB 277 means that I don’t think it’s an excellent law. It is. It’s passage is a major victory in the struggle to protect children from the ravages of infectious disease and a major defeat for the antivaccine movement, which marshaled pretty much everything it had to defeat it and still came up short. The California legislature and Governor Jerry Brown are to be commended, as are the innumerable advocates for children “on the ground” who worked tirelessly for its passage. But it is not perfect. It’s politics. Compromises had to be made.

SB 277 makes the situation in California much better than it was before with respect to child health and should serve as a model for the remaining 47 states that allow religious and personal belief exemptions. It is a beginning, not an end, and part of what needs to be done now is to keep an eye on its implementation. While I suspect that there will be some doctors who profit as a result of the law, fortunately I also suspect that the number of doctors who will be willing to go much beyond the CDC/AAP guidelines for medical contraindications to vaccination is and will remain small.

Categories: Medicine, Skepticism

Cochrane Review on your precious bodily fluids Community Water Fluoridation

Science Based Medicine - Fri, 07/03/2015 - 09:00

Dr. Strangelove has really great teeth, and really pure bodily fluids too!

One of the overriding themes of the Science Based Medicine blog is to use rigorous science when evaluating any health claim – be it medical, dental, dietary, fitness, or any other assertion put forth with the intention of improving one’s health. Once the scientific evidence is evaluated as to efficacy, there are other criteria which must be taken into consideration, such as ease of administration, costs, possible adverse effects, and so on. Benefits have to be carefully weighed against risks to properly determine any appropriate course of action. For example, if a new pill is developed which is significantly better at , say, managing hypertension than existing medications, but it kills 10% of patients taking it, it obviously would not be the drug of choice. Conversely, if a proposed treatment, say homeopathy, is touted as being 100% safe with no side effects, but has absolutely zero benefits, it too would not be a recommended treatment. It’s a complicated and often ambiguous algorithm, and is imperfect due to the impossibility of attempting to quantify non-quantifiable values and qualities.

The perils and profits of fluoride

And so it is with the never-ending fluoride debate. Fluorosis is the major “risk” of fluoride ingestion, while decay prevention is the primary benefit (ignoring unsubstantiated claims by anti-fluoride groups of fluoride toxicity causing lowered IQ, chronic diseases, and other maladies). I’ve covered this topic before here and with Dr. Clay Jones here, but a new systematic review from the Cochrane Collaboration was recently released, its goal being “to assess the effects of water fluoridation (artificial or natural) for the prevention of tooth decay. It also evaluates the effects of fluoride in water on the white or brown marks on the tooth enamel that can be caused by too much fluoride (dental fluorosis).” This marks the most comprehensive literature review to date on the subject, and instead of crystallizing our grasp on the effectiveness of community fluoridation programs, it has raised more questions than it answered. In this brief and admittedly superficial overview (cut me some slack; I had to work under a tight deadline while traveling!), I will attempt to unpack what the Cochrane Report says and means and, perhaps more importantly, what it doesn’t say and mean.

Review design

First things first: let’s look at the design of the systematic review. The consortium of Cochrane reviewers, possibly cloistered in a concrete bunker far beneath the Urals, searched through all of the major databases – The Cochrane Oral Health Group’s Trials Register, The Cochrane Central Register of Controlled Trials, MEDLINE via OVID, EMBASE via OVID, Proquest, Web of Science Conference Proceedings, and ZETOC Conference Proceedings . They searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization’s WHO International Clinical Trials Registry Platform for ongoing trials. From these sources, they found 4,677 references after eliminating duplicate search query results. For their inclusion criteria for tooth decay rates (also called dental caries), they included only prospective studies with a concurrent control that compared at least two populations – one receiving fluoridated water and the other non-fluoridated water – with outcome(s) evaluated at least twice, at separate times. For the assessment of fluorosis, they included any type of study design, with concurrent control, that compared populations exposed to different water fluoride concentrations. After applying these criteria to the large initial group of research literature, they winnowed it down to 155 papers that were suitable for evaluation. Twenty studies examined tooth decay, most of which (71%) were conducted prior to 1975. A further 135 studies examined dental fluorosis. Overall, it was a well-done, rigorous systematic review.

Results

Fluorosis
Let’s look at the results and conclusions, shall we? We’ll start with the fluorosis arm of the study, since it’s the easiest and most straight-forward. The researchers calculated that, in areas with a fluoride level of 0.7 ppm in the water (which is the current recommended concentration of community fluoride programs in the US), approximately 12% of the people evaluated had fluorosis that could cause concern about their appearance. And although the majority of the research articles (135 out of 155) were about fluorosis, the Cochrane Group still concluded that “(t)here is a significant association between dental fluorosis (of aesthetic concern or all levels of dental fluorosis) and fluoride level. The evidence is limited due to high risk of bias within the studies and substantial between-study variation.”

So, for this part of the report, there is no real earth shattering news. At the recommended doses of fluoride, there is a small risk of fluorosis, harmless but
potentially annoying cosmetically. We knew this already, and no new light was shed on the subject. However, what is of note here is that of the 135 studies – the best, most rigorous studies, mind you – the evidence was generally found to be not of high qualitative value. In fact, the authors stated “(o)ver 97% of the studies were at high risk of bias and there was substantial between-study variation.” Does that mean the research is wrong? No, it doesn’t, and the research probably isn’t wrong. The report merely speaks to the confidence one has in using said research for drawing any sort of definitive conclusions or making recommendations based upon it. It also speaks to what we Science Based Dentists have been screaming for years – that the quality and quantity of dental research at the population level is woefully thin and inadequate in many areas.

Caries
Which brings us to fluoride and dental caries. Here things get a little murkier, and the stakes are higher. After all, the entire raison d’être for the recommendation of fluoride by just about every dental, medical, governmental, and public health organization is to prevent cavities, the number one disease affecting the human species. If fluoride is shown to offer no protection against tooth decay, then its use cannot be justified, no matter how insignificant any side effect might be.

For this arm of the review, only twenty studies out of the original 4,677 search hits fit the criteria for evaluating the role of fluoridation and caries prevention. These studies too showed a high risk of bias, and even more problematic was that most of the studies included in the systematic review were done prior to 1975, before fluoride was used routinely in toothpastes, mouthwashes, and even topically in dental offices. At that time the city water supply was the primary source of fluoride. But since the pre-1975 studies and the post-1975 studies were merged into one meta-analysis, the confounding factor of fluoride sources other than municipal water obfuscate the significance of the results. Overall, community water fluoridation has resulted over time in a 35% reduction in tooth decay in primary teeth and a 26% reduction in permanent teeth. Moreover, fluoridation increased the percentage of children with no decay by 15%. These are very impressive numbers and attest to the vast reduction in pain, suffering, and dental health care expenses over every demographic group in society. That is why the Centers for Disease Control (CDC) has called fluoridation one of the Top Ten public health victories of the twentieth century.

But here’s the rub. Historically, it was thought that the benefits of fluoride occurred primarily via systemic ingestion, where it would be incorporated into the tooth enamel as it formed. Unfortunately, that is also the route by which fluorosis forms – a spanner in the works during tooth development. More recent research, however, has demonstrated that much (if not most) of the strengthening of the enamel is due to the topical effects of fluoride. Fluoride from toothpastes, fluoride varnishes, mouthwashes, and yes, even drinking water, “soaks” into the outer layers of enamel to make it more acid resistant and therefore less susceptible to dental caries. I hope that by now you can see why this systematic review is problematic in ascertaining if community water fluoridation programs are justified. Are the benefits we enjoy from fluoride primarily from toothpastes, professional dental applications, processed foods made with fluoridated water? What role does community water fluoridation still play in the twenty-first century?

Despite the new report, fluoridation is still unanimously supported and endorsed by all of the major health organizations – the American Dental Association, American Academy of Pediatrics, American Association of Public Health Dentistry, the World Health Organization, the CDC, and so on. And while the pure benefits of water fluoridation aren’t as obvious due to widespread fluoride consumption by various other means, they are still important. For example, people living below the poverty line may not have access to good-quality fluoride toothpaste or professional dental fluoride varnish applications. Fluoridated water is a cheap and effective means to administer fluoride, and is non-discriminatory. Unfortunately, this too could not be substantiated in their report.

Ambiguity and qualifications

When you read the conclusions of the systematic review, the wording is much more ambiguous and non-committal in their endorsement of water fluoridation. To wit:

Although these results indicate that water fluoridation is effective at reducing levels of tooth decay in children’s baby and permanent teeth, the applicability of the results to current lifestyles is unclear because the majority of the studies were conducted before fluoride toothpastes and the other preventative measures were widely used in many communities around the world.

There was insufficient information available to find out whether the introduction of a water fluoridation programme changed existing differences in tooth decay across socioeconomic groups.

There was insufficient information available to understand the effect of stopping water fluoridation programmes on tooth decay.

No studies met the review’s inclusion criteria that investigated the effectiveness of water fluoridation for preventing tooth decay in adults, rather than children.

They sure said “insufficient information” a lot, didn’t they? If you weren’t a regular reader of Science-Based Medicine, you might read the report and conclude that the fluoride ship has sailed, that there is no longer a justification for putting fluoride in municipal water supplies. But since you are a regular reader, I’m certain the phrase “absence of evidence is NOT evidence of absence” immediately popped into your head. And that, dear reader, is (in my opinion) the crux of the review. Although it can be (and already has been) spun by the anti-fluoride crowd as evidence that fluoride isn’t effective, that’s not what the report says at all. Fluoride has a proven track record in the reduction of tooth decay. The main unanswered question (which the Cochrane Group hoped would be answered in this meta-analysis) is: to what degree of protection against dental caries does community water fluoridation currently confer? I think it can be assumed that if pre-1975 research papers were eliminated from the systematic review, and more recent high quality studies were available, the overall reduction in decay would be less than the pre-1975 levels. The authors state:

Our confidence in the size of effect shown for the prevention of tooth decay is limited due to the high risk of bias in the included studies and the fact that most of the studies were conducted before the use of fluoride toothpaste became widespread.

It’s this statement of limited confidence that has not only allowed the anti-fluoriders to seize upon it for their own aims, it has even led mainstream new sources to report on the report in such a way to mislead their readers. Newsweek’s headline, for example, reads “Fluoridation May Not Prevent Cavities, Scientific Review Shows“. Of course, this is irresponsible journalism, as that’s not what the review showed at all. But it does peddle false scientific information to its huge readership, which is regrettable for a news outlet of Newsweek’s caliber.

So until further research is in, you don’t have to attend anti-fluoride rallies or write a letter to your local newspaper calling for the cessation of community water fluoridation. It is still safe and effective, one of the best prevention values in health care. Each dollar spent on fluoridation reduces dental costs many fold, not to mention untold pain, suffering, loss of teeth, and loss of productivity.

 

 

Categories: Medicine, Skepticism

A Quick Logic Lesson

Neurologica Blog - Fri, 07/03/2015 - 08:19

Try your hand at this quick puzzle, then come back and read the rest of this post.

How did you do? This is a great little test with a very important lesson.

The discussion that follows the puzzle is a fairly good explanation of confirmation bias, which is a partial explanation for why people might fail to solve the puzzle. It is a partial explanation only, however, and therefore missed an opportunity to  teach a critical lesson in scientific reasoning.

Confirmation bias is the tendency to seek out, perceive, accept, and remember information that confirms beliefs we already hold, coupled with the tendency to miss, ignore, forget, or explain away information that contradicts our beliefs.

How many times have you either said yourself or heard someone else say, “well, that’s an  exception?” Is it, or is it just data? By calling an example an “exception” you are assuming that there is a rule it violates. This is a way of dismissing information that contradicts your beliefs.

The puzzle article explains that people seek our information that confirms their hypothesis, rather than seeking out information that contradicts their hypothesis (confirmation bias). Therefore, they come up with a hypothesis about the rule governing the number sequence, they enter in a sequence that should yield a positive answer if their hypothesis is correct, and if it is correct they believe their hypothesis to be confirmed.

In testing a hypothesis there are actually three things a good scientist should do, and the article only discusses one of them – testing your hypothesis against information that should yield a negative result.

Another critical step that the article ignores, however, is the need to test alternate hypotheses – try to come up with a hypothesis that is also consistent with the existing data and then test that. Specifically you should have entered in a number sequence that would fulfill the alternate hypothesis but not your original hypothesis.

Failure to consider or test alternate hypotheses is called the congruence bias, and it is a type of heuristic. This is less well known than confirmation bias, but in many situations is just as important to understand.

The third step, which is not really relevant to this particular test, is to consider the effects of a negative result from any of your tests. In this case, since you are trying to figure out a mathematical rule, results are definitive – if a result breaks the rule, the rule is wrong, period. When testing scientific hypotheses, however, results are not always definitive and simply increase or decrease the chance that the hypothesis is correct.

To give a real-world example of this type of reasoning, let’s consider medical diagnosis. One of the reasons this puzzle was trivial for me is because I am familiar with confirmation bias and congruence bias, and the need to look for negative outcomes and to test alternate hypotheses. Hypothesis testing like this is a daily part of the practice of medicine.

When confronted with a patient with a set of signs and symptoms, physicians should create a differential diagnosis – a list of possible diagnoses from most likely to least likely. It would be a supreme mistake to only consider your first guess or only the most likely diagnosis.

Physicians then need to order tests; each test (physical exam findings, blood test, X-ray, biopsy, whatever) is a test of their diagnostic hypothesis. The pitfall physicians need to learn to avoid is to test only their pet diagnostic hypothesis, and interpret a positive outcome as absolute confirmation of their diagnosis.

They should also order workup to test other possible diagnoses, and they also need to consider the real predictive value of a positive or negative outcome of each test on each diagnosis they are considering.

This logic does not only apply to professional fields like medicine (although it is critical to any investigational profession). We could use this logic in everyday life. Consider political opinions, for example. We tend to seek out examples which confirm our political beliefs, and fail to consider the impact if those examples were negative, the effect those examples have on alternative views, and examples that contradict or views.

The combination of confirmation bias and the congruence bias can create a powerful sense that the world confirms our ideology, when in fact that ideology can be partly, mostly, or even completely wrong.

Conclusion

I love it that a somewhat viral article in the New York Times is teaching a core lesson of critical thinking – confirmation bias. A more nuanced discussion, however, would have included the congruence bias as well, which is even more pertinent, in my opinion, to why people might fail that puzzle.

The real challenge, however, is to get people to internalize these logic lessons and consistently apply them to themselves in everyday life.

Categories: Medicine

This stimulant can kill, yet you can legally buy it online. Why?

Science Based Medicine - Thu, 07/02/2015 - 07:00

This stimulant drug is highly toxic and perfectly legal.

If there’s one thing that unites all countries and cultures, it’s our love of caffeine. Whether it’s coffee, tea or other foods, caffeine is the most widely consumed drug in the world — more than alcohol, and more than tobacco: 90% of adults worldwide consume caffeine daily. At doses found in food and beverages, the effects are predictable and the side effects are slight. But natural or not, caffeine is a drug; isolate the pure substance, and the risks change. It would be difficult for most people to drink 16 cups of coffee in a row, but that’s the equivalent of just one teaspoon of caffeine powder. If that doesn’t hospitalize you, a tablespoon of the powder will probably kill you. Yet despite the risks, there are no restrictions on the sale of caffeine powder. You can buy a 1kg bag for $35, which provides the caffeine of about 5,000 cups of coffee. Caffeine powder is freely available to buy because regulators treat it differently – not because of its inherent properties, but because it’s “natural” and sold as a dietary supplement rather than a drug. This is a regulatory double-standard that harms consumers. It’s leaving a body count. And it needs to change:

A year ago, Logan Stiner of LaGrange, Ohio, was an honors student and prom king looking forward to his high school graduation. “He was burning the candle at both ends, because he had a couple of projects that he had to finish for finals,” said his mother, Kate Stiner. On May 27, his brother found him unresponsive on their living room floor. In an effort to increase his energy, Mr. Stiner had used caffeine powder a friend had purchased on Amazon, but miscalculated the dosage, overdosed and died. The medical examiner said the cause of death was “cardiac arrhythmia and seizure, due to acute caffeine toxicity due to excessive caffeine ingestion.”
A few weeks later, 24-year-old James Wade Sweatt, a newly married, recent college graduate living in Georgia, blended a drink with powdered caffeine, also purchased online. Health conscious, he reasoned that pure caffeine and water would be a healthier way to get a lift than the Diet Mountain Dew that he usually drank. He overdosed, fell into a coma and died.

Caffeine is a natural substance produced by over 60 plants. Chemically, caffeine is 1,3,7-trimethylxanthine. Why so many plants produce this chemical is not well understood, as it’s not essential for a plant’s survival. Whether caffeine is a pesticide (repelling invaders) or a herbicide (fallen leaves inhibiting plant growth) isn’t clear. When consumed, caffeine is a central nervous system stimulant, increasing your heart rate and respiration. It also relaxes smooth muscle (producing another known effect) and is a mild diuretic. When used at modest (food-like) doses, caffeine is considered safe to consume. At usual daily doses of 100-200mg per day, caffeine reduces feelings of fatigue and raises perceptions of alertness. As a drug, caffeine has some medicinal uses. Caffeine is chemically very similar to theophylline, an old drug used to treat asthma and other lung diseases. It is combined with some painkillers for headaches and migraine. There’s some evidence it can improve athletic performance. Then there’s a long list of unproven but promising attributes, such as reducing the risk of type 2 diabetes or Parkinson’s disease. I’ve written before about how it is used for conditions like ADHD without good evidence it actually works.

Given its frequency of use, caffeine overdoses are rare, because the amount in foods and drinks are modest enough to make overdose difficult. Abuse can occur, and at high doses (the equivalent of 80+ cups of coffee), caffeine can be fatal. When abused, caffeine can produce feeling of euphoria. In an overdose situation, caffeine causes delusions, hallucinations, and heart conduction abnormalities, leading to death.

Despite its roots as a natural product, powdered caffeine is similar to the caffeine in soda in that it is synthetic, and not actually derived from natural sources at all. Apparently Americans are importing 17 million pounds of it, with much of it going to soda. Recently it has started to appear in other products, like gum, marshmallows, gummi bears and even sunflower seeds.

A lack of meaningful regulation

Caffeine that’s packaged as a dietary supplement is sold virtually unregulated in the United States, not because of a loophole in regulations but because of the explicit intent to remove regulatory barriers and limit any action from the FDA. The Dietary Supplement Health and Education Act of 1994 (DSHEA) is an amendment to the U.S. Federal Food, Drug and Cosmetic Act that establishes a regulatory framework for dietary supplements. It effectively excludes manufacturers of these products from virtually all regulations that are in place for prescription and over-the-counter drugs. The FDA notes:

Generally, manufacturers do not need to register their products with FDA nor get FDA approval before producing or selling dietary supplements. Manufacturers must make sure that product label information is truthful and not misleading. FDA’s post-marketing responsibilities include monitoring safety, e.g. voluntary dietary supplement adverse event reporting, and product information, such as labeling, claims, package inserts, and accompanying literature. The Federal Trade Commission regulates dietary supplement advertising.

The FDA recognizes the problem with powdered caffeine, but in its warning to consumers, it is clear that the agency is powerless to do anything meaningful about it:

The FDA is warning about powdered pure caffeine being marketed directly to consumers, and recommends avoiding these products. In particular, FDA is concerned about powdered pure caffeine sold in bulk bags over the internet. The FDA is aware of at least two deaths of young men who used these products. These products are essentially 100 percent caffeine. A single teaspoon of pure caffeine is roughly equivalent to the amount in 25 cups of coffee. Pure caffeine is a powerful stimulant and very small amounts may cause accidental overdose. Parents should be aware that these products may be attractive to young people.

No recalls, or “stop sales” orders. Just a warning to consumers. The FDA notes that manufacturers can add caffeine to foods as long as they include it on the ingredient list. When it approved adding caffeine to cola back in the 1950s it could not have contemplated how many foods and products like energy drinks would be supplemented with caffeine today. The only recent action was in 2010 to prohibit caffeinated alcoholic beverages – for obvious reasons.

While some supplement industry groups are supportive of restrictions on the sale of bulk powder, others disagree. The Natural Products Association does not support regulation. After all, salt and water can kill you, just like caffeine:

Take water [or] salt for example — if you use too much, it creates problems. I think that’s really the issue here. People safely use caffeine every day.

But this argument ignores fundamental facts. It’s true that the dose makes the poison, but the recommended dose of caffeine is tiny. You can’t accurately measure or weigh 200mg of caffeine powder using home measures and scales. And no-one is likely to seek an energy boost from consuming sodium or water.

Short of any federal regulation (the FDA remains noncommittal beyond a warning), other legislation is pending. Some senators have asked the FDA to act. While caffeine sales bans have been proposed at the state level, it’s not likely to have any meaningful effect when you can buy this product over the internet. There’s also the litigation approach:

Amazon.com and caffeine powder distributors didn’t provide proper warnings about the supplement’s dangers, resulting in the death of an Ohio high school student last year, the teen’s father said in a lawsuit filed Friday.

Eighteen-year-old Logan Stiner was just days from graduating high school in northeast Ohio when, on May 27, his brother found him unresponsive in the family’s home in LaGrange, southwest of Cleveland. A coroner ruled that Stiner died of cardiac arrhythmia and seizure due to acute caffeine toxicity. The amount of caffeine in his system was about 23 times greater than the level in a typical soda or coffee drinker. Stiner was a popular student who was voted prom king, wrestled and planned to study chemical engineering at the University of Toledo.

The lawsuit names as defendants a classmate who gave Stiner the caffeine powder; Amazon, which shipped it to the woman last March; and six Arizona-based companies that the father’s attorney said packaged and sold the pharmaceutical-grade powder under the name Hard Rhino. The lawyer, Brian Balser, said Friday that the Arizona companies appear to be related.

As long as we maintain a regulatory double-standard for supplements and “natural” products, there is not likely to be much change, and we can probably expect more people to die from caffeine powder overdoses.

“It’s natural, therefore it’s safe” is an appealing yet baseless health myth. Yet this is the primary argument that has been used to give supplements and natural health products completely different regulatory structures than what exist for drug products. Weaker regulation of supplements and natural health products has been a boon to manufacturers, but the same can’t be said for consumer safety. Natural or not, we need to assess the risk and benefits of products on their own merits, not simply because some chemicals happen to be produced by plants. We need meaningful regulation that acknowledges this.

Categories: Medicine, Skepticism

Caution vs Alarmism

Science Based Medicine - Wed, 07/01/2015 - 08:44

When I lecture about the need for science-based medicine (SBM), about half-way through my list of all the things wrong with the current practice of medical science, I have to pause. I balance my discussion by emphasizing what I am not saying – I am not saying that medical science is completely broken. It is just really challenging, we need to set the threshold for what we consider reliable higher than most people think, and there are some practical fixes we can do, some of which are already in the works.

It is easy, however, to “demonize” any person, institution, or philosophy by taking all the negative aspects that are inevitably present and wrapping them up in a frightening package, perhaps throwing in some conspiracy thinking or sensational alarmism.

Take, for example, a recent article by F. William Engdahl, Shocking Report from Medical Insiders. The headline alone warns you that you may be in for some sensationalism.

For background Engdahl is a journalist with some ideas that are out of the mainstream. He believe the theory that oil is not biological in origin but geological, and therefore “peak oil” is a myth, specifically designed to create panic in the public for political control. He also believes that the warnings of global warming are exaggerated. He is the author of Seeds of Destruction, which in my opinion is a propaganda hit piece against the technology of genetic modification.

In other words, Engdahl appears to be a journalist with an ideology, with the result being some skillfully written but ultimately misleading pieces.

His recent article is based upon recent statements made by medical editors about the state of medical research. He quotes Dr. Richard Horton, Editor-in-chief of the Lancet:

“Much of the scientific literature, perhaps half, may simply be untrue. Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness.”

Actually I think 60% may be a better figure than half. This should not be news to regular readers of SBM. We often highlight the problems of poor methodology, overreliance on P-values, P-hacking, researcher bias, publication bias, testing implausible hypotheses, failure to replicate, citation bias, and conflicts of interest.

We don’t deny these very serious problems exist within the institution of medical science. Our point in exploring them, however, is two-fold. The first is to provide a helpful guide to distinguishing reliable science from unreliable science. There is still good science out there, and we can come to confident conclusions. We just need to set the threshold at a higher level than most people think.

Second – we want to improve the practice of science by fixing the problems. You can either point to these known issues as if they are part of some dark conspiracy, or you can point to them in a constructive way in order to advocate for change.

Horton, to his credit, is doing the latter. He goes on to write:

Instead of changing incentives, perhaps one could remove incentives altogether. Or insist on replicability statements in grant applications and research papers. Or emphasise collaboration, not competition. Or insist on preregistration of protocols. Or reward better pre and post publication peer review. Or improve research training and mentorship. Or implement the recommendations from our Series on increasing research value, published last year. One of the most convincing proposals came from outside the biomedical community. Tony Weidberg is a Professor of Particle Physics at Oxford. Following several high-profi le errors, the particle physics community now invests great eff ort into intensive checking and rechecking of data prior to publication.

That list should also be familiar to regular readers of SBM. Engdahl doesn’t quote that part of the paper or even mention its existence, because it does not serve his conspiracy alarmist narrative.

Engdahl also quotes Dr. Marcia Angell, previous editor-in-chief of the New England Journal of Medicine (which he misnames the “New England Medical Journal).

“It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of the New England Journal of Medicine.”

Angell, of course, is referring in part to the many problems with published medical science as discussed above, and I agree with much of what she says. However, in my opinion she overstates the situation as well. I shared a stage with her about 10 years ago at an alternative medicine conference. She seemed far more interested in taking on the pharmaceutical industry than pseudoscience itself, and said as much.

There is much to criticize in how the pharmaceutical industry has tried to subvert medical research to their advantage. This is why they need to be carefully monitored and regulated. They are not the only ones, however. I would argue that the entire supplement and CAM industries are far far worse, and they are not as well regulated.

Conclusion

There are many endemic problems with the science of medicine as it is currently practiced. It is possible to draw the wrong lessons from these problems, often influenced by one’s ideology.

While a great deal of published research is preliminary, implausible, or of low methodological rigor, not all of it is. We can still pick through the research to find the most reliable studies that have survived independent replication. I agree that with any lower threshold, you might as well flip a coin.

In addition to looking at the literature with open and critical eyes, a valuable lesson is that we need to make serious efforts to fix identifiable problems with the institutions of science (as outlined above).

The big challenge, as Horton himself points out, is not that we don’t know what to do, but no one has the power to do it. There is no central power hierarchy of science, and when power is distributed it is often difficult to accomplish major changes. Everyone thinks it’s someone else’s responsibility.

What we need is for the issue to become well known, to cross that nebulous threshold of political will. We need many voices pointing out the problems that need fixing, and we need to put pressure on those with any power.

The problem with conspiracy-mongering is that it is often not constructive – there is no call to action, just the sense that the world is hopelessly corrupt. Engdahl concludes his article with:

Corruption of the medical industry worldwide is a huge issue, perhaps more dangerous than the threat of all wars combined. Do we have such hypnosis and blind faith in our doctors simply because of their white coats that we believe they are infallible? And, in turn, do they have such blind faith in the medical journals recommending a given new wonder medicine or vaccine that they rush to give the drugs or vaccines without considering these deeper issues?

I conclude this article, as I do many of my essays here at SBM, with a call to action. These problems can easily be fixed. They do not require new resources or even great sacrifices. They just require a change in standard practice. Universities, journal editors, regulators, and professional organizations can make it happen. In many cases they know exactly what to do – they just need to do it.

Categories: Medicine, Skepticism

Lessons From GM Wheat Failure

Neurologica Blog - Tue, 06/30/2015 - 09:08

So-called “whiffy wheat” was genetically modified to release a pheromone that repels aphids. The obvious purpose of this modification was to reduce pests without the need for insecticides, and thereby reduce insecticide use.

The trait worked well in the lab. The wheat released sufficient amounts of a warning pheromone that aphids release when attacked. The pheromone both warns aphids to stay away, and also attracts predators, such as a parasitic wasp. The pheromone was derived from the peppermint plant.

The laboratory success meant the wheat was ready for field trials where the GM crop is put to the test in close to real world conditions. The results of those field trials were just published, and unfortunately they showed that the new trait essentially didn’t work – the aphids were not significantly decreased compared to controls, nor was yield increased.

The scientists discuss a few possible reasons for the failure. One is that during the field trials, cold wet summers made for low baseline levels of aphids, below the threshold where fields would normally be sprayed. There was therefore not much room for improvement, but still if the trait worked it should have been evident.

They also report that the aphids demonstrated habituation in the lab, meaning they were less effected by the pheromone over time. Finally the scientists speculate that the failure may be due to the timing of release. When aphids are attacked they release the pheromone in a burst. The wheat, however, released it in a slow and continuous manner. Perhaps they have to engineer the wheat to release the pheromone in larger amounts in a short period of time.

The researchers believe that this approach, using pheromones to repel insects and/or attract natural predators, has promise. This specific application needs to go back to the drawing board, however.

What is more interesting than the study itself is how different people responded to it. Scientist reacting with statements to the effect that negative results are still results, we need to accept the data even if it is not what we want, and now we can take what we learned and move forward.

Dr. Toby Bruce, first author on the study, is quoted as saying:

“This trial has ended up yielding more questions than answers, but that means we have more work to do to understand the insect-plant interaction and to better mimic what happens in nature.”

Anti-GMO activists, however, are using this one failure of one GM variety as if it represents the failure of the entire concept of genetic modification. The same BBC article quotes Liz O’Neill, director of GM Freeze, as saying

“The waste of over £1m of public funding on a trial confirms the simple fact that when GM tries to outwit nature, nature adapts in response.”

That is interesting the O’Neill is concerned about the wast of public funding, because, as Nature reports:

The protests did not disrupt the research, but making the site secure added around £1.8 million (US$2.8 million) to the study’s research cost of £732,000.

Protests from groups like GM Freeze, who have vandalized field trials of GM crops, cost more than twice as much because of needed security than the trial itself. It’s more than a bit disingenuous to complain about the cost of such trials now. She goes on to say:

 “The truth is that nature is just too complex for the simplistic thinking behind GM.

“Meanwhile, we are crying out for investment in proven solutions like integrated pest management, companion cropping, conventional plant breeding, and novel chemistry.

Sure, nature is complex and adaptive. That is a inherent challenge of all agriculture, which in itself is inherently “unnatural.” She is drawing a false dichotomy, however, between the methods she mentions and GM technology – GM is just one method that can be successfully incorporated into things like integrated pest management.

Further, methods that are ideologically preferred by organic growers and anti-GM activists are themselves susceptible to the same limitation, the complexity of the ecosystem and the tendency for nature to adapt. They do not magically make these problems disappear.

I do have to wonder what the attitude of those like O’Neil would be toward a pest management system that includes spraying wheat with a natural pheromone derived from the peppermint plant that repels aphids, attracts natural predators, and thereby reduces the need for pesticide. I doubt they would be decrying this approach as overly simplistic and be calling to abandon the entire technology.

Conclusion

There are several lessons from this latest episode in the battle over GMO.  One is that there is a real price tag attached to the vandalism used by some anti-GM activists. In this case adding £1.8 million to a field trial that would otherwise have cost only £732,000.

This is a common tactic employed by many anti-science activists – creating a problem and then using that very problem they create as an argument against the science they oppose.

A second lesson is that GM scientists appear to be doing honest science, at least in this case. They genuinely want to find solutions that work, and if field trials are negative, they publish the negative results and move on. This is not a small point, as anti-science rhetoric is often tinged with conspiracy thinking, and the results of positive studies are often dismissed as fraud (without any evidence).

Finally, this is further evidence that the anti-GMO crowd do not have a coherent position. Their arguments against GMO largely come down to “it ain’t natural.” They also create a straw man comprising a false dichotomy between GM technology and other agricultural methods.

There is general agreement that sustainable methods of agriculture are needed, and that some form of integrated pest management is best. Nature is complex and adaptive, and therefore if we are going to try to squeeze as much food production out of as few resources as possible, in a sustainable way, we need to use a variety of techniques and technologies.

GM can be one of those technologies. It is not a panacea, but it has certain advantages over other methods. We should be using the best options available in a rational and evidence-based way.

Anti-GMO activism, however, is based on ideology, not evidence or reason.

This is usually the point at which many of those who are anti-GMO would state that the “real” reason they oppose GMO is because they are against corporate power, patents, etc. If that is the case, then you are fighting the wrong battle. As I and others have pointed out, your problem is not with GM technology but with regulations.

I would also point out that many of the anti-corporate talking points are simply false. They are based on misinformation and propaganda, so if you are going to take that position definitely make sure you have your facts right. (For example, Monsanto does not sue farmers for seeds blown onto their land, they do not market terminator seeds, and GM crops have not caused suicides in India.)

I do not know if this approach, using pheromones to repel pests, will pan out as a useful strategy. Neither do the scientists, or the anti-GMO activists. It is an interesting concept, and it seems to me is sufficiently reasonable to warrant the relatively small amount of investment to do the research. This kind of research may also yield unanticipated benefits. Let’s do the science and find out.

Categories: Medicine

Answering Cancer Quackery: The Sophisticated Approach to True Believers

Science Based Medicine - Tue, 06/30/2015 - 03:00

You can lead a true believer to facts, but can you make him think?

I got an e-mail with a link to a video featuring “Dr.” Leonard Coldwell, a naturopath who has been characterized on Rationalwiki as a scammer and all-round mountebank.  Here are just a few examples of his claims in that video:

  • Every cancer can be cured in 2-16 weeks
  • The second you are alkaline, the cancer already stops. A pH of 7.36 is ideal; 7.5 is best during the healing phase. [We are all alkaline. Normal pH is 7.35-7.45.]
  • IV vitamin C makes tumors disappear in a couple of days
  • Very often table salt is 1/3 glass, 1/3 sand, and 1/3 salt. The glass and sand scratch the lining of the arteries, they bleed, and cholesterol is deposited there to stop the bleeding.
  • Patients in burn units get 20-25 hard-boiled eggs a day because only cholesterol can rebuild healthy cells; 87% of a cell is built on cholesterol.
  • Medical doctors have the shortest lifespan: 56. [Actually they live longer than average.]

My correspondent recognized that this video was dangerous charlatanism that could lead to harm for vulnerable patients. He called it a “train wreck, with fantasy piled upon idiocy.” His question was about the best way to convince someone that it was insane. He said, “If you could rely on someone to follow and understand basic information about the relevant claims, it would be a gimme. But to the casual disinterested observer, who can interpret the whole video as ‘Well, he just wants people to eat right,’ pointing out the individual bits of lunacy just looks like so much negativity.”

He asked, “How do I best represent what’s happening to someone who is either a) emotionally invested in this and/or b) casually approving of it?… I just want to be patient, not shout anyone down, not make anyone defensive, and then win. Very surprised I don’t already know how. But I feel like I don’t. What is the psychologically sophisticated approach to this?”

Here’s how I answered him

You can’t change someone else’s mind; they have to change their own mind. The sophisticated approach is to ask them questions that lead them to doubt, and gently lead them to discover the truth for themselves. That is something Socrates was very good at; I’m not. But I can suggest some questions to ask. Maybe start with some kind of validation: Wow, that really sounds good; I can see why you’re impressed, but there are some things I’m wondering about… If alkalinization works so well to eliminate cancer, why do you suppose he bothers to recommend a lot of other ways to cure cancer, with vitamin C, oxygen, a vegan diet, etc? Why do you suppose oncologists don’t offer any of those treatments to their patients? How likely is it that this one man is right and the entire scientific medical community is wrong about everything from salt to vitamins to cholesterol? How do you think he arrived at those conclusions? Have you ever seen a video that you knew was wrong about anything? How could you go about finding out if anything in this one was inaccurate? Have you read what other doctors have had to say about the alkaline diet? Is there a way you could verify his claims through other sources? Would it be worthwhile to look for the scientific evidence he cites? If you think “he just wants people to eat right,” don’t you think all those people who disagree with him also want people to eat right? If you get cancer and try the alkaline diet and it hasn’t eliminated the cancer as promised in two days, what will you think? What will you do?

Do you believe that “very often, table salt is one-third glass, one-third sand, and one-third salt”? Did you know that the FDA requires that all US table salt be at least 97.5% pure sodium chloride, and it is usually much purer?  We can find out for ourselves. Let’s do a little experiment. Glass and sand don’t dissolve in water. Put some table salt in a glass of water. The salt will dissolve and any impurities will sink to the bottom and form a visible sediment. Do you see a residue of sand and glass particles in the bottom?

How could sand and glass in the diet get into the arteries and scratch them? Aren’t insoluble materials indigestible? Don’t they pass through the digestive system and end up in the toilet?

My “SkepDoc’s Rule” is before you accept a claim, try to find out who disagrees with it and why. There are almost always two sides, and it quickly becomes obvious which side is supported by the best evidence and reasoning. If your interlocutor refuses to even look at any contradictory evidence, there is no point in continuing the discussion.

Don’t expect to “win.” True believers are impervious to evidence and reason. The best you can hope to do is plant a seed. Sometimes it takes many seeds of doubt, planted and watered by many different sources over the years, to finally have an effect.

Further thoughts

 Since I wrote that, I’ve learned more about how to talk to true believers, and I’ve been persuaded that the task is not as hopeless as I thought. I heard philosopher and educator Peter Boghossian speak at a conference and was intrigued enough to seek out and read his book, A Manual for Creating Atheists, where he describes a method to engage the faithful in conversations that will help them question how certain they can be about the truth of beliefs that are based on faith alone, to help them value reason and evidence over faith, superstition, and irrationality. Instead of discussing specific beliefs, he tries to get people to analyze how they arrive at beliefs in general. It occurred to me that most of what he says applies to true believers in CAM as well as to true believers in religion. Not everyone wants to create atheists, but I hope we all want to create critical thinkers.

Questioning epistemology, not specific beliefs

Rather than questioning specific beliefs, Boghossian questions epistemology: the study of knowledge, how we come to know what we know, how we decide whether to accept a belief as true. His approach is based on the Socratic method of asking questions that get his interlocutors to think more clearly. You can see Boghossian’s methods in action in a series of YouTube videos by Anthony Magnabosco. He does “street epistemology,” asking random people how they arrived at their God belief, and if they are using a possibly unreliable method to arrive there, trying to help them discover that.

How do we know what we know? In the Tuyuca language spoken by a tribe in the Amazon rain forest, to say that someone is chopping trees requires that one also specify how one knows this.[1] If you hear that someone is chopping trees, then you say: Kiti-gï tii gí where gí serves to indicate that this is something you hear. But if you actually see him chopping trees, then you say Kiti-gï tii-í where the í indicates your having seen rather than heard it. If you have not actually perceived him chopping trees but have reason to suppose that he is doing so, then the sentence is Kiti-gí tii-hXi;[2] if your source of information about the tree chopping is hearsay, then this requires a special marker: Kiti-gï tii-yigï. It would be helpful if English specified the source of knowledge; our grammar doesn’t do it, but we can specify it using other words.

Boghossian gives 5 reasons why people embrace absurd propositions:

  1. They have a history of not formulating their beliefs on the basis of evidence.
  2. They formulate their beliefs on what they thought was reliable evidence but wasn’t.
  3. They have never been exposed to competing epistemologies and beliefs.
  4. They yield to social pressures.
  5. They devalue truth or are relativists.

All of these are applicable to CAM.

True believers do change their minds. Plenty of people have converted from one religion to another or rejected religious beliefs entirely; plenty of believers in CAM have come to reject it in favor of science. Swift said, “You do not reason a man out of something he was not reasoned into.” But people have been reasoned out of religious beliefs, including many ex-preachers. How can we best assist that process?

The Socratic method

 The Socratic method has five stages:

  1. Wonder (I wonder if there is intelligent life on other planets)
  2. Hypothesis (There must be, since the Universe is so large)
  3. Elenchus (Q&A) – facilitator generates ideas about what might make the hypothesis untrue. (What if we’re the first? Or the last?)
  4. Accept or revise hypothesis (There probably is, but maybe not)
  5. Act accordingly (Stop saying you are certain there must be.)

For a CAM belief:

  1. I wonder if tea tree oil will cure my toenail fungus
  2. I know it will work, because it worked for my cousin
  3. But what if it would have cleared up on its own without treatment? What if your cousin didn’t actually have a fungus? What if a controlled study had shown tea tree oil wasn’t effective?
  4. I can’t know for sure whether it works, but I’m going to try it.
  5. If your toenail clears up, don’t tell people you have proved that it works.

 Implementing the Socratic method for CAM

 It helps to establish a friendly, trusting relationship with your interlocutor. Try to establish some things you have in common. Show an interest in his beliefs; try to understand exactly what it is that he believes and how he arrived at the beliefs. Say, “Tell me more about that.” Validate his experience. Don’t assume he is wrong. Assume he might be right, and show that you are willing to change your own beliefs if provided sufficient evidence. This should not be an adversarial relationship. Remember that you can learn from anyone; everyone you meet knows something you don’t know.

Don’t talk about facts. If the person didn’t form his belief because of facts, he won’t change his mind because of facts. The idea is not to change beliefs, but to change the way people form beliefs. Try to avoid arguing about the belief itself and concentrate on how the belief was arrived at and how one can best arrive at beliefs that are true. Do other people ever arrive at beliefs that are wrong? How does that happen? Ask your interlocutor to think of examples of false beliefs that other people hold, and talk about where they went wrong. Ask him to rate on a numerical scale how confident he is that his beliefs are true. Magnabosco uses a scale of 1-100 where 100 is absolute certainty.

If you can think of a claim that contradicts the believer’s claim, ask how you could go about determining which of two claims is correct. If two believers believe equally strongly in two different religions, they can’t both be right; how could you go about determining which one is right? If one CAM claims that all disease is due to subluxations and another claims that all disease is due to disturbances of qi in the meridians, point out that they can’t both be true.

If they claim to have evidence, you might ask, “For all evidence-based beliefs, it’s possible that there could be additional evidence that comes along that could make one change one’s beliefs. What evidence would you need to make you change your mind?”

If your interlocutor bases his belief on something he “felt,” ask how could we differentiate between that kind of feeling and a delusion? (It’s much less likely to be a delusion if the believer is willing to revise the belief.)

Boghossian uses this series of questions in the classroom:

  1. Is it possible that some people misconstrue reality?
  2. Do some people misconstrue reality?
  3. If one wants to know reality, is one process just as good as any other? (Flipping a coin? Interpreting a dream? Doing a scientific experiment?)
  4. So then are some processes worse and some better?
  5. Is there a way we can figure out which processes are good and which are not?

Most students quickly figure out that processes that rely on reason and evidence are more reliable than other processes.

Understand that some people are epistemological victims who have never encountered competing ways of understanding reality. Some religious believers have been deliberately isolated and protected from exposure to any information outside their religious tradition. For CAM, even some doctors and scientists fail to truly understand how the scientific method works and how important it is. CAM advocates seek out like-minded people. Internet “filter bubbles” deliver customized information so people are not likely to find contradictory or disconfirming information by googling.

Surely it is worthwhile trying to help people think more clearly. Think of it as an intervention, like deprogramming a cult member. These are people who need your help. Certainty is the enemy of truth. It removes curiosity and stifles investigation. Susan Jacoby said “I think of the first atheist as someone who, while grieving over the death of a child in ancient times, refused to say, ‘It’s the will of the gods,’ and instead began searching for a natural rather than a supernatural explanation.” If everyone had believed homeopathy was the cure for all disease, antibiotics would never have been discovered. Reality is always a better guide to life than fantasy and error.

Boghossian cites another author who calls religion a kind of virus that infects people, spreads to others, programs the host to replicate the virus, creates antibodies or defenses against other viruses, takes over certain mental and physical functions and hides itself within the individual in such a way that it is not detectable by the individual. In that sense, belief in CAM is also a virus.

It’s cruel to take away people’s cherished beliefs without offering a replacement that offers hope for a better life. Boghossian has proposals for helping religious believers who have given up their belief but are devastated by the loss of their community and need a new source of support. For CAM, we can offer a truly effective way of determining whether a treatment works, the scientific method; and we can direct them to credible sources of information and empower them to tell for themselves whether something is science and pseudoscience. As Bill Nye says, “Science rules!” It doesn’t always provide certainty, but isn’t uncertainty preferable to false certainty? Science is fascinating and exciting and full of wonders and it has the added advantage of being true.

If you fail

If you think your intervention has been a failure, you may be wrong. If believers get angry or seem to become even more entrenched in their beliefs, it may be that they are already experiencing doubts. They may have become more self-aware. Boghossian says, “They may have said things or taken positions to justify the beliefs to themselves.” You may have made a small dent in their certainty, and dents may set the stage for a later breakthrough.

The final comeback

True believers often end with these final arguments:

  1. “It’s true for me.”
  2. Even if it isn’t true, it helps people (by providing hope, motivation, etc.)

At this point, you can ask if people are really helped by forming false beliefs.

Another skeptic’s approach to a true believer

Benjamin Radford’s recent article in Skeptical Inquirer[3] also offers some very constructive advice. He describes his response to a woman who believes she has been cursed and asks him how to remove the curse. He sympathizes with her and assures her that he is concerned about her welfare. He validates her experience that “something” is going on. He plants a seed of doubt and offers an alternate, non-threatening explanation for what she experienced. He demonstrates open-mindedness. He gives her accurate information about psychic scams. He establishes his bona fides as an expert on the subject, focusing on the psychology of curse beliefs. He explains that all curses are fundamentally the same. He empowers her: he advises her to stop going to psychics, to remember that everyone has some of the same troubles she is attributing to the curse, and to not focus on the negative things but on positive things she can do to help herself.

A final word

 I can’t claim that there are any controlled studies to show that this method works to persuade true believers to change their minds or that it is better than any other method. But other methods have few success stories, and in my opinion this sounds like it might be worth trying. It certainly isn’t easy. I recently tried to apply Boghossian’s methods in an e-mail exchange with a woman who holds all kinds of weird beliefs, and I failed miserably. In my experience of many similar discussions, the true believer always eventually makes new claims that are so outrageous that I lose self-control and simply can’t restrain myself from throwing facts at them to show them how wrong they are, and that ends any chance of a productive discussion. I’ll keep trying. I would appreciate hearing from others who have had successes or failures in discussions with true believers.

 

At any rate, the purpose of SBM is not to convince true believers but to provide accurate information so people whose minds are not irrevocably made up can make informed health decisions. And we have had considerable success doing that.

[1] The Power of Babel, by James McWhorter.  New York: Henry Holt and Company, 2002. P. 180

[2] The X stands for a linguistic symbol I was unable to reproduce.

[3] Radford, B. A skeptic’s guide to ethical and effective curse removal. Skeptical Inquirer 39:4, p. 26-8. July/August 2015

Categories: Medicine, Skepticism

Drinking the “Integrative” Kool-Aid at the Atlantic

Neurologica Blog - Mon, 06/29/2015 - 08:50

A recent article at the Atlantic by Jennie Rothenberg Gritzi demonstrates just how thoroughly the alternative medicine movement (I will refer to this as CAM) has been able to influence the cultural conversation over the practice of medicine.  This is great evidence of how successful a persistent marketing campaign can be.

Gritzi relates early on in the article that she was predisposed to CAM from a young age, which might explain her journalistic failures in this piece.  She writes:

After visiting the NIH center and talking to leading integrative physicians, I can say pretty definitively that integrative health is not just another name for alternative medicine.

The only evidence she gives that she spoke to critics of CAM is a couple quotes from Paul Offit, her “token skeptic.”  In the end there is nothing new in the piece. She recycles the CAM marketing talking points quite faithfully, without any real analysis or journalistic skepticism.

She spends some time talking about the limitations of modern medicine, as if that is justification for incorporating nonsense into medicine. She buys the CAM propaganda that they somehow invented things like nutrition and stress reduction .

There was one new bit in the revisionist history that makes up CAM marketing.  She writes:

As the Institute of Medicine report put it, pain flouts “the long-standing belief regarding the strict separation between mind and body, often attributed to the early 17th-century French philosopher René Descartes.”

This may be why so many chronic pain sufferers are drawn to traditional medicine: The Cartesian idea of mind-body duality never found its way into these ancient systems.

She actually claims that scientific medicine is somehow dualist while CAM rejects dualism and understands that the mind and body are one.  This is, of course, the exact opposite of the truth. She doesn’t appear to pick up how muddied and confused her characterization is when she later writes:

It’s hard to talk about integrative health without using abstract terms likewellnessvitality, and healing. Most traditional medicine systems are built around these ideas. They start with the assumption that there’s some kind of life force that wards off disease. Then they treat specific illnesses by balancing elements or unblocking energy flow—whatever it takes to get the body back to its natural state of equilibrium.

The scientific view is that the mind is what the brain does, and therefore mind and body are the same thing.  It is scientific medicine that worked out things like the ways the brain influences the function of other systems through the neuroendocrine axis, for example.

Modern medicine also operates by the biopsychosocial model, in which we consider the entire patient, their biological processes as well as their psychological and cultural factors.

CAM (which is, by the way, the exact same thing as “integrative” medicine) is inherently dualist. The entire idea of a life force is dualist – that there is a force that is somehow separate from material biology. Many CAM treatments start with the assumption of a life force, and idea that was rejected by science over a century ago because of a total lack of evidence and such a notion is entirely unnecessary.

Of course Gritzi spends a lot of time talking about pain management. This is one of CAMs favorite areas because pain is subjective and highly amenable to psychological factors. Our perception of pain, emotional response to it, and ability to tolerate it are all capable of being manipulated by a host of factors. No one doubts this, and these ideas are already part of science-based medicine.

CAM proponents, however, like to point to the pain research and then say, essentially, “Aha, my magic is real.”

Gritzi also accepts the CAM interpretation of the state of current research with respect to things like acupuncture. She concludes that acupuncture works for pain, and then cites only the infamous Vickers meta-analysis as evidence.

A more scientific view of the evidence, in my opinion, clearly leads to the conclusion that acupuncture doesn’t work. The evidence for acupuncture is about as convincing as the evidence for ESP or free energy. You never get what we actually need to conclude that a new phenomenon is real – a rigorous study design that shows significant results with a meaningful effect size that can be independently replicated. Instead you get marginal and ephemeral results out of which a motivated researcher can squeeze a sliver of significance.

Gritzi concludes with another marketing point of CAM propaganda – the science-based medicine treats only acute illness, while CAM is better suited to managing chronic illness. This is utter nonsense, a narrative construct of CAM revisionist history.

First, all of the interventions that actually work for prevention and health promotion were discovered by scientific medicine and have already been incorporated into practice. Yes, we can criticize how quickly and thoroughly new knowledge makes its way to the practitioner in the field, but this is a separate point entirely.

CAM proponents incorporate science-based prevention methods, like nutrition, exercise, and stress reduction, and call it CAM to give their loose collection of nonsense a patina of legitimacy. Of course if you peak under the hood, the same load of CAM pseudoscience is still there.

I do notice a trend of rejecting homeopathy as evidence that the CAM practitioner is discriminating. This is perhaps a new development, but I wonder if it will last. Gritzi relates that some practitioners she spoke to won’t prescribe homeopathy, but won’t dissuade their patients from using it either. If it doesn’t work, then why won’t they say so, and counsel not to use it?

Some practitioners are distancing themselves from homeopathy, because it is so heavily under criticism, but they still can’t bring themselves to criticize it also, because once they start criticizing a treatment for being unscientific, the entire house of cards will collapse.

Conclusion

Despite all of the careful rhetoric, the constant name changes, and the “evolving” marketing strategies – at the end of the day the CAM/integrative movement is about one thing, rejecting a single science-based standard of care.

Proponents make elaborate excuses for using magic, and sophisticated arguments for using poor scientific evidence, for ignoring inconvenient evidence, and for essentially being pseudoscientists.

Gritzi’s piece is essentially an advertisement for a marketing brand. Her article utterly lack any true investigative journalism or skepticism. As a result she entirely missed the reality of the subject she allegedly investigated, and therefore misinformed her readers.

Categories: Medicine

NCCIH and the true evolution of integrative medicine

Science Based Medicine - Mon, 06/29/2015 - 03:00

There can be no doubt that, when it comes to medicine, The Atlantic has an enormous blind spot. Under the guise of being seemingly “skeptical,” the magazine has, over the last few years, published some truly atrocious articles about medicine. I first noticed this during the H1N1 pandemic, when The Atlantic published an article lionizing flu vaccine “skeptic” Tom Jefferson, who, unfortunately, happens to be head of the Vaccines Field at the Cochrane Collaboration, entitled Does the Vaccine Matter? It was so bad that Mark Crislip did a paragraph-by-paragraph fisking of the article, while Revere also explained just where the article went so very, very wrong. Over at a blog known to many here, the question was asked whether The Atlantic (among other things) matters. It didn’t take The Atlantic long to cement its lack of judgment over medical stories by publishing, for example, a misguided defense of chelation therapy, a rather poor article by Megan McArdle on the relationship between health insurance status and mortality, and an article in which John Ioannidis’ work was represented as meaning we can’t believe anything in science-based medicine. Topping it all off was the most notorious article of all, the most blatant apologetics for alternative medicine in general and quackademic medicine in particular that Steve Novella or I have seen in a long time. The article was even entitled The Triumph of New Age Medicine.

Now, The Atlantic has published an article that is, in essence, The Triumph of New Age Medicine, Part Deux. In this case, the article is by Jennie Rothenberg Gritz, a senior editor at The Atlantic, and entitled The Evolution of Alternative Medicine. It is, in essence, pure propaganda for the paired phenomena of “integrative” medicine and quackademic medicine, without which integrative medicine would likely not exist. The central message? It’s the same central (and false) message that advocates of quackademic medicine have been promoting for at least 25 years: “Hey, this stuff isn’t quackery any more! We’re scientific, ma-an!” You can even tell that’s going to be the central message from the tag line under the title:

When it comes to treating pain and chronic disease, many doctors are turning to treatments like acupuncture and meditation—but using them as part of a larger, integrative approach to health.


No, that’s what they say they are doing (and—who knows?—maybe they even believe it), but what that “integrative” approach to health actually involves is “integrating” quackery like acupuncture with scientific medicine. Elsewhere, in her introduction to the article in which she explains why she did the story, Rothenberg Gritz describes a visit to the National Center Complementary and Integrative Health (NCCIH), which is how the National Center for Complementary and Alternative Medicine (NCCAM) was renamed last December:

After visiting the NIH center and talking to leading integrative physicians, I can say pretty definitively that integrative health is not just another name for alternative medicine. There are 50 institutions around the country that have integrative in their name, at places like Harvard, Stanford, Duke, and the Mayo Clinic. Most of them offer treatments like acupuncture, massage, and nutrition counseling, along with conventional drugs and surgery.

One notes that the renaming of NCCAM to eliminate the word “alternative” was a longstanding goal of NCCAM, its supporters, and “integrative medicine” advocates. The reason is obvious: “Alternative” implies outside the mainstream in medicine, and that’s not the message that proponents of integrating quackery into medicine want to promote. One can’t help but wonder if it was a retirement present for Senator Tom Harkin (D-IA), the legislator most responsible for the creation and growth of NCCAM who retired at the end of the last Congressional term. Whatever the case, the name change was, as I put it, nothing more than polishing a turd.

Be that as it may, no one, least of all here at SBM, argues that “integrative” medicine is “just another name for alternative medicine.” It isn’t, as most integrative MDs use conventional, science-based medicine as well. The problem with “integrative” medicine is that, to paraphrase Mark Crislip, mixing cow pie with apple pie does not make the apple pie taste better; i.e., mixing unscientific, pseudoscientific, and mystical quackery like acupuncture and much of traditional Chinese medicine, does not make science-based medicine better. Rather, it contaminates it with quackery, just as the cow pie contaminates the apple pie.

Basically, integrative medicine is a strategy for mainstreaming alternative medicine, even though the vast majority of alternative medicine has either not proven scientifically to be efficacious and safe, has been proven not to be efficacious, or is based on physical principles that violate laws of physics (such as homeopathy or “energy healing). Indeed, if the term “integrative medicine” were not thus, it would be a completely unnecessary moniker. The reason is, to paraphrase Tim Minchin, Richard Dawkins, John Diamond, Dara Ó Briain, and any number of skeptics, there is no such thing as “alternative” medicine because “alternative” medicine that is shown through science to work becomes simply medicine. Thus, newly validated medical treatments have no need to be called “integrative” because medicine will integrate them just fine on its own. That’s what medicine does, although admittedly the process is often messier and takes longer than we would like. Integrative medicine, like alternative medicine before it, is a marketing term that is based on a false dichotomy. Only unproven or disproven medicine needs the crutch of being “integrative,” a double standard that asks us to “integrate” unproven treatments as co-equal with science-based medicine even though they have not earned that status.

Unfortunately, this is a false dichotomy that Rothenberg Gritz promotes wholeheartedly. The only hint of skepticism is a brief passage near the beginning in which she refers to Paul Offit’s 2013 book, Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine and briefly quotes him saying what I’ve been saying all along, that “integrative medicine” is a brand, a marketing term, rather than a specialty. She also noted his criticism in his book of what is now NCCIH, and includes a quote by Dr. Offit about Josephine Briggs (the current director of NCCIH) that she is “certainly was very nice” and assured him that they “weren’t doing things like that anymore” (referring to “things” NCCCIH studied in the past, like distance healing, magnets for arthritis). This is, of course, hardly even a criticism at all, but rather getting Dr. Offit to state for her Dr. Briggs’ frequent claim that NCCIH doesn’t study pseudoscience any more. It’s a claim she made when Steve Novella, Kimball Atwood, and I met with her five years ago, and, yes, back then Dr. Briggs was also very nice to us, although she did rapidly turn around and, in a painful fit of false balance, use that meeting as evidence of her even-handedness in meeting with both critics and homeopaths. It’s a claim embedded in the 2011-2015 NCCAM strategic plan, which I now like to characterize in talks as “Hey, let’s do some real science for a change!” In any case, Rothenberg Gritz’s account isn’t false balance. It’s no balance at all, with the token skeptic role taken by Dr. Offit.

Revisionist history about NCCIH

Advocates for “integrative medicine” have used a variety of talking points over the years, and Rothenberg Gritz hits most of them in her article quite credulously. Indeed, it is very clear from her introduction that she was predisposed to believe. Early in the article, she tells the tale by looking back to the early 1990s, when she was in high school and her father was a family physician who was clearly into some woo, including Transcendental Meditation, Ayurveda, and the like, even going so far as to incorporate them into his practice. The inescapable implication is that she considers her father a trailblazer for what is now integrative medicine.

Unfortunately, it is very clear that her knowledge of history in this area, particularly how NCCAM/NCCIH came to be, is sorely lacking, which leads her to parrot the version of history that integrative practitioners want you to believe:

Back in the 1990s, the word “alternative” was a synonym for hip and forward-thinking. There was alternative music and alternative energy; there were even high-profile alternative presidential candidates like Ross Perot and Ralph Nader. That was the decade when doctors started to realize just how many Americans were using alternative medicine, starting with a 1993 paper published in The New England Journal of Medicine. The paper reported that one in three Americans were using some kind of “unconventional therapy.” Only 28 percent of them were telling their primary-care doctors about it.

And:

Enough Americans had similar interests that, in the early 1990s, Congress established an Office of Alternative Medicine within the National Institutes of Health. Seven years later, that office expanded into the National Center for Complementary and Alternative Medicine (NCCAM), with a $50 million budget dedicated to studying just about every treatment that didn’t involve pharmaceuticals or surgery—traditional systems like Ayurveda and acupuncture along with more esoteric things like homeopathy and energy healing.

Now there’s some revisionist history! The word “alternative” was just popular because there was so much other “alternative” stuff (alternastuff?) going on in the early 1990s! But it’s not the 1990s any more; so “alternative” isn’t as cool as it used to be. Of course, the word “alternative” as applied to quackery dates back at least to the 1960s.

Longtime readers know how NCCAM really came about. One wonders if Rothenberg Gritz ever came across Wally Sampson’s classic 2002 article, Why the National Center for Complementary and Alternative Medicine (NCCAM) Should Be Defunded or Kimball Atwood’s The Ongoing Problem with the National Center for Complementary and Alternative Medicine. Even if you buy into the false notion that NCCIH (ne NCCAM) has completely reformed itself and doesn’t study or promote quackery any more, a history lesson is important. What really happened matters.

Basically, Sen. Tom Harkin was a believer in a lot of alternative medicine. Thus, in 1991 he used his power as the chair of the Senate Appropriations Committee to create the precursor to the NCCIH. His committee declared itself “not satisfied that the conventional medical community as symbolized at the NIH has fully explored the potential that exists in unconventional medical practices” and, to “more adequately explore these unconventional medical practices,” ordered the NIH to create “an advisory panel to screen and select the procedures for investigation and to recommend a research program to fully test the most promising unconventional medical practices.” This advisory panel became the first incarnation of NCCIH, the Office of Unconventional Medicine, which was quickly renamed the Office of Alternative Medicine (OAM).

This next part is very important. NIH didn’t request this new office. There were no scientists and physicians in the NIH leadership clamoring for such an office. Congress didn’t respond to a “groundswell” of support to establish this office. Rather, a single powerful senator with a proclivity for quackery used his power to get this enterprise off the ground, and he continued to nurture it over his remaining two decades in the Senate. The OAM was, in essence, imposed on an correctly unwilling NIH, and has been ever since. Indeed, after she left as NIH director, Bernardine Healy revealed that she had considered the project to link research scientists with true believers in therapies like homeopathy to conduct experiments as foreshadowing nothing but disaster, but conceded that the NIH had “had no choice” because it couldn’t refuse to carry out a mandate from Congress.

And, make no mistake, Harkin was big into quackery, not to mention being in the pockets of quacks:

Harkin had been urged to take this legislative step by two constituents, Berkley Bedell and Frank Wiewel. Bedell, a former member of the House, believed that two crises in his own health had benefited from the use of unconventional medicine: colostrum derived from the milk of a Minnesota cow, he held, had cured his Lyme disease; and 714-X, derived from camphor in Quebec by Gaston Naessens, had prevented recurrence of his prostate cancer after surgery. Bedell, giving evidence of his Lyme disease recovery at a Senate committee hearing, observed: “Unfortunately, Little Miss Muffet is not available to testify that the curds and whey which she was eating are safe.” Wiewel had long been a vigorous champion of immunoaugmentative therapy for cancer, scorned by orthodox specialists; made in the Bahamas, this mixture of blood sera was finally barred from import by the Food and Drug Administration. Wiewel then began operating from his home in Otho, Iowa, an agency called People Against Cancer, a referral service for cancer treatments that orthodox medicine considered questionable.

Harkin, having lost two sisters to cancer, was susceptible to an interest in alternative therapies. Soon after sponsoring the law that launched the Office of Alternative Medicine, Harkin himself became a true believer in an unorthodox “cure.” On Capitol Hill, Bedell introduced the senator to Royden Brown of Arizona, promoter of High Desert bee pollen capsules. Harkin suffered from allergies; persuaded by Brown to take 250 bee pollen capsules within five days, he rejoiced that his allergies had disappeared. The senator did not know at the time that Brown had recently paid a $200,000 settlement under a consent agreement with the Federal Trade Commission, promising to cease disguising television infomercials as objective information programs and to stop including in his scripts dozens of false therapeutic claims for his capsules. These promotions also averred that “the risen Jesus Christ, when he came back to Earth,” had consumed bee pollen; a more recent customer, Brown’s infomercial declared, was Ronald Reagan. Brown later wrote Hillary Clinton, warning that her husband should begin dosing with bee pollen lest he develop fatal throat cancer.

So NCCIH started out at the urging of two quack constituents of Harkin; then Harkin became a believer himself. Not surprisingly, it soon became clear that the OAM was not intended to rigorously study alternative medicine, but rather to provide a seemingly scientific rationale to promote it. The office was initially set up with an acting director and an ad hoc panel of twenty members, many of which Harkin hand-picked, including advocates of acupuncture, energy medicine, homeopathy, Ayurvedic medicine, and several varieties of alternative cancer treatments. Deepak Chopra and Bernard Siegel were also included. Critics of quackery were consulted and considered for panel membership but—surprise, surprise!—were not selected. These pro-alt med panel members became known in the OAM as “Harkinites.”

Against this background, the first director of the OAM, Joseph M. Jacobs, almost immediately ran afoul of Harkin by insisting on rigorous scientific methodology to study alternative medicine. To get an idea of what Jacobs was up against, consider that in 1995 the inaugural issue of Alternative Therapies in Health and Medicine featured not just one, but two, commentaries by Senator Harkin, The Third Approach and A Journal and a Journey. In these two articles, Harkin basically introduced the new journal as a “journey—an exploration into what has been called ‘left-out medicine,’ therapies that show promise but that have not yet been accepted into the mainstream of modern medicine.” and explicitly stated that “mainstreaming alternative practices that work is our next step.” Unfortunately, he had a bit of a problem with the way medical science goes about determining whether a health practice—any health practice—works and railed against what he characterized as the “unbendable rules of randomized clinical trials.” Citing his use of bee pollen to treat his allergies, went on to assert, “It is not necessary for the scientific community to understand the process before the American public can benefit from these therapies.” It is an attitude that did not change. In 2009, Harkin famously criticized NCCAM thusly:

One of the purposes of this center was to investigate and validate alternative approaches. Quite frankly, I must say publicly that it has fallen short. It think quite frankly that in this center and in the office previously before it, most of its focus has been on disproving things rather than seeking out and approving.

Truly, this was a profound misunderstanding of how science works. Also, the reason NCCAM had failed to “validate alternative approaches” is because they were, largely, pseudoscientific quackery that, as expected, failed scientific testing.

Ultimately Jacobs resigned under pressure from Harkin, who repeatedly sided with the quacks. It also didn’t help that Jacobs complained about various “Harkinites” on the advisory panel who represented cancer scams such as Laetrile and Tijuana cancer clinics. That Jacobs became tired of fighting and finally resigned is especially noteworthy given that Jacobs, too, had been handpicked to run OAM because of his openness to the idea that there were gems to be found in the muck of alternative therapies. Meddling by Harkin was a theme that kept repeating itself. Later, in 1998 after then-NIH director had tried to impose more scientific rigor on the OAM, Harkin sponsored legislation to elevate the OAM to a full center, and thus was NCCAM born. Not coincidentally, the NIH director has much less control over full centers than over offices.

Bad science and revisionist history about how alternative medicine evolved into “integrative” medicine

The key message promoters of unscientific medicine hammer home again and again is that they’re not quacks. Oh, no. They’re real scientists and don’t use medicine that’s not scientifically proven. Rothenberg Gritz drives that point home thusly:

But I was intrigued by the NIH center’s name change and what it says about a larger shift that’s been going on for years. The idea of alternative medicine—an outsider movement challenging the medical status quo—has fallen out of favor since my youth. Plenty of people still identify strongly with the label, but these days, they’re often the most extreme advocates, the ones who believe in using homeopathy instead of vaccines, “liver flushes” instead of HIV drugs, and garlic instead of chemotherapy.

In contrast, integrative doctors see themselves as part of the medical establishment. “I don’t like the term ‘alternative medicine,’” says Mimi Guarneri, a longtime cardiologist and researcher who founded the Academy of Integrative Health and Medicine as well as the integrative center at Scripps. “Because it implies, ‘I’m diagnosed with cancer and I’m going to not do any chemo, radiation, or any conventional medicine, I’m going to do juicing.’”

As I characterized it, “We’re not quacks! We’re not quacks!” Later Rothenberg asserts:

The actual treatments they use vary, but what ties integrative doctors together is their focus on chronic disease and their effort to create an abstract condition called wellness. In the process, they’re scrutinizing many therapies that were once considered alternative, subjecting them to the scientific method and then using them the same way they’d incorporate any other evidence-based medicine.

Except that that’s not the case. Here are a couple of examples that I like to use to show why this characterization of integrative medicine is a delusion.

First, I like to cite a certain medical society that I’ve butted heads with on more than one occasion and whose leadership really, really doesn’t like me, namely the Society for Integrative Oncology, declaring that it has “consistently encouraged rigorous scientific evaluation of both pre-clinical and clinical science, while advocating for the transformation of oncology care to integrate evidence-based complementary approaches. The vision of SIO is to have research inform the true integration of complementary modalities into oncology care, so that evidence-based complementary care is accessible and part of standard cancer care for all patients across the cancer continuum.” Would that this were true! If that truly is the case, then how does SIO reconcile itself with the fact that its current president, Suzanna Zick, and immediate past president, Heather Greenlee, are both naturopaths, one of whom authored official SIO guidelines for the integrative care of breast cancer patients? (Even more depressingly, Zick is a naturopath working in the Department of Family Medicine at my old alma mater the University of Michigan Medical School.) That alone puts the lie to any claims SIO has of being scientific, given that naturopathy is a cornucopia of quackery and pseudoscience. In particular, homeopathy—or, as I like to call it, The One Quackery To Rule Them All—is an integral part of naturopathy, to the point where it is a major component of the curricula of schools of naturopathy and is a required component of the naturopathic licensing examination (NPLEX). If you don’t believe just how quacky naturopathy is, read what they say to each other when they think no one is watching; learn about how full of pseudoscience their education and practice are, as related by a self-described “apostate“; and how unethical their research can be.

Despite all this, it’s not just integrative oncology that’s embracing naturopathy. (There’s even a specialty now known as naturopathic oncology that’s advertised by places like the Cancer Treatment Centers of America.) Meanwhile a whole host of integrative medicine programs offer the services of naturopaths, including Kansas University, UC Irvine, Beaumont Hospital (in my neck of the woods!), the University of Maryland, and, of course, the Cleveland Clinic, where a naturopath runs a traditional Chinese medicine clinic, just to name a few.

Now, here’s where the second point comes in. It goes way beyond naturopathy, whose tendrils have become firmly entwined with those of “integrative oncology,” perhaps more so than with other specialties. If, as its advocates claimed ad nauseam to Rothenberg Gritz, integrative medicine is all about the science, then its approach is all wrong. Let’s put it this way. They themselves admit that many of the modalities they are using are unproven. If they truly accept that, then for them to offer such services outside of the context of a clinical trial would be as unethical as offering a non-approved drug or unproven surgical treatment to patients. Yet, as I’ve described more times than I can remember, there are quite a few academic institutions out there offering reiki, which is just as quacky, if not more so, than homeopathy, given that it postulates the existence of a “healing energy” that has never been detected and in its particulars is no different than faith healing, except that it substitutes Eastern mystical beliefs for Christian beliefs. Under the banner of “integrative medicine,” academic medical centers offering high dose vitamin C for cancer, anthroposophic medicine, functional medicine. Indeed, there are academic medical centers out there that offer everything from acupuncture to chiropractic to craniosacral therapy to naturopathy. Heck, the University of Maryland offers reflexology, reiki, and rolfing, none of which have any good evidence to support them, while more integrative medicine programs than I can keep track of offer acupuncture and various other bits taken from traditional Chinese medicine, even though acupuncture is nothing more than a theatrical placebo.

In other words, integrative medicine puts the cart before the horse. Hilariously, Rothenberg Gritz inadvertently undermines her own praise of the science of integrative medicine by relating that Dr. Guarneri, whom she just represented as a paragon of science who only wants to use scientifically validated treatments, offers onsite massage therapy, herbal baths, craniosacral therapy, and acupuncture, the latter two of which are pure quackery. (Oh, and she teams with naturopaths, as well.) Indeed, craniosacral therapy is such ridiculous quackery that Guarneri’s offering it pretty much eliminates any chance I’ll buy her claim of adhering to science in her practice of “integrative medicine.”

My amusement at this aside, especially irritating is Rothenberg Gritz’s description of acupuncture. After noting that chronic pain is one reason why people seek out alternative medicine, she writes:

One reason pain is so hard to treat is that it isn’t just physical. It can carry on long after the initial illness or injury is over, and it can shift throughout the body in baffling ways, even lodging in phantom limbs. Two different people can have the same physical condition and experience the pain in dramatically different ways. As the Institute of Medicine report put it, pain flouts “the long-standing belief regarding the strict separation between mind and body, often attributed to the early 17th-century French philosopher René Descartes.”

This may be why so many chronic pain sufferers are drawn to traditional medicine: The Cartesian idea of mind-body duality never found its way into these ancient systems. Acupuncture, for instance, has been shown to help with problems like back, neck, and knee pain. But it’s very hard for science to figure out how it works, since it involves so many components that are mental as well as physical. The technique of inserting the needles, the attitude of the practitioner, the patient’s own attention—all of these are built into the treatment itself. In Acupuncture Research: Strategies for Developing an Evidence Base, researchers note that ancient Chinese physicians saw the mind and body as “necessarily connected and inseparable.”

Note that the study to which Rothenberg Gritz links is the acupuncture meta-analysis by Vickers et al, which so failed to show what it claimed to show that one SBM post wasn’t enough to explain why. It required discussion by Steve Novella, Mark Crislip, and myself, much to Vickers’ dismay.

The funny thing is, mind-body dualism is not a part of modern medicine, making it odd that the IOM would get it so very, very wrong 11 years ago. Remember, the concept of dualism posits that consciousness (the mind) is, in part or whole, something separate from the brain; i.e., not (entirely) caused by the brain. Now, if there’s anything modern neuroscience has taught us, it’s that dualism is untenable as a scientific hypothesis, that the “mind” is wholly a manifestation of the function and activity of the brain—or, as it’s sometimes stated, the brain causes the mind. In other words, science-based medicine rejected mind-body dualism a long time ago. Of course, as we’ve discussed here more times than I can remember, when rigorously studied acupuncture has never been convincingly shown to do anything more than placebo. Indeed, the reason why acupuncture “outcomes” (such as they are) are so dependent on practitioner and patient is because acupuncture is placebo.

In fact, my retort to Rothenberg Gritz’s outright silly argument about mind-body dualism is that it’s the integrative practitioners who emphasize mind-body dualism, whether they realize it or not. After all, they have a whole category of therapies known as “mind-body” medicine, an implicit acceptance, at least on some level, of dualism. Nor does their overblown appropriation of epigenetic studies as evidence that the “mind heals the body” (or, as I like to refer to it, wishing makes it so), which infuses so many alternative medicine practices, help. In actuality, given that the vast majority of alternative medicine practices, when rigorously studied, do no better than placebo, this new emphasis is basically integrative medicine rebranding the pseudoscientific practices it “integrates” as “harnessing the power of placebo.” Since placebo effects require that physicians in essence lie to their patients (albeit with good intent), it’s not for nothing that Kimball Atwood and I have dubbed the placebo medicine as practiced by integrative medicine practitioners as a rebirth of paternalism in medicine due to the lure of being the shaman-healer.

The rest of the article is full of the same old old pro-integrative medicine tropes that I’ve seen over and over and over again. For example, Mark Hyman, the “functional medicine guru” now trusted by Bill and Hillary Clinton who regularly mangles science about autism and cancer while advocating anecdote-based medicine, opines that we have “an acute-disease system for a chronic-disease population,” that the “whole approach is to suppress and inhibit the manifestations of disease,” and that “the goal should be to enhance and optimize the body’s natural function,” whatever that means—and whatever “functional medicine” is. (For a reminder, look at Wally Sampson’s multi-part analysis of what functional medicine is claimed to be here, here, here, here, and here.)

Rothenberg Gritz also relies on the ever-annoying “science has been wrong before” canard, listing all sorts of areas where medicine got it wrong before getting it right, as though that justifies integrating alternative medicine into science-based medicine because, I suppose, science could be wrong about that too. It does not; it’s a fallacy. She also parrots the charge that doctors haven’t thought enough about prevention, a claim that has always irritated me. After all, what are vaccines, but prevention? What are diet and drugs to treat elevated blood sugar but prevention of diabetic complications? What are antihypertensive drugs but a means to prevent the complications of hypertension, such as heart attacks and strokes? What are smoking cessation programs but a means of preventing cancer, heart disease, and chronic obstructive pulmonary disease, the three most deadly consequences of smoking. (Note how integrative medicine only defines “prevention” as non-pharmacologic, or “natural,” approaches.) Yes, it’s difficult to practice some forms of prevention because making lifestyle changes, such as losing weight, drinking less, smoking less, and exercising are hard. Patients don’t want to do them and have a hard time achieving them. I’ve yet to see much evidence that “integrative” medicine will do any better after having appropriated lifestyle interventions and rebranding them as somehow being “integrative.”

What is integrative medicine, anyway?

Perhaps the most inadvertently telling passage in Rothenberg Gritz’s article comes near the end:

After months of speaking to leading integrative doctors and researchers, I found that I was still having trouble summing up exactly what integrative health was all about. It’s not a specialty like obstetrics or endocrinology. There are integrative training programs and certifications out there, but none of them has been universally recognized throughout the medical profession. “At this point it’s really a self-declaration,” Nancy Sudak, the chair of the Academy of Integrative Health and Medicine, told me. “And nobody has a tool kit that includes absolutely everything. It largely depends on who you are as a practitioner.”

In other words, integrative medicine is, as I said, a brand, not a specialty. Pretty much every other specialty has a definition of what it encompasses that is clear. Integrative medicine is this fuzzy entity about which I can’t help but recall the words of Humpty Dumpty in Lewis Carroll’s Through the Looking Glass, who said scornfully, “When I use a word, it means just what I choose it to mean—neither more nor less.” So it is with integrative medicine, which is why last week integrative medicine could be defended on using a fallacious argument that science-based medicine is “nonsense” or that “Western medicine” has lost its soul, while this week I can sit back an grit my teeth reading an article regurgitating the advocate line that integrative medicine is just as scientific as science-based medicine.

Rothenberg Gritz is correct that integrative medicine has evolved, but it hasn’t evolve in the way she thinks it has. In her final paragraph, she wonders whether the rise of integrative medicine is a result of cultural shifts (which is possible) but comes to an untenable conclusion that it may be the only way to treat chronic disease. In actuality, it is only the language that has evolved. I was half-tempted to recycle the introduction to my post on how integrative medicine is a brand not a specialty, where I describe the evolution of integrative medicine, but instead I’ll just give you the CliffsNotes version instead and you can read the original in all its snarky glory if you like. In fact, you should. You won’t regret it.

Basically, starting around the late 1960s and early 1970s, in a bid to gain respectability for what was then called quackery or health fraud, the term “alternative medicine” was coined, which didn’t have all the harsh connotations of the usual language. Around that same time, in response to credulous Americans like James Reston, a New York Times editor who underwent an emergency appendectomy while visiting China in 1971. His story was represented as successful “acupuncture anesthesia,” when it was anything but. However, the word “alternative” implied that this was not “real” medicine, that it still was somehow unrespectable (which it was and still is, for good reason). Consequently, in the 1990s, around about the time Rothenberg Gritz was in high school admiring her dad’s woo-filled medical practice, a new term was born: complementary and alternative medicine (CAM). The idea was that you need not fear these quack medical practices because they would be used in addition to medicine, not instead of it. This term contributed greatly to the increasing embrace of CAM by medical academia, but it was still not good enough for its advocates. After all, the word “complementary” implies a subsidiary status, that CAM is not the main medicine but just icing on the cake, so to speak.

That did not sit well with advocates, who wanted their woo to be fully part of medicine, even though they didn’t have the evidence for that to happen naturally. Thus was born the current term “integrative medicine.” No longer did CAM practitioners have to settle for having their quackery be merely “complementary” to real medicine. They could use this term to claim co-equal status with practitioners of real medicine. The implication—the very, very, very intentional implication—was that alternative medicine was co-equal to science- and evidence-based medicine, an equal partner in the “integration.” Thus was further advanced the false dichotomy that has been used to justify alternative medicine from the very beginning, that a physician can’t be truly “holistic” unless he embraces pseudoscience.

The true evolution of integrative medicine is not that it has become more scientific. Rather, it is that its advocates have gotten much, much better at branding quackery as being medicine under the guise of being “holistic” and “patient-centered.” It’s a false dichotomy that I reject and that Rothenberg Gritz clearly doesn’t understand.

Categories: Medicine, Skepticism

The Disco-Tute’s Despicable Narrative

Neurologica Blog - Fri, 06/26/2015 - 08:11

The Discovery Institute, in my opinion, is an intellectually dishonest propaganda organization trying desperately (and failing) to disguise itself as a legitimate scientific group. They promote the unscientific notion of intelligent design, which itself it just “scientific creationism” in disguise.

Because they dishonestly pursue an ideological agenda, they are the epitome of the phenomenon of allowing a narrative to control the interpretation and selection of facts and arguments, a process known as motivated reasoning. In the case of the Disco-Tute their narrative is that evolution is bad, and they therefore spend the bulk of their time trashing evolution in every way possible. Sometimes this leads to absurd positions, even by the baseline absurd standards by which the Disco-Tute lives.

A recent article on their blog, Evolution News and Views, hits what is perhaps a new low watermark, even for them: In Explaining Dylann Roof’s Inspiration, the Media Ignore Ties to Evolutionary Racism. That’s right – author David Klinghoffer is trying to exploit the horrible tragedy in South Carolina in order to score imaginary points against evolution. For quick background, Roof (allegedly) is a horrible young white supremacist racist who thought he needed to go into a black church in South Carolina and start shooting people.

First Klinghoffer makes a serious attempt to fry irony meters across the internet by writing:

Guilt by association is a nasty business. It’s often very selective, too. It leaves things out that don’t fit the desired narrative.

Then the follow up:

When I read these articles, I noted that the official spokesman for Holt’s group is a person called Jared Taylor, best known for leading another, slightly more polished white nationalist web publication, American Renaissance. These organizations have their different emphases and preoccupations. While the Council of Conservative Citizens is obsessed by “black-on-white” crime,American Renaissance has as one of its specialties science-flavored, notably evolutionary, justifications for racism. In the media coverage I’ve seen, the latter fact has gone unmentioned.

So even though Roof’s manifesto does not mention evolution or evolutionary arguments, the spokesperson for the white supremacist group to which Roof belongs also heads a separate group that justifies their racism with evolutionary arguments. Therefore…

This is part of the anti-evolution narrative that evolutionary theory somehow inspired racism, which is utter nonsense. Racism predates evolutionary theory. Racism is also quite at home among creationists. There is absolutely nothing in evolutionary theory that carries with it a value judgement that supports racism. That some modern racists use evolutionary arguments to support their beliefs is completely irrelevant. I’m sure that Christians would not want to be tagged with every belief for which the Bible has been offered up as justification – which includes racism.

Klinghoffer’s absurd article does offer a teaching moment. First, it nicely exposes the despicable intellectual dishonesty of the Disco-Tute, and Evolution News and Views as a propaganda rag. At least they do conveniently marginalize themselves with such nonsense.

There is also a deeper lesson here, in my opinion. This is an extreme case of a phenomenon that I believe is widespread – shoehorning a cause-and-effect explanation into a situation in order to support a preferred narrative. This happens whenever a major tragedy occurs; people seek for an explanation within their existing narratives. This becomes an exercise in confirmation bias and motivated reasoning, and then further supports the narrative.

If you have spent any time discussing politics with friends, you have likely experienced this. Conservatives can always find a way to blame liberals for anything, and vice versa. Whatever social issue is most important to you, that is the lens through which you will view events, and the explanation that fits the issues you care about will pop out.

In reality most events are the result of a complex network of interacting variables. When a shooter killed many children in an elementary school in Sandy Hook, many commentators focused on one factor as “the” cause. It was either lax gun laws, or not enough security in schools, or lack of recognition and treatment for mental illness, or poor parenting. Perhaps Klinghoffer thinks it was due to teaching evolution in schools.

As is usually the case, it is far easier to see this behavior in others than in ourselves. It is important, therefore, to make a conscious effort to step back and try to think of such events and the result of the complex interacting forces that it probably is, rather than quickly settle into your preferred narrative. We also have to let the evidence for each individual case speak for itself, rather than use individual incidents as automatically representative of the larger issues we care about (even if those issues are perfectly legitimate).

In the case of Roof, the evidence that is available so far strongly points to the conclusion that he was a white supremacist racist, filled with the usual beliefs and hatred fostered by such groups. He has pretty much stated that was the motivation for his actions, and his previous writings are also pretty clear. Other factors about Roof may have interacted with his racism, but they are likely incidental to his actions. He may have been an avid gamer, for example, but that does not mean gaming caused his violence.

In other words, we have to resist the temptation to assume that any correlation is a causation, especially when it fits our preferred narrative. We have to be skeptical and ask, what does the evidence actually indicate?

A critical thinker should do, in short, what Klinghoffer at the Disco-Tute failed to do. Be skeptical.

Categories: Medicine

Chiropractic and Stroke: The question is not answered

Science Based Medicine - Fri, 06/26/2015 - 02:44

I am off to Chicago for 5 days to wow the SMACC crowd with my ID/SBM acumen. I hope. Given that most of my multiple-personalties do not seem to be able to get any work done, I am forced to write a brief post this week, limited by the battery life on my MacBook Air. What ever I get down on paper? pixels? RAM? before the battery dies as I fly over the Rockies will be the post. It is times like this I wish I had Gorskian typing skills.

SBM has discussed the many limitations of chiropractic: the low grades for entry into Chiropractic school, the inadequate training, their reason d’être, subluxations and their adjustments being divorced from reality, the lack of efficacy of chiropractic for any process beyond low back pain, and even that is no better than safer interventions, the fondness of chiropractors for other useless pseudo-medicines and their opposition to vaccines.

Hm. When I put it like that Chiropractic does appear a little sketchy. But is chiropractic safe? It is a hands-on intervention, for a brief period of time applying the same force to the neck as about 40% of hanging from the neck until dead. So there is certainly the potential for chiropractic to cause harm.  

30 plus years in medicine has only reinforced the concept that under the right conditions, a perfect storm, even the most benign of interventions can kill.  As an intern I had a patient whose IV, placed for an acute heart attack, became infected with S. aureus that went to her aortic valve that rapidly blew out and she died.   There is always the potential of medical equivalent of Because a Little Bug Went Ka-Choo!

Can chiropractic care cause a stroke? No. Because chiropractic care covers a lot of interventions, from the realigning nonexistent subluxations to the uber-silliness of applied kinesiology and more.

Does neck manipulation, the high velocity, low frequency, neck snap of a brief hanging lead to occasional stroke? Now that is the question.

Chiropractors love to point to the Cassidy study as the be all end all evidence that neck manipulation does not cause stoke.  It is the poster child for chiropractic  motivated reasoning.

A careful reading, such I as did over at Science-Based Medicine, suggests that the Cassidy points to an increase risk for stroke following chiropractic, especially in the young. It was a flawed study, but if you are a chiropractor who doesn’t read carefully or beyond the abstract, you might think the paper supports the safety of chiropractic.

The authors of Chiropractic care and the risk of vertebrobasilar stroke: results of a case–control study in U.S. commercial and Medicare Advantage populations also like the Cassidy study,

The work by Cassidy, et al. [32] has been qualitatively appraised as one of the most robustly designed investigations of the association between chiropractic manipulative treatment and VBA stroke

Which says something about the quality of the chiropractic literature and the safety of neck manipulation. But the study was done in Canada. What we really need is to reproduce the same lousy study in the US.

The paper looked at stoke 30 days following a PCP visit or a chiropractic visit for neck pain and found no difference in stroke.

Among the commercially insured, 1.6% of stroke cases had visited chiropractors within 30 days of being admitted to the hospital, as compared to 1.3% of controls visiting chiropractors within 30 days prior to their index date. Of the stroke cases, 18.9% had visited a PCP within 30 days prior to their index date, while only 6.8% of controls had visited a PCP

Which really says nothing. There is no information about why those who had a stroke were visiting either provider.

We do not know which patients had neck manipulation or even spinal manipulative therapy (SMT) since

Less than 70% of stroke cases (commercial and MA) associated with chiropractic care included SMT.

Also

There were statistically significant differences (p = <0.05) between groups for most comorbidities.

So it would appear that the two populations were not even remotely comparable.

Unlike Cassidy et al. and most other case–control studies our results showed there was no significant association between VBA stroke and chiropractic visits. This was the case for both the commercial and MA populations. In contrast to two earlier case–control studies, this lack of association was found to be irrespective of age. Although, our results (Table 8) did lend credence to previous reports that VBA stroke occurs more frequently in patients under the age of 45 years.

As the authors note

Our results add weight to the view that chiropractic care is an unlikely cause of VBA strokes.

A conclusion based on comparing different populations whose intervention is uncertain.  That is a “robustly designed investigation”? Perhaps chiropractic care is safe but how about neck manipulation? They are not the same thing. It is a fine point distinguishing between chiropractic care and neck manipulation, one that the authors recognize:

However, the current study does not exclude cervical manipulation as a possible cause or contributory factor in the occurrence of VBA stroke.

It is not death row care that matters, but that short drop through the trap door at the end. I suspect that the chiropractic organizations will fail to recognize this distinction.

I can’t see where the paper adds any information about the safety of chiropractic neck manipulation and will stick with the preponderance of data and the AHA/ASA Guideline.

But it does add FUD and I am sure there will be no end of blog entries trumpeting the paper and declaring that chiropractic is safe. It would appear that the approach to patient safety by chiropractors is embrace the good, yet flawed studies and rationalize away the bad, and who cares about patient safety when their subluxations need a fixin’.

The striking thing about chiropractic, and SCAM in general, is the aggressive denial that their interventions could and do cause harm, and the unwillingness to alter or abandon practices for  increased patient safety.

Chiropractic advocates, and SCAM apologists in general, do love to mention the harm caused by NSAIDS or the deaths due to medications.

I have sat on hospital Quality Councils for 25 years as well as chaired my hospitals infection control programs. I can proudly point to an enormous about of work in that time to slowly drive down infections, morbidity and mortality.  My hospitals are markedly safer than they were 25 years ago. This has occurred because we recognize that our interventions can harm and continually refine practice to minimize those risks.  And because we apply the medical literature, always erring on the side of patient safety.

There still remains only one quality intervention to improve patient care in the entire SCAM universe, using sterile acupuncture needless, and the practice of acupuncture renders that intervention useless.  Gloves are not high on their to do list.

There are, to the best of my ability to locate, no other examples of SCAM practice being modified or abandoned due to evidence of harm.

And of course harm has to be balanced with efficacy. The first rule of medicine is not “do no harm.”  Any and all interventions can harm. The first rule should be “on balance the good should outweigh the harm.” Chiropractic fails on that measure as well, since the benefit is negligible only for low back pain and no better than safer interventions.

We do need better data. Many hospitals have stroke programs to maximize care for patients with stroke. When I last asked, the programs do not enquire into recent neck manipulation. Some clever epidemiologist needs to leverage information from all the stoke programs to help determine what the real risk of a brief hanging is.

And the pilot has let us know it is time to shut things down for landing.  This is as good as it is going to get.

Categories: Medicine, Skepticism

The Tim Hunt Hubbub

Neurologica Blog - Thu, 06/25/2015 - 08:15

I have watched from the sidelines the recent controversy over the comments made by Nobel Laureate, Tim Hunt. Here is what sparked the controversy:

The British scientist told delegates at the World Conference of Science Journalists in South Korea that when women work alongside men in labs, three things happen: “you fall in love with them, they fall in love with you, and when you criticize them, they cry.” He then went on to suggest that perhaps the best way to solve this problem is to have sex-segregated labs.

Hunt was widely criticized for his comments, which were interpreted (quite reasonably) as sexist. Within days he was pressured to resign from his honorary post at University College London. In response to that others came to his defense, including 8 Nobel laurates and Richard Dawkins, who characterized the reaction as a “witch hunt.” Others, like Brian Cox, did not go that far but did say the response was “disproportionate.”

This has lead to a round of criticizing those defending Tim Hunt. And now the Tim Hunt camp has responded further, saying that Hunt was taken out of context, that he followed up those words with, “Now seriously, women are needed in science,” indicating the whole thing was just a bad joke. That claim, however, is disputed, and there is no objective record to resolve the dispute.

The whole situation can be charitably characterized as a mess. I think there are some interesting lessons to derive. The first is how social media and the internet has so radically changed our society. The Hunt affair played out very quickly, with camps forming, prominent people expressing their opinions, multiple rounds of claims and counter-claims, all within days. This is a new reality, and we all have to adapt to it or will be vulnerable to…well, whatever you want to call this.

I think to some degree it represents a fundamental loss of privacy. I am a modest figure on social media within a fairly small subculture, and yet I have had to shift my attitude significantly over the last decade. I pretty much assume I have no privacy unless I am alone or with only family. Anything I say, any e-mail I send (even if in my mind it is private), I just assume that it can and will be made public at some point. This means that the circle of my private completely unedited persona has shrunk very small.

This is not to say I have anything to hide, but there is something to be said for having a space where our thoughts can run free, where we can consider unpopular ideas and sort out how we really feel about things. It seems to me that increasingly this private space is merging with the public space. This has now become the background noise of social media, sometimes magnified by a feeling of distance or anonymity.

Of course, Hunt was speaking in front of journalists, so he should have known that every word he uttered was completely public. I don’t know Hunt at all, and so I have no context in which to relate what he said to his character. Perhaps it was a bad joke gone horribly wrong. Perhaps it was an “ironic” joke – the kind where you say what you really feel but hide behind the cover of irony. How we joke often reveals how we think, just with a layer of plausible deniability.

Hosting a podcast every week and getting literally thousands of e-mails with feedback over the years has been a valuable experience. I have learned, essentially, not to do that – not to joke in a way that can be superficially interpreted as sexist, racist, or whatever and then think that the intended humor will negate the implied attitude. It is tricky, because we try to be funny, lighthearted, familiar, and spontaneous – all setups for saying things that can give the wrong impression about how we actually feel. (I do have the benefit of editing, of which I make good use.)

The lesson here is that, if you are a successful standup comedian, you can probably get away with this. If you aren’t, then you should be very careful, and probably just avoid this kind of humor. If Hunt is sincere that his comments were bad humor, then he provides an excellent example of why it is a bad idea.

Along similar grounds, I think we have all had the experience of what we have in our heads and the words that come out of our mouths being two very different things. Crafting what you say in real time is a difficult skill. Successful politicians develop this skill, and it shows. It also tends to come at the expense of seeming genuine. Unless you are brilliant or very talented, it is difficult to be crafted and seem genuine at the same time.

I suspect that most working scientists have not developed their skill for giving finely crafted interviews that allow them to avoid saying anything that can be taken out of context or give the wrong impression.

In the end, Hunt is responsible for what he said, especially since it was overtly in public (in front of journalists). Perhaps he harbors sexist ideas, and he was essentially caught with his pants down. Perhaps his comments made him sound more sexist than he actually is. I don’t know (although it is hard to imagine he isn’t sexist at all, even if he intended the comments purely as humor).

I think history has shown that the best response to saying something in public we then regret is to just suck it up and thoroughly apologize. Rip that bandage off in one go. Hunt has sort of apologized, in a way that really doesn’t mitigate what he said, as evidenced by the lingering controversy.

Hunt should have also been especially careful as a Nobel Laureate, a de facto representative of the institution of science. Women have historically been given the short end of the stick in science, and this injustice, although improving, persists to this day. It was profoundly unwise to utter comments that could only be interpreted as reinforcing old prejudices against women in science. What he says has real consequences, and therefore should also carry real responsibility.

 

Categories: Medicine

FDA & CDC find raw pet food unpalatable

Science Based Medicine - Thu, 06/25/2015 - 01:00

Awww!

The FDA recently announced it would send field staff out to collect samples of commercially-manufactured raw dog and cat food. The samples will be analyzed for Salmonella, Listeria monocytogenes and E. coli, all of which have been found in raw pet food, in the animals who eat it, in their feces, on their bodies after eating it, in the areas they inhabit, and on their owner’s bodies.  Not surprisingly, this has led to both pet and human infection and illness. If the FDA finds pathogens, it could result in a recall, a press release and Reportable Food Registry Submission. The next day, the CDC joined the effort to curb illness caused by pathogens in raw pet food by posting information on safe handling.

Because of the risk to public health, and the lack of any proven benefit of raw pet food diets, the FDA does not recommend them.

However, we understand that some people prefer to feed these types of diets to their pets.

And why is that? For some of the same reasons humans follow absurd diet fads: the “lone genius” discovery, it’s “natural,” anecdotal evidence, appeal to antiquity, anti-corporate sentiment, and “holistic” practitioner recommendations.

The “lone genius” discovery

Although he may not have been original inventor of the raw pet food diet, Australian vet Ian Billinghurst is its most ardent popularizer, in the form of his trademarked “Dr. Billinghurst’s BARF Diet.” BARF is an acronym for “Biologically Appropriate Raw Food,” although other gastrointestinal-related events are called to mind.

Billinghurst recounts how the health of his own dogs declined after he started feeding them high quality commercial pet food. (Oddly missing from this story is information about what he was feeding his pets before he started them on commercial pet food and why he didn’t just go back to this diet.) However, it took him two years to realize his error. That realization came only when he switched them to a diet of raw meat, including bones, and household scraps. The results, as you might imagine, were “immediate and dramatic.” He urged his clients to switch their pets’ diets as well, with the same amazing results.

He reasoned that raw meaty bones and vegetable scraps were “very close to the evolutionary diet of cats and dogs.” He was also influenced by his study of acupuncture, although it is unclear how that led to the BARF diet, other than a willingness to trade the scientific method for anecdotal evidence as a basis of one’s practice.

Billinghurst wrote a book in the 1980s, catchily titled Give Your Dog a Bone, setting forth his unique pet nutritional theories. It became something of a pet-owner cult hit and was followed by more books. He later partnered with Robert Mueller, a pharmacist (not the former FBI director) who wrote the similarly lone-genius discovery book,  Living Enzymes: The World’s Best Kept Pet Food Secret. Together with another partner, they created “BARF World,” which sells, among other things, commercially prepared raw pet food. We’ll return to this enterprise in a moment.

Billinghurst makes big claims for BARF, or at least the “raw meaty bone-eating” element:

Raw meaty bone-eating dogs lived much longer than their commercially fed counterparts, . . . Bone-eating dogs have the wonderful benefits of clean teeth with no periodontal disease, wonderfully improved digestion, a reduction in obesity, fabulous eating exercise, healthy stools, no anal sac problems, and the wonderful psychological, emotional, and immune system benefits that eating raw meaty bones has conferred on dogs for millions of years.”

The raw food diet for dogs is based on a combination of the naturalist and appeal to antiquity fallacies:  the notion that your dog is really, at heart (and stomach, I guess), a wolf.  And cats are tiny tigers, I suppose. While raw cat food is promoted as well, the whole “theory” appears to be largely dog-centric. Because wolves ate a raw diet, it must necessarily follow that raw meat, with a few herbs, is best for your dog. (Wolves got their plant matter by eating the stomach contents of their prey.)

In this, the diet also is a form of evolutionary medicine, which is based on the faulty assumption that chronic diseases and degenerative conditions arise from a mismatch between our (and our pet’s) Stone Age genes and recently adopted lifestyles, including diet. It is the same fallacy that lies at the heart of the paleo diet for us humans.

Brennen McKenzie, DVM, sliced and diced the “dog as wolf” theory nicely in a previous SBM post. (You can find more raw pet food posts on his blog, Skeptvet.)  In summary,

  • Yes, dogs and wolves are both in the order Carnivora, but so are giant Pandas, who are almost exclusively herbivores.
  • Dogs have not been wolves for a very long time — like 100,000 years or so.
  • The claim that dogs and wolves are anatomically identical with respect to an appropriate diet is simply untrue:

If you try to picture a pack of Chihuahuas bringing down and savaging an elk, the impact of thousands of years of artificial selection is obvious. . . . Dogs have lived with humans, eaten our table scraps, and been intensively bred for features we desire, none of which is likely to make them ideally designed for the diet of a wolf.

  • Wolves don’t have such a great life in the wild anyway. Disease, parasites and malnutrition are major factors in wild wolf mortality and they don’t live as long as captive wolves. And captive wolf breeders have found that the best diet for their wolves is – guess what? – commercial dog food.

An analogous argument has sprung up that feral dogs and cats eat raw meat, as if this is some conscious healthy lifestyle choice on the animal’s part instead of the result of appalling neglect and irresponsibility on the part of pet owners. Of course, feral dogs and cats also lead terrible lives, subject to malnutrition and early death, and don’t live as long as pet dogs and cats.

Bad, bad commercial dog food

The other main argument in favor of raw pet food has the flavor of “death by medicine.” Like that argument, trotted out to demonize “conventional medicine,” the failings of the commercial pet food industry do nothing to make raw pet food more nutritious, less risky, or otherwise better for your pet.

It is also underpinned by some grossly exaggerated and downright false claims about the commercial pet food industry. (And here we use the term “commercial pet food” to mean “conventional” commercial pet food, even though raw pet food has become plenty “commercial” as well.) While the commercial dog food industry has its problems, it is not the bogeyman that raw pet enthusiasts make it out to be. Dr. McKenzie has shredded these arguments for us as well. Briefly:

  • No, commercial pet food doesn’t make your pet sick. Like humans, pets live longer because of better nutrition and medical care. This means that illnesses of the aging pet, like cancer and degenerative diseases, are more prevalent. Coupled with the lack of a full understanding of what causes these diseases, this leaves raw food enthusiasts an opening to claim it must be the food.
  • No, commercial pet food is not “toxic.” This is based on the fact that commercial pet food contains preservatives and artificial coloring, two favorite boogeymen of the “natural food” crowd.
  • Yes, dogs can digest the grains used in pet food, contrary to claims otherwise.
  • No, cooking does not destroy all the nutrients. Some, but not all, by a long shot. It also kills bacteria and parasites, two big plusses in any food.
  • No, dog food is not made from dead pets. This offensive urban myth was investigated by the FDA and found wanting.

There are other myths raw pet foodies like to promote, such as veterinary schools don’t teach nutrition and what little they learn is controlled by the pet food industry. But let’s get to the facts.

Once fully digested, the raw pet food movement doesn’t seem so palatable.

As noted, the FDA plans to send agents out into the field for testing. Why? Because

the scientific literature indicates that feeding raw foods to household pets such as dogs or cats carries a risk to human and animal health. Even if the pets do not appear to be sick after consuming raw pet foods containing pathogens such as Salmonella and Listeria monocytogenes, they can become carriers of such pathogens and transfer the pathogens to the environment. Humans can be infected by contacting pathogens in the contaminated environment. Raw pet foods containing pathogens can also contaminate food contact surfaces and human hands that increase the risk of human exposure.

But that’s not the only risk. Julie Churchill, DVM, a specialist in companion animal nutrition at the University of Minnesota’s College of Veterinary Medicine, strongly disagrees with the BARF diet, because eating bones can be fatal.

Bones, even raw and ground ones, can perforate the [gastrointestinal] tract. This can lead to peritonitis, severe infections, require emergency surgery, and dogs die from this each year…

Risks aside, what about evidence that a raw food diet is better for your pet? There is none. In fact,

on the basis of published diet reviews, most home-prepared diets (both raw and cooked) are deficient in 1 or more essential fatty acids, vitamins, or minerals or a combination thereof. Although the perceived benefits of home-prepared diets may be reinforced daily to owners through a pet’s appetite or coat quality, nutrient deficiencies and excesses in adult animals are insidious and can lead to long-term complications if not detected and corrected.

In addition to the FDA and the CDC, the American Veterinary Medical Association, American College of Veterinary Nutritionists, American Animal Hospital Association, National Association of State Public Health Veterinarians and American Association of Feline Practitioners have all warned of the lack of benefit, as well as the dangers, of raw pet food diets. The American Holistic Veterinary Medical Association doesn’t take a position, in deference to the “holistic” vets who recommend raw diets and sell raw pet food products.

So, risks to pets and their owners from infections and, to pets, from bone fragments and nutritional deficiencies, and no evidence to support it supposed benefits.

Billinghurst rejects the lack of evidence with that ubiquitious CAM practitioner claim – “I’ve seen it work.” As far as the risks, he blows them off with the unfounded assertion that eating pathogens is no big deal, because dogs are “designed” to eat these things. It’s even ok for immune-compromised animals.

All of this is nonsense, but Billinghurst has his reputation and a raw pet food empire to think about. For example, you can get two 3 lb. bags of BARF World “Juicy Chicken Nuggets,” which contains not only chicken, but also vegetables, fruits, cayenne pepper and garlic, for a mere $37.97, plus $15.50 in shipping costs. If this is really what wolves eat, they are surely the unheralded gourmets of the animal world. Who knew animals used herbs and spices? But wait – there’s more: if you sign up for the BARF World automatic shipping plan (meaning, they’ll automatically send you the right amount of food, expertly calculated for your pet, in perpetuity) you get free shipping.

But what if your dog or cat doesn’t tolerate BARF World pet food? Not to worry. Some may exhibit brief symptoms of “detox,” like diarrhea and vomiting, but this is normal, especially when converting from a “processed diet.”

BARF World also sells a lot of other CAM stuff for your pet, such as Kefir and “Eastern Medicine” herbal supplement formulas. For example, “G.I Tract Herbal Formula for Dogs,” “harmonizes the stomach,” and, as an added bonus, “helps maintain contentment during travel” for dogs that have digestion issues, as well as those who “don’t want to travel in a vehicle.”  You can even get a consultation with a “holistic” vet.

Although BARF World may have the imprimatur of Billinghurst himself, several other raw pet food companies have gotten on the gravy train, and at similar prices.  No benefit, more risk, and higher prices. Yep, sounds like CAM to me.

If you want to subject yourself to unproven raw food fads, I suppose that’s your business. But leave your poor pet out of it.

Categories: Medicine, Skepticism

Trying to Impose Religion on Medicine

Science Based Medicine - Wed, 06/24/2015 - 08:13

One of the major themes of science-based medicine (unsurprisingly) is that medicine should be based on science. We consider ourselves specialists in a larger movement defending science in general from mysticism, superstition, and spiritualism. We are not against anyone’s personal belief, and are officially agnostic toward any faith (as is science itself), but will vigorously defend science from any intrusion into its proper realm.

The so-called alternative medicine movement (CAM) is largely an attempt to insert religious beliefs into the practice and profession of medicine. CAM is also an attempt to create a double standard or even eliminate the standard of care so that any nonsense can flourish and con-artists and charlatans can practice their craft freely without being hounded by pesky regulations designed to protect the public. These are both insidious aspects of CAM that need to be exposed and vigorously opposed.

A recent article by Dr. Michel Accad demonstrates how brazenly some are trying to insert faith healing and spiritualism back into medicine. He does so by couching his arguments in philosophy and marketing terms, but in the end he is essentially saying that doctors should practice his faith. He doesn’t really make any arguments for this position, but rather simply gives a history of progress in Western thought as if that is sufficient.

Why medicine needs to be science-based

Before I deconstruct Accad’s article let me explore the arguments for SBM. As a profession, medicine enjoys a special privilege in our society. Practitioners are licensed, which is a contract giving them exclusive rights to practice their trade in exchange for requirements to ensure quality control and ethical behavior. The health professions also benefit from public funding to pay for research, education, institutions, and patient care.

In exchange for this public support, the public has a right to demand regulations to ensure honesty, transparency, and quality in healthcare products and services. Such guarantees are only possible within a strictly scientific practice.

Science is transparent, and fairly and thoroughly considers all evidence in order to determine safety and efficacy. A science-based system is the only system that can ensure claims are fair and accurate. Once you erode the scientific basic of healthcare, then anything goes, and there is no possible way to maintain standards. Anything you do to ensure quality standards is essentially doing science, and then the only question is – are you doing it well?

CAM proponents want to allow what is essentially magic back into the practice of medicine precisely because magic cannot be held to any standard. Magic can also be optimized for marketing purposes – you can make grandiose claims without having to back them up with rigorous evidence. It is for this reason that CAM proponents have been attacking science and the scientific standard in medicine from every angle.

“Holistic” medicine

Accad falls for many CAM tropes in his article, but the main one is to confuse religion-based medicine for “holistic” medicine. He writes:

So why does conventional medicine seem so unable to attend to the complete welfare of the patient? Why, despite the manifest efficacy of scientific treatments, do growing numbers of patients consider their medical care altogether unhealthy?

The answer may have to do with what is meant by a whole person.

Each of his premises is false. First, medicine does address the whole patient. This is referred to as the “biopsychosocial” approach to medicine, and I learned it in medical school long before “holistic” medicine became hip. Every medical student at some point in their training will be told by an attending that they cannot treat their patient as if they were a disease – they have to treat the patient. You need to understand the patient’s psychological and social background and how that influences their understanding of their own symptoms and disease. Treatments need to be individualized to the patient’s values, desires, goals, and beliefs. This all needs to be done while respecting the need for informed consent.

Accad and other CAM apologists, however, ignore this reality. They have created the fiction that “Western” medicine is mechanistic, cold, and reductionist. To be fair, the demands of modern medicine can make it challenging at times to maintain the more cuddly aspects of medicine. We do use procedures and diagnostic tools that can be scary and unpleasant. We do try, at least in principle, to manage the patient experience to mitigate the demands of the modern technology of medicine, and don’t always succeed. This is not a philosophical problem with “Western” medicine, however, just a practical challenge of trying to balance the benefits of modern technology with the patient experience. We don’t always succeed, but good doctors, practices, and hospitals do this well.

The second premise is simply a naked assertion, also part of the CAM mythology. Surveys do not support the notion that people are increasingly seeking CAM because of negative attitudes toward scientific medicine. People who use CAM generally report they did so for philosophical reasons, or because they heard it might work, not because they are unhappy with their doctors. In fact, people are not seeking CAM in increasing numbers, the numbers are stable and low (unless you artificially inflate them by including things like prayer and nutrition in CAM).

These CAM claims are all about marketing – this is one brand trashing a competitor. For the record, I don’t think there should be any “brands” within medicine. There should be one fair and consistent science-based standard of care.

“What is meant by the whole person”

Accad has set up his false premise, that “Western” medicine is not holistic, and then defines “holistic” in a specific way that leads to the specific point he is trying to make. He asks, “what is meant by the whole person,” and his answer essentially encompasses his religious faith. “Holistic,” he asserts (again, he doesn’t actually make any arguments) means treating the soul.

If his essay can be construed as an argument, through inference, he is only making an argument from antiquity – we should treat the soul because people did it in the past. He writes:

St. Thomas Aquinas, borrowing from Aristotle’s philosophy of nature, explained that a human being is a substantial unity of body and soul or, to be more technically precise, a composite of “prime matter” (the principle of potency) informed by a rational soul (the principle of act).

He never states why we should care what Aquinas or Aristotle believed. Ironically, he reviews the progression of thought in this area sufficiently to explain why science has rejected the notion of a soul. He acknowledges:

The heightened attention given to the material aspects of the universe promoted the achievements of a bewildering revolution in the empirical sciences. And under the influence of the new sciences, diseases came to be conceptualized in similar terms: illnesses are accident [sic] of nature due to defective arrangements or to faulty motions of material stuff. Fix the defect and you fix the patient. This approach has yielded such astounding benefits to mankind that Descartes’ dream of conquering illness through the methodical application of empirical science seems to be well under way.

That is a wordy way of saying that “science works.” Over the centuries we tended to go with what works, and science undeniably “delivers the goods,” as Carl Sagan said. Why would we stick with a pre-scientific philosophy of illness that accomplished nothing in thousands of years, when a scientific approach revolutionized healthcare in tens of years?

Accad still has to cling to this notion that, despite scientific medicine’s undeniable success, something is missing. He accomplishes this by confusing “mind” and “spirit.”

But when medical science rests on a basis of material reductionism, the human mind—the intellectual and willful aspects of the soul—has a hard time finding its proper place. Descartes dealt with this difficulty by splitting apart the body and the soul of man

The human mind is not an aspect of the soul, it is what the brain does. The material reductionist approach to the mind is progressing quite well, thank you, without the need to appeal to any dualist notions. The mind, the psychological and social aspects of patients, is fully considered in modern medicine. We do not have to appeal to a “ghost in the machine” to be holistic. The only reason to appeal to such notions is to open the door for religious belief to enter into medicine.

Accad himself gives a partial explanation for why this is:

Following Descartes’ conceptual sundering of body and soul, scientists sought for a time to identify and isolate the vital principle of living organisms—as if that were possible. Vitalism, mesmerism, romanticism, and idealism became influential currents in Western Medicine in the eighteenth and nineteenth century. But when these efforts at grasping the essence of life proved futile or problematic, the inconvenient soul fell into neglect and was finally abandoned altogether as a subject worthy of inquiry or acknowledgment in polite scientific company.

That’s right – scientists gave a fair hearing to the notion of a vital force or spirit. In fact, this was the default assumption for a long time; it is what scientists assumed to be true. After a couple centuries of failing to find even the slightest bit of evidence for a vital force, scientists properly dropped the concept as a dead end.

There is another aspect to this that Accad misses, however. The vital force was also dropped because it ceased to become necessary. In the early days of science, before much was known about biology, vitalism was used to explain biological processes that were currently mysterious. It was a placeholder for our ignorance. Over time, however, everything that the vital force was supposed to do was eventually explained as a natural biological process. The role of the vital force shrank and shrank until it finally disappeared.

Can you blame scientists for discarding a pre-scientific notion that was of no value (it had no explanatory power and made no predictions) and for which there was no evidence? The history of progress in science is largely a history of discarding such notions. Scientists today don’t even think about vitalism because it’s “not even wrong” – it is of no scientific value.

The same is true of dualism, the notion of a spirit separate from the functioning of our brains. Neuroscientists have no need for such a notion, which adds no explanatory power, solves no problems, and makes no successful predictions.

Conclusion

Science-based medicine not only works, it is necessary if we are to have any effective regulations and standard of care. Introducing philosophical and religious beliefs into medicine goes hand-in-hand with eroding the standard of care and failing to protect the public from false or misleading claims, and unsafe or ineffective practices.

Further, similar to creationism and other anti-science movements, CAM proponents want to roll back the clock to a pre-scientific era. They want to rehash a fight they lost a couple centuries ago. Vitalism and dualism were given more than a fair chance, and they completely failed, because they are not scientific notions and they are not based in reality.

We should no more integrate these discarded notions back into science than we should reintroduce astrology back into astronomy, phrenology back into neuroscience, or alchemy back into chemistry. These ideas are best left on the trash heap of history.
 
 

Categories: Medicine, Skepticism
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