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The Problem of Space Junk

Neurologica Blog - Fri, 10/02/2015 - 07:50

We have been putting stuff into orbit around the Earth, especially low-Earth orbit, for the last 58 years. Space is a big place, so no one probably worried at first that we would start junking it up, but that is exactly what has happened in this short span of time. This is now a serious issue we have to confront.

It’s disappointing, and I hate having one more thing to worry about, but Earth orbit has become so cluttered with debris that it poses a serious risk to our assets in space. Recently former NASA scientist Donald Kessler said in an interview:

“We’re at what we call a ‘critical density’ — where there are enough large objects in space that they will collide with one another and create small debris faster than it can be removed.”

NASA scientists also fear a scenario similar to that portrayed in the movie, Gravity. There were some scientific problems with the movie, but the core idea is valid – there is so much debris in orbit that a collision of two large objects can start a chain-reaction, they will scatter debris which will collide with other objects causing more debris.

Here are NASA’s estimates for the amount of debris in orbit:

More than 21,000 orbital debris larger than 10 cm are known to exist. The estimated population of particles between 1 and 10 cm in diameter is approximately 500,000. The number of particles smaller than 1 cm exceeds 100 million.

Many of these objects may be moving extremely fast relative to other objects, like the International Space Station (ISS), for example. Even a small piece of debris can act like a bullet, causing serious damage to the station, a satellite, or any ship we may want to put into orbit.

Kessler believes the biggest problem is large decommissioned satellites. If they crash into each other that can start a chain reaction because of the amount of debris they will cause.

How to Address the Problem

So what do we do about this? First, we need to have policies in place that limit the amount of new debris we are putting into orbit. One major aspect of this is to build satellites with the capability of de-orbiting themselves once their lifespan is over. This is called “post-mission disposal” (PMD).

One solution for this uses a long (several kilometers) conducting tether. The conducting wire interacts with the Earths magnetic field and ambient plasma to create drag, essentially pulling the satellite out of orbit. Rockets can also be used to reduce the orbit to the point that atmospheric drag will do the rest.

There is also On-orbit satellite servicing (OOSS), which seeks to extend the lifespan of active satellites with missions to refuel, repair, upgrade, or otherwise service the satellites. This could reduce the need to send new satellites in orbit.

PMD and OOSS alone, however, will not solve the current problem. We also need “active debris removal” (ADR). This is very tricky, as we are dealing with a large number of small bits of debris moving in various orbits at 28,000 kph or more. However, even if we go after only the large dead satellites that will help tremendously and reduce the risk of a chain reaction.

One proposed solution is to use the upper stage of rockets that place new satellites into orbit. Once the payload is delivered, these upper stages are useless. However, they could be fitted with enough propellant and additional equipment so that, once they are in orbit, they can chase down a dead satellite, grab it, then de-orbit itself and the dead satellite. At least this way, every time we put a new satellite into orbit we will also be taking down an old one.

This is a technically non-trivial task, however, as one aerospace company describes it:

Almost no spacecraft are designed to be physically grappled once they are in orbit, and they may have antennas, solar arrays, or other fragile projections.  They may be tumbling or spinning, making them difficult to grapple and control. Many of these old satellites and rocket upper stages weight thousands of pounds, making them difficult to move. Some of the objects have been in orbit for decades and so may not be as sturdy as when launched or may contain fuel that could be triggered to explode.

To make this more efficient, there is a proposal to have a grappler that will sling a dead satellite out of orbit, and at the same time slingshot itself onto the next target.

Another solution is to attach a tether to an existing dead satellite or upper rocket stage to help drag it into the atmosphere. The tether can be as described above, or just have a balloon attached to increase atmospheric drag. Yet another alternative is to use a large sail to slow down the debris.

One interesting idea is to create puffs of air in the upper atmosphere designed to blow low orbiting debris out of orbit. This would only work for the lowest of debris, however.

Finally there is a design to used an electrified net to capture debris and drag it down into the atmosphere.

Darpa is working on a plan not to remove debris from orbit, but to recycle it. They want to grab dead satellites and then harvest pieces from them, like antenna or solar panels, and attach them to new satellites.


It is disappointing that we allowed ourselves to end up in this situation in the first place. In less than 60 years we are on the brink of making low Earth orbit unusable, and it is already highly dangerous. We treated space like we have treated our oceans or atmosphere – thinking that they were so vast nothing we could do would be a problem.

So now we have a crisis and we have to undo some of the damage we have already done, while enacting plans for sustainability that we should have thought about decades ago.

There is also a problem of political will. Hopefully this won’t be a serious problem. For example, we can’t just drag a satellite that we do not own out of orbit. We have to ask the country that owns the satellite for their permission. We need international agreements to facilitate the removal of space debris, and to enforce the extra expenditures that sustainable options will require.

Every major space agency seems to recognize the problem of space debris and is at least talking about it. The main question I have at this point is this – will we take major action to correct space debris before or after it causes a major catastrophe in orbit?

Categories: Medicine

More Lyme ‘Guidelines’

Science Based Medicine - Fri, 10/02/2015 - 01:23

I noted with understanding that the Doubtful News can’t take it anymore. The relentless Tsunami sewage slurry of pseudo-science (who says I can’t alliterate?) has worn her down. She is

currently experiencing a phase in which I can’t seem to bring myself to promote another ridiculous story in the media about a haunted location, scary sounds from the sky, or the latest outrage fueled by ancient superstition. You might call that… jaded. It’s been over four years now of nearly daily effort to keep track of the weird world of woo. It can wear one down when virtually or literally the same thing appears and reappears over and over as if it hasn’t already been passed around a million times.

I sympathize. I have had a touch of SCAM ennui of late. It is a bit due to the repetitiveness of the SCAMs. I still find the variations on the theme of pseudo-sciences curious. It is like Infectious Diseases where every case has unique and subtle diversity so no two SCAMs are the same. But there are almost 4000 clinical trials on acupuncture and I would wager that they all have  several of the same half dozen fatal errors.  It is like hand hygiene at work.  We have known for, oh what, 160 years, that hand hygiene prevents the spread of disease but people still can’t do it right. We know how to do a good clinical trial but the SCAMsters just can’t seem to figure it out.

The ennui is not the seeming futility of the endeavor. I have always been comfortable with futility, secure, as an example, in the knowledge that some day I will be consumed by the bacteria I spent a career killing. Unless, of course, they get me cremated right away.  I keep looking for a motto for SfSBM; I am attracted to “Sisyphus had it easy.”

There are some topics I feel an obligation to cover,  a necessity that is hard to tackle with enthusiasm, like taking out the trash. But after 6 years of  writing for this blog I fear I am running out of ways to discuss SCAMs in novel ways.   Simply rolling my eyes and making a gagging motion is hardly a sufficient blog entry, which was my initial response to Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease over at the National Guideline Clearinghouse (NGC). Not unlike Publishers Clearinghouse, the NGC are not responsible for the content of the product they offer as long as the guidelines  meet criteria, but I doubt they are going to send me a big check.

Some of those criteria include

A description of study selection that includes the number of studies identified, the number of studies included, and a summary of inclusion and exclusion criteria.

A synthesis of evidence from the selected studies, e.g., a detailed description or evidence tables.

A summary of the evidence synthesis (see 3d above) included in the guideline that relates the evidence to the recommendations, e.g., a descriptive summary or summary tables.

I am reminded of several posts ago where I discussed how the system was gamed to allow a naturopathic clinic to be a center of excellence.  I have filed a Freedom of Information request for more information on that farce.  I get the hint that these Lyme guidelines are the same.  This guideline is like that curious incident of the dog in the night-time; it is what is not mentioned that is interesting.

There are numerous issues with the ILADS guidelines, sone of which I have discussed in the past. One problem I have as I write this is that the IDSA guidelines are being updated with an expected release date in the fall of 2016. So we have at least a year to wait before we have a more reality based approach to Lyme disease.

Time and energy preclude addressing every part of even this brief guideline. I hope that when the IDSA releases their guidelines they will also do a compare and contrast with ILADS. But I will not hold my breath. When it has come to Lyme and vaccination the IDSA has not been on the front lines of defending science against pseudo-science.

So I will focus on one section, the need for retreatment of Lyme:

…in the panel’s judgment, antibiotic retreatment will prove to be appropriate for the majority of patients who remain ill. Prior to instituting antibiotic retreatment, the original Lyme disease diagnosis should be reassessed and clinicians should evaluate the patient for other potential causes of persistent disease manifestations. The presence of other tick-borne illnesses should be investigated if that had not already been done. Additionally, clinicians and their patients should jointly define what constitutes an adequate therapeutic trial for this particular set of circumstances.

When antibiotic retreatment is undertaken, clinicians should initiate treatment with 4 to 6 weeks of the selected antibiotic; this time span is well within the treatment duration parameters of the retreatment trials. Variations in patient-specific details and the limitations of the evidence imply that the proposed duration is a starting point and clinicians may, in a variety of circumstances, need to select therapeutic regimens of longer duration.

What do you call a recommendation based on very low quality data? Belief. Belief is what you do in the absence of data. Like most the ILADS recommendations, the recommendations, often strong recommendations, are based on low quality data. But more than basing their suggestions on low quality data, they ignore the fact that is there data that contradicts their position.

There are clinical trials that address the issue of re-treating lyme. Like all clinical trials you can find issues study design when you read them carefully. But they say the more or less the same thing:  treating patients with persisting symptoms of  Lyme has no long lasting effects.

A randomized, placebo-controlled trial of repeated IV antibiotic therapy for Lyme encephalopathy. “IV ceftriaxone therapy results in short-term cognitive improvement for patients with post-treatment Lyme encephalopathy, but relapse in cognition occurs after the antibiotic is discontinued.”

Study and treatment of post Lyme disease (STOP-LD): a randomized double masked clinical trial. “Because fatigue (a nonspecific symptom) was the only outcome that improved and because treatment was associated with adverse events, this study does not support the use of additional antibiotic therapy with parenteral ceftriaxone in post-treatment, persistently fatigued patients with PLS”

Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease.“There is considerable impairment of health-related quality of life among patients with persistent symptoms despite previous antibiotic treatment for acute Lyme disease. However, in these two trials, treatment with intravenous and oral antibiotics for 90 days did not improve symptoms more than placebo.”

You can quibble over issues in these studies.  I can with every clinical trial.  But all the information points in the same direction: there is no persisting symptoms after treatment for lyme that are amenable for further antibiotic therapy.  And it is better data than that used to support retreatment.

As an ID doc who spends a lot of time with hard to kill organisms, spirochetes are refreshingly susceptible to antibiotics and die with ease.  I am well aware of the various arguments to suggest that Lyme has developed ways to avoid being killed by antibiotics.  That would be a  blog entry in itself, but I have read the papers and find them less than compelling and, when considering the biology of spirochetes, probably not even wrong.  I have suspected that the complete lack of response to even months long courses of iv antibiotics is a strong clinical suggestion that there is nothing there to kill.  Patient being treated for chronic Lyme just never seem to get better with ILADS based therapies.

In 2006 there was an antitrust investigation by the Connecticut Attorney General that cost the IDSA money they could ill afford. They settled and as part of the settlement the IDSA agreed

to convene a Review Panel whose task would be to determine whether or not the 2006 LymeGuidelines were based on sound  medical/scientific evidence and whether or not these guidelines required change or revision.

I will also mention with no irony that one of the complaints about the IDSA guidelines is that those who were involved with their production were compromised by ties with industry, biased against chronic Lyme and its treatment. These guidelines were written in part by the President of ILADS, the organization that is the biggest proponent for the long term treatment of Lyme. Oh no, no bias here. Keep on moving.

Here now are the results of that IDSA review

2006 Recommendation
To date, there is no convincing biologic evidence for the existence of symptomatic chronic B. burgdorferi infection among patients after receipt of recommended treatment regimens for Lyme disease.
Panel Determination/Discussion – The Review Panel determined that this recommendation is medically/scientifically justified in light of all of the evidence and information provided (7-1).


2006 Recommendation
Antibiotic therapy has not proven to be useful and is not recommended for patients with chronic (>6 months) subjective symptoms after recommended treatment regimens for Lyme disease (E-I).
Panel Determination/Discussion – The Review Panel determined that this
recommendation is medically/scientifically justified in light of all of the evidence and information provided (8-0)

and they further noted on review.

  1. The prospective, controlled clinical trials for extended antibiotic treatment of Lyme disease have demonstrated considerable risk of harm, including potentially life- threatening adverse events…
  2. Prospective, controlled clinical trials have demonstrated little benefit from prolonged antibiotic therapy. Nearly all primary outcome measures have failed to demonstrate a benefit to prolonged antibiotic therapy. Statistically significant improvements in treatment groups were not demonstrated across studies, were nonspecific, were of unclear clinical importance, and in one case, not sustained at
    the end of the trial.
  3. The risk/benefit ratio from prolonged antibiotic therapy strongly discourages prolonged antibiotic courses for Lyme disease.

In the NGC guidelines not only use weak data, they ignore the data that doesn’t fit their world view.  I suspect next they will run for President of the United States.

Categories: Medicine, Skepticism

Yogic Farming in India

Neurologica Blog - Thu, 10/01/2015 - 08:03

If I had to choose the one thing that has most transformed human civilization it is science. Prior to this remarkable invention history was characterized by conflicting ideologies, philosophies, superstitions, and religions.

Some practical knowledge managed to move forward, including various technologies and even enlightenment philosophy, but our attempts to understand and manipulate the world were burdened with magical thinking. Science set us on a new track, and in the last few centuries we have systematically replaced our old traditional thinking about the world with scientific thinking.

A thousand years ago European physicians attempted to understand and treat illness by manipulating the four humors while their eastern counterparts were faring no better with an astrology-based system of blood letting. If we wanted to anticipate future events, an astrologer would consult fanciful charts that have no actual influence on reality.  If we wanted to make our lives better, ensure a good harvest, or survive a plague we would pray to imaginary powerful beings.

We wasted a tremendous amount of time and effort on what is essentially worthless magic. Science, however, has given us the most powerful tool humans have devised for actually taking control of ourselves and our environment, for understanding and manipulating the world.  Humans, however, do not surrender their beliefs easily, and so many people still waste time and effort on magical solutions to real problems.

One recent example of this comes from India. The BBC reports:

The Indian agriculture minister has said his government is supporting “yogic” farming to “empower seeds with the help of positive thinking”.
Radha Mohan Singh said it would help improve yield and soil fertility and contribute to making India prosperous.

Mr Singh is part of India’s governing Bharatiya Janata Party (BJP) which is accused by the critics of trying to promote traditional beliefs even when they are not backed by scientific evidence.

Unfortunately magical beliefs are often part of “tradition,” which means they are tied to cultural identity. This gives such beliefs respect and power they don’t deserve.

The idea behind yogic farming is simply making something happen by wishing. This is just a traditional version of “The Secret,” and is at the core of much magical thinking. Advocates of yogic farming also support other similar magical beliefs, such as the idea that your thoughts can affect the pH or crystalization of water.

The claim that thoughts and emotions can affect water almost always reference the experiments of Masaru Emoto, who believes that yelling at water will make it form “ugly” crystals. This is an excellent example of the unholy marriage of science with magical thinking, resulting in rank pseudoscience. While some people today are happy to maintain and promote their spiritual beliefs against the tide of science, other try to use science to support their beliefs. The result is often terrible pseudoscience, as Emoto demonstrates.

Another example of this is the scientific study of intercessory prayer. Overall such studies show that prayer does not work, but all research generates noise, and the noise has been used to claim that science supports the power of prayer magic.

Radha Mohan Singh is in charge of agriculture in India, which as the BBC points out supports 50% of the Indian population (not to mention feeding the population). It is difficult to imagine a greater malfeasance than to use that position to promote one’s personal religious beliefs rather than promote effective measures to improve agriculture.

Rather than fixing predatory lending practices that drive some Indian farmers to suicide, Singh wants farmers to think happy thoughts so that their seeds will be more fertile. Rather than engaging thoughtfully with the science of genetic modification, Singh wants farmers to project their positive thoughts into the soil through meditation.


When I read about the lingering of magical thinking into our modern world I can’t help but ponder how much more efficient, just, and prosperous our world could be if we simply removed the yoke of superstition and pseudoscience from around our necks. How much of our resources are wasted due to belief in complete nonsense?

On the positive side, I do think as a species and a civilization we are moving in the right direction. We will likely never be rid of magical thinking, but its power in the world is on the wane while science and reason are gaining purchase.

Every time someone sharply criticizes the Radha Mohan Singh’s of the world for promoting magic, we take one more step toward rationality. Every time someone attempts to promote magic and superstition, that is another opportunity to point out the advantages of science and reason.

Categories: Medicine

October is National Chiropractic Health Month!

Science Based Medicine - Thu, 10/01/2015 - 01:00

October is National Chiropractic Health Month (NCHM) and chiropractors can’t resist the opportunity to overstate, obfuscate and prevaricate in celebration.

They do this in the face of some unfortunate (for them) statistics revealed by a recent Gallup Poll. The Poll was paid for by Palmer College of Chiropractic as part of an effort to increase the chiropractic share of the health care pie. (There is also a secondary analysis of the poll in the Journal of Manipulative and Physiological Therapeutics.) We’ll get to those stats in a few minutes.

But first, in celebration of NCHM, the American Chiropractic Association (ACA) has produced a set of six graphics chiropractors can download and display. Four of them fudge on the facts. Let’s take a look at these graphics, compare them to the evidence cited in support of their claims, and see where the ACA went astray.  (The ACA also hosted a twitter chat  yesterday with the hashtag #PainFreeNation.)

The study cited as evidence for this graphic actually compared both manual thrust manipulation (MTM) and mechanical-assisted manipulation (MAM) to each other as well as manipulation versus usual medical care (UMC). Although MAM, such as the Activator Method, is the second most common manipulation technique used by American chiropractors, is increasing in popularity among them, and is touted to be a safe and effective alternative to MTM, this study found that MTM is more effective (at 4 weeks) than MAM and that MAM had no advantage over UMC. But you don’t see that in this graphic.

The study did not look at “Prescribed Medications vs. Spinal Manipulation” at all. UMC consisted of this:

participants were told that most new episodes of back pain are typically self-limiting, were prescribed over-the-counter analgesic and nonsteroidal anti-inflammatory drugs medications [sic], given advice to stay physically active and avoid prolonged bed rest.

Other limitations not revealed in the graphic, but discussed in the study:

  • no placebo control,
  • participants were unblinded as to treatment,
  • the differences among the groups at 4 weeks were not significant at 3 and 6 months,
  • modest size of study, and
  • 3 UMC visits versus 8 for the chiropractic treatments.

Also not mentioned was conflicting evidence from other studies, including a 2013 Cochrane Review Update, which concluded that SMT (spinal manipulative therapy)

is no more effective for acute low back pain than inert interventions, sham SMT or as adjunct therapy. SMT also seems to be no better than other recommended therapies.

Most importantly, given that most acute back pain will get better on its own, the authors said:

We could not determine what portion of the healing response was attributable to natural history, direct treatment effect, and/or nonspecific factors, because there was no natural-history control.

Plus, there was this gem from the study’s authors: “Segmental levels where the manipulation was applied was determined by using palpation and the Activator method of leg length analysis,” a totally bogus diagnostic method.  And here we’ve been promised that NCCIH, which funded the study, wasn’t going to do this sort of thing anymore. By the way, how did this nonsense slip pass the University of Pittsburg Institutional Review Board?

This is yet another attempt by “CAM” practitioners to exploit current concerns regarding overprescribing of opioid painkillers to shill for their own practices. It is ironic that the red flags of over-prescription were raised by, and are being addressed by, the medical community, in an honest attempt to face up to the problem and find solutions. You will find almost no comparable public discussion of the many deficiencies  of chiropractic practices by chiropractors.

This sensationalistic graphic is meaningless in the context of chiropractic practice. It is entirely correct that chiropractors don’t prescribe opioids, because their practice acts don’t allow it, the reason being that they lack the proper education and training. The ACA didn’t even get the citation right. The statistics are from Volkow NC, et al., Characteristics of opioid prescriptions in 2009. JAMA. 2011; 305(13): 1299-1301. These are simply raw statistics that do not account for why the prescriptions were written or whether prescribing was appropriate.

I’m afraid not. The study cited by the ACA as evidence did not say anything about cost effectiveness. Funded by the ACA (so they, of all people, should know the results), it analyzed the experience of one Tennessee-based general health insurer and found that its claimants “had lower overall episode costs for treatment of low back pain if they initiated care with a DC, when compared to those who initiated care with an MD.”

As Scott Gavura said, don’t call CAM cost effective unless it is actually effective. And as Harriet Hall pointed out, you can reduce costs to zero by eliminating care altogether, which we can all agree is not a good solution.

Once again, the ACA can’t even get the title of its graphic right. They would have you believe that all of these are treatments are for “neck pain.” In fact, none of them are exclusively for neck pain. Spine surgery includes all spine surgery. Cervical spine surgery includes surgery for such things as scoliosis and fractures. NSAID/aspirin use comprises many uses, including those not according to directions. This is likely true of opioid use as well, although we are not provided with the actual content of the e-mail on which they rely for this figure. (And, I would imagine, includes criminal use.) Even cervical manipulation isn’t always for neck pain. Chiropractors “adjust” the neck if the putative “subluxation” is found there, no matter what the patient’s complaint.

But wait, that’s not all:

  • No risk-benefit analysis. No matter how small the risk, no treatment is worth it if it confers no benefit. For example, there is no benefit from neck manipulation for “maintenance treatment.”
  • No information on pre-existing conditions that may complicate treatment. It may well be that the 80-year-old with cardiovascular disease had a surgical complication. How do you compare that to the healthy 20-year-old who suffered a stroke following chiropractic neck manipulation?
  • Lack of uniformity in outcomes. Why are all serious side effects from cervical spine surgery counted but all not serious side effects of cervical manipulation?

This is simply a grab bag of statistics thrown together to tamp down any legitimate criticism of the risks of neck manipulation, which is, in any event, not accurately reflected in this chart. The study cited used chiropractic malpractice claims, which are not indicative of actual risk. Other studies report a range of one in 400,000 to one in 5.8 million manipulations

Of course when you are facing:

  • The American Heart Association and the American Stroke Association (with approval by the American Academy of Neurology), stating: “practitioners should both strongly consider the possibility of CD [cervical dissection] and inform patients of the statistical association between CD and CMT [cervical manipulative therapy], prior to performing manipulation of the cervical spine.”
  • A lack of evidence that cervical manipulation is beneficial even for a plausible use, that is, neck pain.
  • A recent, and unflattering, analysis of the Cassidy study: “Prior studies grossly misclassified cases of cervical dissection and mistakenly dismissed a causal association with manipulation. Our study indicates that the OR [Odds Ratio] for spinal manipulation exposure in cervical artery dissection is higher than previously reported.”
  • A Gallup poll showing that almost 25% of the public thinks chiropractic is dangerous.

you simply do what you have to do.

The deficiencies in the ACA’s celebratory graphics I found are based on a layman’s interpretation of the evidence. A more sophisticated analysis might well discover more problems. (And you are welcome to point them out.) The ACA fully realizes that few people will actually look behind their claims and even fewer would be able to decipher the evidence they cite.

Galluping right along

As promised, back to that Gallup Poll, which, as noted, is decidedly a mixed bag for chiropractors. In spite of this, the ACA, the International Chiropractors Association (ICA) and Palmer Chiropractic College are soldiering on, trying to spin the poll to achieve a positive result. I’m not so sanguine.

Undoubtedly, the most distressing among the stats was the revelation that an MD is the first choice of 54% of American adults when choosing a health care provider for back or neck pain, versus only 29% who would choose a chiropractor. In fact, of all health care providers listed, 69% would not choose a chiropractor first. (This question was predicted on the assumption that the cost was about the same.) When your bread and butter is back and neck pain, this is not particularly good news.

Nevertheless, Palmer made the most of it with this graphic:

Wait a minute. Where’d the 57% come from? This was determined by asking those surveyed about their choices every which way but Sunday. Of those whose first choice was a medical doctor, physical therapist, massage therapist, acupuncturist or other provider, 58% said they would see a chiropractor only if all other treatment methods didn’t work. However, somehow they picked out a group of “expected users” and “likely users” by rejiggering the numbers and reached the conclusion that 57% were actually “likely to see” a chiropractor for neck or back pain, even though this number includes those whose first choice was not a chiropractor. Go figure.

Perhaps to boost these disappointing numbers, Palmer also includes the misleadingly named “neck treatment” comparison available from the ACA.

To be fair, there is another graphic with the all stats comparing health care providers, but, of course, no one has to show that one if they don’t want to.

61.4% of those surveyed agreed that chiropractic was effective in treating back or neck pain. Again, considering that back and neck pain is the chiropractor’s bread and butter, it would be cold comfort to learn that almost 40% of adults did not think you were effective at your job.  There was a similar result on the question of trustworthiness.  A little over half of respondents agreed that chiropractors were trustworthy, which means a little under one-half don’t think they can be trusted.

This did not dampen the ICA enthusiasm for the poll’s results. The ICA announced, in an email, that “nearly 70 percent of the study participants indicat[ed] that chiropractic care is effective with neck and back pain.” When I took math, if we were measuring in 10s, 61.4% would be rounded down to 60%, not up to 70, which appears to be what happened. And a poll is not a “study,” nor can it determine the effectiveness of a treatment. Undeterred by such subtleties, the ICA’s headline for this announcement claimed:

Gallup study highlights chiropractic effectiveness and popularity with neck/back pain.

70% of those surveyed believe they know what chiropractors do. Which is interesting because chiropractors themselves can’t agree what it is they do. Some chiropractors think they are primary care physicians and should be able to prescribe drugs. Others think they are spine care specialists who treat musculoskeletal problems. Still others hold on to the notion that phantasmagoric blockages in “nerve energy” running through the spine (the illusory “vertebral subluxation“) can affect bodily function and that chiropractic “adjustments” are effective for all manner of ills.

So what is it that everyone else thinks chiropractors do, even if they don’t know themselves? Of the 12% of respondents who have actually seen a chiropractor in the last 5 years (“chiropractic users”), 41% want to see a chiropractors only for back and neck pain, while the same percentage disagree that they would see their chiropractor for these health issues only, although we are not told just what other problems they would see a DC for.

60% of chiropractic users want to see a chiropractor only if they are in pain, but 31% want to see a chiropractor on a regular basis, even if not in pain. (Again, this is 31% of the 12% who have actually seen a chiropractor within the last 5 years.)  I would bet that many of these have been lured into regular treatments for “maintenance care,” based on the totally unproven and highly implausible idea that regular spinal “adjustments” are necessary to maintain one’s health.

There’s bad news here for the “DC as PCP” proponents: of chiropractic users, only 9% would choose their chiropractor as the first healthcare provider they want to talk to about their health. (You can find the entire SBM series on the “DC as PCP” here.) Even then, “talk about their health,” which is the way the question was phrased, is pretty general.  I have to imagine a much different result if you started naming specific health issues normally treated by PCPs, such as cardiovascular disease or diabetes. Or even the question: “Do you regard your chiropractor as your PCP?” More users (22%) would talk to their chiropractors about general wellness issues, such as diet and nutrition, but almost 60% of users would not.

They can’t blame the MDs for the bad news. Only 13% of respondents said they had been discouraged from going to a chiropractor by an MD, although that figure rose to 21% for the chiropractic users.

Finally, nearly half of all respondents think chiropractors need only 4-6  years of education beyond high school to become a chiropractor. Palmer is all over this one with another graphic.  Obviously, the implication here is that the “degree requirements” for a D.C. degree are about equal to that of an M.D. or D.O. degree. I have no idea if these figures are even correct because I couldn’t find them anywhere on the source listed.

Using this same measure of comparison, I can make the argument that high school is more than equal to college:

High school: 3600-4000 “educational hours”

College: 2160 – 2700 (also here) “educational hours”

See how easy it is?


Figures often beguile me, particularly when I have the arranging of them myself; in which case the remark attributed to Disraeli would often apply with justice and force: ‘There are three kinds of lies: lies, damned lies, and statistics.’

Mark Twain, Chapters from My Autobiography

Categories: Medicine, Skepticism

Open vs Blinded Peer-Review

Science Based Medicine - Wed, 09/30/2015 - 08:11

The overall goal of science-based medicine is to maintain and improve the standard of science in the practice of medicine at every level. At the heart of the scientific basis of medical knowledge and practice is a process known as peer-review. We have occasionally written about peer-review on SBM, and once again the process is under the microscope over a specific question – should peer review be open or blinded?

What is peer review

The term peer-review refers to a pre-publication process in which a journal editor will send a submitted manuscript to 2-3 experts in a field relevant to the paper to carefully examine every aspect of the paper. They then provide a detailed analysis of the paper: is the research question relevant and appropriate, did the study design properly address the question, were the methods rigorous, was the statistical analysis appropriate, was the data presented fairly, are the conclusions supported by the data, did the authors account for other publications addressing the same issue, and did they address every possible question or objection?

The reviewers’ reports will make specific recommendations for changes that would be necessary to improve the paper, and also make their bottom-line recommendation: accept as is, accept with revisions, or deny. The journal editor(s) then rely upon those reviews, plus their own assessment, to make a final decision.

The quality of a scientific journal is directly tied to the quality of peer review, which is a key part of the overall editorial quality.

Open vs blinded peer review

Traditionally most peer review is single-blinded. This means that the reviewers know who the authors are, but the authors do not know who the reviewers are. The reviewers remain anonymous (except to the editors). Authors may suggest reviewers to the editors, but the editors ultimately pick them.

The idea behind blinded reviews is that reviewers will feel free to express their true opinions, without worrying about the political fallout, or making enemies with a colleague if they recommend their paper be rejected. This also avoids tit-for-tat reviews, where a reviewer gives a negative review because one of the authors previously gave one of their papers a bad review, or colleagues exchanging positive reviews.

Some journals are experimenting with an open peer review process, in which the reviewers are publicly known, and their reviews are entirely transparent. In this model the transparency is the mechanism of quality control. The idea is that reviewers will do a thorough and fair job of peer review because all their colleagues will be able to see the job they did. If they were sloppy, or unfairly positive or negative, their peers will see it.

Open peer review should not be confused with open-access peer review. Val Jones wrote about this previously – open access peer review means that anyone can review a paper, which is made available in a public space for anyone to review and comment. This isn’t even really “peer review” – it’s just open access review, because the reviewers don’t have to be peers. This is the crowd-sourcing/Wikipedia approach to peer-review.

As Val pointed out, Peter Frishauf, the founder of Medscape, published a webcast editorial in 2008 predicting that:

Peer review as we know it will disappear. Rather than the secretive prepublication review process followed by most publishers today, including Medscape, most peer review will occur transparently, and after publication.

This seems like a premature prediction. I suspect open-access post-publication review will supplement, and not replace, peer-review. Or, this kind of system may exist parallel to the peer-reviewed published literature.

Head-to-head comparison

There doesn’t seem to be a clear choice between blinded and open peer-review, as both have their strengths and weaknesses. A recent study in BMJ Open directly compared blinded vs open peer review: “Retrospective analysis of the quality of reports by author-suggested and non-author-suggested reviewers in journals operating on open or single-blind peer review models.”

The study compared 200 reviews for articles each from open and blinded journals that were otherwise similar:

BMC Infectious Diseases and BMC Microbiology are similar in size, rejection rates, impact factors and editorial processes, but the former uses open peer review while the latter uses single-blind peer review.

They also did a second comparison. BMC Inflammation was open and then transitioned to blinded peer review, so they compared 200 reviews from the open period with 200 reviews from the blinded period.

In all cases the reviews were independently evaluated and given a standard assessment of quality.

The study also tracked the results of author-suggested reviewers vs other reviewers. What they found was that the quality of reviews submitted by author-suggested reviewers was the same as other reviewers under both models. However, author-suggested reviewers were much more likely to recommend acceptance. They also found that editors put less weight on author-suggested reviewers than other reviewers.

Regarding open vs blinded reviews, the results were mixed. When comparing BMC Infectious Diseases (open) to BMC Microbiology (blinded) they found that the quality of the open reviews on average scored 5% better than the blinded reviews. This result was barely statistically significant at p=0.042.

When comparing BMC Inflammation before and after transitioning from a blinded to an open peer review model, they found no difference in quality.

Conclusion – both methods seem valid

The bottom line of this study is that there does not seem to be much of a difference between the quality of reviews from an open vs blinded peer review model. From the press-release of the study:

Maria Kowalczuk, lead author, BioMed Central’s Biology Editor for the Research Integrity Group and co-Editor-in-Chief of Research Integrity and Peer Review, said: “As advocates of openness, we are excited to find that upon analysis reviewer reports under open peer review are of comparable, or even higher, quality than those of the more established model of single-blind peer review. However, we appreciate our results do not undermine the single-blind model of peer review.

Given that the blinded peer review model is more established, even showing no difference would tend to validate the newer open peer-review model. Of course, this one study does not end the debate, as it was limited to only three journals within one publishing group.

This study also does not address concerns about the downstream effects of open vs blinded review on the culture of science. Do scientists want their reviews to be public, and do they want to know who their reviewers are? How will this affect the community of scientists? These questions are much more difficult to assess.

As the two models seem roughly equivalent (if these results hold up), it does not seem like an objective measure like review quality is going to settle the debate.



Categories: Medicine, Skepticism

Study Correlates Brain Connections to Intelligence

Neurologica Blog - Tue, 09/29/2015 - 08:03

One marker of a good scientific study is that it provokes more questions than it answers. That thought kept occurring to me as I read a recent study: A positive-negative mode of population covariation links brain connectivity, demographics and behavior. The study essentially correlates specific patterns of brain connectivity – the degree to which different parts of the human brain talk to each other – with a suite of what are generally considered positive traits, such as education, income, and self-control.

Let me describe the study and then we’ll try to unpack the many layers of what such a study might mean.

The authors are among the first to avail themselves of the Human Connectome Project (HCP), part of the NIH funded BRAIN project. The HCP seeks to perform high definition function MRI scanning on 1,200 individuals while also gather large amounts of data about those same individuals, such as IQ testing, personality profile, and a host of demographic and historical information. The HCP has already released its data for the first 500 subjects to be scanned, so that other scientists can use the data for their own research.

The authors of the current study did just that. They used the data from 461 individuals to create a map of the strength of connections between many different regions of the brain. They then did a massive statistical number crunching to search for any correlation between the strength of any particular connections and specific traits of those subjects. They found:

“We identified one strong mode of population co-variation: subjects were predominantly spread along a single ‘positive-negative’ axis linking lifestyle, demographic and psychometric measures to each other and to a specific pattern of brain connectivity.”

In other words, if you ranked the 461 subjects on one linear scale of classically positive to negative traits (for the sake of this article I won’t get into the philosophical question of what makes these traits positive or negative), there was a strong correlation with with strength of a specific pattern of connections – the more positive traits a subject had, the stronger their connections among these specific regions.

This is the point at which the study provokes a long list of further questions. The bottom line right now is that we don’t know what all this means, but it is intriguing on many levels.

First (always first) – is the correlation real?  This finding was the result of a massive data mining project. The correlation is statistically strong, but it could be a fluke of looking for many possible correlations. Fortunately there is an easy way to replicate the study – wait for the HCP to release data from the next 500 subjects and then repeat the process on that data, specifically looking for the alleged correlation.

Assuming the correlation is real, and it holds up to replication, the next question for any correlational data is – what is the direction of causation? The standard causal hypotheses include: do the strong brain connections cause people to be intelligent and successful, does a lifetime of study and discipline strengthen those particular brain connections, or do success and the strength of those connections both result from some other third factor?

This kind of data will not definitively answer the causal question. For that we will need to look at people at different ages, to see what comes first – the strong connections or the positive traits. Ideally we could do an experiment in which we try to impose certain positive traits (like education, or discipline) and then see if it changes the strength of those connections. I also think we will need to have a deeper understanding of the modules and networks in the human brain to develop a coherent understanding of what those brain connections are doing.

At its heart, the causality question comes down to the old nature vs nurture debate. Are we born with our brain function or is it largely a product of our environment. Usually the answer to this question turns out to be  - both. We are born with talents and predispositions, but these are altered by environment, nurturing, education, training, and effort.

These kinds of studies may help us learn more about the nurturing part of the equation. What environmental factors that we can alter correlate with strong brain connections that in turn correlate with positive life outcomes? Of course, we can eliminate the neuroscience middle-man here and just correlate environmental factors to desirable outcomes, but this is tricky business. Having an objective marker in the brain might strengthen this type of data, and also enable us to see benefits through altered brain connections without having to wait decades to determine life outcomes.

The next question raised by this data is another old neuroscience question, sometimes referred to as the “g-factor”  - is there a module, network, or series of networks in the brain that correlate with “general intelligence?” Of course, we then have to operationally define “intelligence” but for now let’s just use the simplistic definition, intelligence is whatever is measured by IQ tests.

The “g-factor” question is this – is there a network in the brain that is central to overall cognitive function and therefore by itself correlates to a long list of positive intellectual traits? Another way to state this question is this – are the various measurable cognitive abilities (such as verbal skill, math skill, music aptitude, self-control, abstraction, problem solving, pattern recognition, etc,) each completely independent variables (anyone can be great at one and terrible at another), or do they all benefit or suffer from a general cognitive ability (the g-factor)? Do people who are smarter in one area tend to be smarter in other areas, and why?

The current study does not resolve this century-old debate, but it does seem to put one pebble on the g-factor side of the scale. The researchers found that one pattern of connections does correlate to a long list of positive traits.

Finally, this study made me wonder about what the ultimate potential of the HCP is. How much can we learn about brain function from studying patterns of connections within the brain? I would think quite a lot.

However, the study also highlights how much we have to sort out. We are in that phase of studying the connectome where as we gather more information we are learning more about how much we don’t know, so it seems that our ignorance is growing. Essentially we are finding that the brain is at least a couple of levels more complex than perhaps our initial guess. Specifically, it does not seem that for much of the brain specific brain areas have one specific function. There are exceptions to this – the primary visual cortex, for example, seems to be dedicated to processing visual information in a very specific way.

As we consider the “higher” brain functions, however, the simple correlation between brain regions and function breaks down. It seems that each brain region can participate in many networks of connections. Those networks seem to correlate with specific tasks or functions, but there also there many not be a simple one-to-one correlation. Networks interact with other networks. Everything ultimately may be context dependent – modules and networks in the higher cognitive areas of the brain may be dependent upon what else is going on in the brain at that moment.

This doesn’t mean we can’t map the brain and assign real functions to different patterns of connections. It just means we are finding that such correlations are complex and we have to be thoughtful about how we ask questions. We may not yet be asking the right questions, and the ultimate result of current connectome research is that it will teach us what are the right questions to ask. (For example, what are the basic cognitive functions and how do they result in what we observe as behavior?)


The current study is exciting not for what it answers but for the questions it provokes. This is not our first glimpse into the complexity of the connections of the human brain, but it does mark a new chapter, utilizing the largest and highest definition data set yet collected.

The HCP gives scientists access to a massive (and growing) data set of information about brain connections and cognitive traits. I expect to see many studies coming from this data, slowly teasing apart the complex questions raised by this and other existing studies.

Categories: Medicine

“Female Viagra?” Misleading Headlines and Regulatory Dilemmas

Science Based Medicine - Tue, 09/29/2015 - 03:00

The FDA recently approved flibanserin (brand name Addyi) for the treatment of hypoactive sexual desire disorder (HSDD) in pre-menopausal women.  The story of flibanserin illustrates several of the issues we have confronted on this blog. It was hyped in the media: misleading headlines called it the female Viagra. It was initially rejected by the FDA and was approved only after extensive lobbying efforts. The drug is only minimally effective and has a lot of drawbacks. Two of the three supporting scientific studies claimed effectiveness based a surrogate measure but failed to show any measurable improvement in sexual desire. A campaign to support “women’s sexual health equity” pushed for approval, framing it as a step towards correcting what they perceived as gender bias. They claimed the FDA was biased because it had provided Viagra to help men have sex but hadn’t done anything to help women have sex. And the validity of the diagnosis of HSDD itself has been questioned.

What is HSDD?

According to the official diagnostic manual, DSM-5, the diagnosis of hypoactive sexual desire disorder requires:

lack of, or significantly reduced, sexual interest/arousal”, manifesting as at least three of the following symptoms: no or little interest in sexual activity, no or few sexual thoughts, no or few attempts to initiate sexual activity or respond to partner’s initiation, no or little sexual pleasure/excitement in 75%-100% of sexual experiences, no or little sexual interest in internal or external erotic stimuli, and no or few genital/nongenital sensations in 75%-100% of sexual experiences. Symptoms must persist for at least six months, cause clinically significant distress, and not be better explained by another condition. Simply having lower desire than one’s partner is not sufficient for a diagnosis. Self-identification of a lifelong lack of sexual desire as asexuality precludes diagnosis.

Other drugs for sexual dysfunction

HSDD has been treated with testosterone and Bupropion. There is some evidence that they can be effective for some women, but they are not without drawbacks. Testosterone has been recommended to increase desire in men, but it probably only helps those whose testosterone levels are abnormally low. Drugs like Viagra are effective for erectile dysfunction in men, but they don’t increase sexual desire. They are used by men whose libido is working just fine but who are unable to sustain an erection. Viagra (sildenafil) works by increasing blood flow to the penis when there is sexual stimulation. It also increases blood flow to the genital area in women, and studies have shown increased sexual satisfaction in postmenopausal women who complained of sexual arousal disorder, but that’s not the same thing as HSDD. Other treatments for HSDD have included individual and couples counseling, education, and stress reduction.

What is Flibanserin?

 The new drug is the first to be approved for the treatment of HSDD. It was originally investigated for depression. The mechanism of action is not known, but it is thought to affect sexual response by increasing dopamine and norepinephrine activity and reducing serotonin activity in the central nervous system.

In two clinical trials, 45% and 39% of participants reported a meaningful benefit from the drug compared to 35% and 27% from placebo. The results suggested that ten women would need to be treated to benefit one. It increased the average number of satisfying sexual events, but only by one a month, and only after 4 weeks of daily treatment. In those trials, there was no significant difference in desire. In a subsequent third study using different questionnaires, they were able to demonstrate significant increases in desire and decreases in the distress associated with low desire.

Side effects included drowsiness, hypotension, fainting, dizziness, nausea, fatigue, insomnia, and dry mouth.

Regulatory history

 The 291-page FDA Advisory Committee Briefing Document is available online.

In 2010, an FDA committee voted 11 to 0 that the overall benefit-risk balance had not been sufficiently established due in large part to failure to reach statistical significance on the pre-specified endpoint of sexual desire. Approval was denied.

In 2013, additional studies were submitted to the FDA with more data on sexual desire assessments, safety, and interactions with alcohol and other drugs. Approval was again denied. The FDA accepted that efficacy had been established; but safety questions remained, and they didn’t feel that the modest benefits justified approval. A Formal Dispute Resolution was filed, requiring further study to determine whether the drug impaired driving ability.

The FDA held a 2-day public workshop to obtain patient and expert views. They investigated “other indicators of meaningfulness.”, A lobbying group was formed with the name “Even the Score: Women’s Sexual Health Equity.” A petition was sent to the FDA and letters written to congress calling for gender equity in drug approval. Lobbyists used slick PR materials. The “patient perspective” became part of the approval process.

On June 4, 2015, the FDA Advisory Committee recommended approval: 18 members voting to recommend approval but insisting on label warnings and other management measures, and 6 members voting against approval. Several members who voted “yes” said they did so with great misgivings because of the drug’s modest benefit and possible side effects.

On August 18, 2015, the FDA approved the drug for marketing. But it did so only with some extraordinary precautions. The label includes a boxed warning that users should not also consume alcohol and that the drug should be avoided by women with liver disease and by those taking drugs that are CYP3A4 inhibitors. Only prescribers and pharmacists certified through an online course will be allowed to prescribe this medication.

The FDA is requiring the company that makes Addyi (Sprout Pharmaceuticals) to conduct three well-designed studies in women to better understand the known serious risks of the interaction between Addyi and alcohol. And to top it all off, the company promised the FDA that they would not advertise the drug on radio or television for the first 18 months after it went on the market. I don’t remember hearing a similar restriction for any other drug; isn’t that an unusual provision?


 Some women’s groups criticized Even the Score as a distasteful attempt to use women’s rights as a cover to get an undeserving drug approved.  One doctor said “To approve this drug will set the worst kind of precedent — that companies that spend enough money can force the F.D.A. to approve useless or dangerous drugs.” She called flibanserin “a mediocre aphrodisiac with scary side effects.” She said that the clinical trials were restricted to healthy women, but that if approved the drug would be used by a wider range of women, resulting in “an epidemic of adverse events.”  The FDA was accused of having succumbed to “emotional blackmail,” valuing the comments of lobbyists and patients over the science.  The satirical Onion reported that the FDA had approved a new female-libido-enhancing man named Gabriel. Using him every day was shown to activate the regions of the brain associated with pleasure, increase blood flow to the genitals, and boost instance of orgasm by almost 40 percent. He was promoted as a safe, effective option, but it was noted that he became less effective when mixed with alcohol.

Questioning HSDD

 The DSM diagnosis of HSDD has come under criticism. It is little more than a convenient label that serves as a starting point to investigate what are probably a number of diverse causes of the included symptoms. There is a lot of normal variation in human sexuality, and asexuality may be a normal variant rather than a mental disorder. Both the social function of the diagnosis and the scientific and clinical criteria have been questioned.


 The approval of flibanserin is being applauded in some quarters and censured in others. Subjectively, the drug will help some patients experience more desire and less distress from lack of desire, but objectively it can only be expected to provide 10% of the patients who try it with one additional satisfying sexual event per month (masturbation included). This raises a lot of questions. Should every drug with a similarly low effect size and a similar benefit/risk ratio be approved? For conditions that are not life threatening? Was approval based on public opinion rather than on science? When is it appropriate to approve a drug that requires warning labels and other risk-reduction measures? Is the FDA doing a good job? Should the media have reported the story differently? What do you think?















Categories: Medicine, Skepticism

Denier vs Skeptic

Neurologica Blog - Mon, 09/28/2015 - 08:09

The AP has recently published an updated version of its Stylebook, which contains the following entry:

To describe those who don’t accept climate science or dispute the world is warming from man-made forces, use climate change doubters or those who reject mainstream climate science. Avoid use of skeptics or deniers.

This debate has been going on as long as the debate about the nature of recent climate change. This is more than a nitpick, as words have real meanings and they often reflect our understanding of an issue. Those who do not accept the current consensus of climate science would prefer they be referred to as “skeptics.” This has caused a problem for the skeptical community, because the majority of scientific skeptics accept the consensus of scientific opinion on anthropogenic global warming (AGW). They feel that AGW deniers are deniers and they taint the brand of “skeptic” by adopting that term.

There is, of course, a continuum of scientific acceptance without a sharp demarcation. Following Aristotle’s golden mean, I would place proper scientific skepticism as a virtue positioned between two extremes, with denial at one end and true-belief or gullibility at the other. This scientific continuum also does not capture the entire picture, as there are those who are anti-science or who follow non-scientific philosophies.

One problem for those who lie somewhere on the scientific spectrum is that everyone tends to use themselves for calibration. In other words, most people think that their specific position on any scientific issue is at the golden mean, and anyone who believes more than they do is a true believer and anyone who doubts more than they do is a denier.

This sliding scale definition, however, misses the real point – skepticism is not about what you believe, but the process you follow in forming your beliefs (and here I use “belief” as shorthand for degree of acceptance of specific claims).

Here is my concise definition of scientific skepticism:

A skeptic is one who prefers beliefs and conclusions that are reliable and valid to ones that are comforting or convenient, and therefore rigorously and openly applies the methods of science and reason to all empirical claims, especially their own. A skeptic provisionally proportions acceptance of any claim to valid logic and a fair and thorough assessment of available evidence, and studies the pitfalls of human reason and the mechanisms of deception so as to avoid being deceived by others or themselves. Skepticism values method over any particular conclusion and takes a position of humility toward complex areas of knowledge requiring extensive expertise.

In order, in my opinion, to qualify as a skeptic one has to rigorously following a method of inquiry that approaches what I just described. This means carefully examining your own ideology and biases, and fully accounting for the consensus of scientific opinion, without overstepping your own expertise in the relevant area.

True deniers follow a different approach, whether they explicitly know it or not. Denialism is a form of pseudoscience. Deniers tend to start with their conclusion, because they are ideologically opposed to the current consensus of scientific opinion, whether it be on climate change, evolution, the safety of vaccines, the legitimacy of mental illness, or the historical accuracy of the holocaust. They then follow a process which is fundamentally different from scientific skepticism, even though they try to portray it as skepticism.

- Deniers do not fairly assess the scientific evidence, but will cherry pick the evidence that seems to support their position.

- They will make unreasonable or impossible demands for evidence, move the goalpost when evidence is presented, and refuse entire categories of legitimate scientific evidence.

- They will attempt to magnify scientific disagreements over lower level details as if they call into question higher level conclusions. (For example, biologists might disagree over the details of evolutionary history, without calling into question evolution itself.)

- They primarily focus on sowing doubt and confusion over the science they deny, rather than offering a coherent alternate theory or explanation.

- They will exploit ambiguity (and even create ambiguity) in terminology or employ shifting definitions in order to create confusion or apparent contradiction.

- They will attack scientists personally, and engage in a witch hunt in order to impugn their reputations and apparent motives.

- They will cast doubt on whether or not a scientific consensus exists, attempt to claim that the tide is turning in their favor, or claim that a secret consensus of denial exists but is suppressed. They may also cite outlier opinions as if they were mainstream.

- When all else fails they will invoke a conspiracy theory to explain why mainstream views differ from their own.

Too often, I think, the debate focuses on whether or not a view is “mainstream.” I have been frequently accused of accepting whatever the mainstream view is, whether that be acceptance of AGW or rejection of ESP or similar claims. My views tend to be similar to mainstream scientific views for good reason – if different people follow the same rigorous methodology, they should reach similar conclusions.

I also think it is completely legitimate to respect the views of those who have greater expertise than you in a specific area. Respect does not mean blind acceptance. You also have to understand that the views of any one individual may not be representative. I always attempt to understand, as best as possible, what the consensus of scientific opinion is on any question, how robust the consensus is, are there any minority opinions, and how robust or legitimate are they? In some areas there isn’t even a consensus, just active controversy.

When there is a robust consensus of scientific opinion without serious opposition, in a field that itself is scientifically legitimate (I don’t put any value on a consensus of opinion of homeopaths), you would do well to take that consensus seriously. I would not casually dismiss a consensus of scientific opinion or indulge in unsupported conspiracy theories to reject the consensus.

Regarding AGW specifically, part of the difficulty with using a binary term like “denier” is that, as always, there is a spectrum. There are those who deny that the planet is warming, or accept that it is warming but deny that humans have any significant role, or accept AGW but reject current proposals for how to fix it, or even that it is possible to fix it.  How do we fairly deal with this situation?

That is the question faced by the AP and why they updated their Stylebook. Their solution is not unreasonable, but it has problems still.

The fact is, there are global warming deniers – those that tick every box in the denialism checklist. When writing about such deniers, those pretty far toward the denialism end of the spectrum, then “denier” is a reasonable shorthand that fairly captures the reality.

The problem is, however, that those who are not that far toward the denial end of the spectrum, but still harbor doubts or may think that political ideologues are exploiting the fact of AGW to further their own political agenda, may feel they are being painted with the same broad brush. I understand this, but I don’t think there is a clear solution. They are, essentially, falling through the cracks of the simplified naming system.

Journalists cannot spend time on a nuanced discussion of the spectrum of opinions on AGW every time they write about it, or correct misinformation being put out by a true denier. A shorthand is often necessary for efficiency. I also think that calling the entire spectrum AGW “skeptics” is far worse, because it confuses the public over what skepticism is and give far too much credit to the far denier end of the spectrum.

I think the AP solution is a reasonable compromise. When referring to the broad group, use a term like “doubters” that is a bit mushy but then, so is the group. A soft term might be best when referring to a continuum. I have done this myself in the past. However, I still reserve the right to use “denier” when I think it is appropriate – when discussing a particular individual or position that is far enough toward the denier end of the spectrum.

I also think that readers need to keep aware that not all articles are about them. Everyone wants their personal position to be presented positively, or at least fairly. Sometimes, however, an article is simply not about you. I say this because I get e-mails almost daily complaining that an article I wrote was not fair to the e-mailer’s position.

What typically happens is that I focus an article on a particular claim or set of claims. For example, I might say – this person rejects GMOs for these stated reasons, and this is why their reasons are not valid. I may then get an e-mail complaining that those are not “the” reasons why people reject GMOs and I was unfair to focus on them and ignore the “real” reasons.

First, do not confuse your position with the range of positions that are out there. Your reasons are not “the” reasons – they are your reasons. Further, I am often responding to a specific person, so clearly there is at least one person making the claims I am analyzing.  Finally, one article is never going to address every nuance, every tangent, or every issue regarding any topic. I have to find some way to focus an article. I may have even already written about the other issues, or will get to them eventually.

The bottom line is that people often take these issues very personally. Just yesterday I received an e-mail saying that the writer was “offended” by my opinions. How can you be offended by a scientific opinion?

This, I think, is a core bias, and one that needs to be specifically worked against. Don’t take scientific claims or opinions personally. Try to emotionally divorce yourself from any particular conclusions. The process is what matters, not acceptance or rejection. Conclusions should flow from the process, and you should not be invested in the conclusions because they should be provisional. If new facts come to light, you should be able to chuck out an obsolete conclusion as if it were sour milk.

Categories: Medicine

“Liquid biopsies” for cancer: Life-saving tests, or overdiagnosis and overtreatment taken to a new level?

Science Based Medicine - Mon, 09/28/2015 - 03:00

Could a blood draw be all you need to diagnose cancer and identify the best treatment for it? Not so fast…


I’ve written many times about how the relationship between the early detection of cancer and decreased mortality from cancer is not nearly as straightforward as the average person—even the average doctor—thinks, the first time being in the very first year of this blog’s existence. Since then, the complexities and overpromising of various screening modalities designed to detect disease at an early, asymptomatic phase have become a relatively frequent topic on this blog. Before that, on my not-so-super-secret other blog, I noted that screening MRI for breast cancer and whole body CT scans intended to detect other cancers early were not scientifically supported and thus were far more likely to cause harm than good. That was well over ten years ago. Now we have a company offering what it refers to as a “liquid biopsy” for the early detection of cancer. I fear that this is the recipe for the ultimate in overdiagnosis. I will explain.

The problem, of course, is that disease progression, including cancer progression, is not always a linear process, in which the disease progresses relentlessly through its preclinical, asymptomatic phase to symptoms to complications to (depending on the disease) death. There is such a thing as disease that remains asymptomatic and never progresses (at which point it’s hard to justify actually calling it a disease). As I pointed out in my first SBM post on the topic, at least three-quarters of men over 80 have evidence of prostate cancer in autopsy series. Yet nowhere near three-quarters of men in their 80s die of prostate cancer—or ever manifest symptoms from it. This is what is meant by overdiagnosis, the diagnosis of disease that doesn’t need to be treated, that would never cause a patient problems.

When teaching medical students and residents, I frequently emphasize that overdiagnosis is different from a false positive because overdiagnosis does diagnose an actual abnormality or disease. For example, ductal carcinoma in situ (DCIS) diagnosed by mammography leading to a biopsy is a real pathological abnormality; it is not a false positive. We just do not know which cases of DCIS will progress to cancer and which will not, leading to a question of how DCIS should be treated or at the very least whether we should treat it as aggressively as we do now, particularly given that the apparent incidence of DCIS has increased 16-fold since the 1970s, all of it due to mammographic screening programs and the increased diagnosis of DCIS and early stage breast cancer has not resulted in nearly as much of a decrease in the diagnosis of advanced stage breast cancer as one would expect if early diagnosis were having an impact in reducing the diagnosis of late stage disease.

Overdiagnosis would not be such an issue if it didn’t inevitably lead to overtreatment. DCIS, for instance, is treated with surgery, radiation, and anti-estrogen drugs. Early stage prostate cancer used to be treated with radical prostatectomy, but now more frequently with radiation. Many of these men and women didn’t actually need treatment. We just don’t know which ones. This is why over the last six or seven years a significant rethinking of screening for breast and prostate cancer. There has been a backlash, of course, but the rethinking seems to have taken hold.

Not everywhere, of course.

A “liquid biopsy” for cancer

The concept of a blood test that can diagnose cancer is, of course, not a new idea. Indeed, prostate-specific antigen (PSA) screening for prostate cancer has been around for decades and is arguably just that: A diagnostic test used to diagnose or follow the progression or treatment of cancer. Ditto carcinoembryonic antigen (CEA) for colorectal cancer, CA19-9 for pancreatic cancer, and CA125 for ovarian cancer. Indeed, there are a wide variety of tumor markers, some useful, some not-so-useful, some worthless, that can be measured in the blood. Usually these are proteins or other chemicals produced more by specific cancers than by normal tissue that can be detected at elevated levels in patients with those cancers and often rise and fall with progression or response to therapy. For instance, for colon cancers associated with elevated CEA, CEA levels should fall to very low or undetectable levels after effective treatment and rising levels can indicate cancer recurrence.

These tests, as reliable or unreliable as they are, depending on the test, are associated with specific cancers. Even so, one question that always comes up whenever tumor marker levels rise is whether the recurrence—if recurrence there is—is a local recurrence where the tumor was resected or a distant (metastatic) recurrence. Local recurrences are often treatable for cure, albeit at much lower success rates than for a primary cancer, while metastatic recurrences usually indicate incurable disease. Another problem is that rising levels of tumor markers often precede detectable recurrence, resulting in a diagnostic challenge: Where is the recurrence? In the case of CEA, for instance, this problem has resulted in various clever strategies to label antibodies against CEA with radiotracers and then using intraoperative probes to seek where the antibodies bind. Even so, demonstrating improved survival with such methods has been problematic.

Enter CancerIntercept™ by Pathway Genomics

With that background in mind, how does a cancer clinician approach the recent press release by Pathway Genomics, which announced that Pathway Genomics Launches First Liquid Biopsy Test To Detect Cancer-Associated Mutations In High-Risk Patients? Here are some of the claims:

Pathway Genomics, a global precision medical diagnostics company, announced the launch of CancerIntercept™, its first liquid biopsy, a non-invasive screening test designed for early cancer detection and monitoring, for as low as $299.

The test detects mutations that are commonly associated with lung, breast, ovarian, colorectal cancers and melanoma, as well as mutations that occur less frequently in other cancer types (such as pancreatic, head and neck, thyroid, gastric and prostate cancers). View an animation of how CancerIntercept works here.

The test is offered for two general populations: CancerIntercept™ Detect is the first liquid biopsy designed to detect tumor DNA in high-risk but otherwise healthy patients; CancerIntercept™ Monitor monitors patients with active or previously diagnosed cancer. Both programs use advanced DNA analysis to identify small DNA fragments that are shed from cancer cells and released into the bloodstream. The tests analyze the presence of 96 frequently occurring DNA mutations in nine cancer genes.

“Early detection is the single most important factor in ensuring successful treatments and improved survival rates,” said Jim Plante, CEO and founder of Pathway Genomics. “Cancer patients and those at risk for the disease can take proactive steps to safeguard their health and fight back against some of the most virulent forms of the disease.”

In addition, with CancerIntercept Monitor, physicians are able to supplement more invasive tissue biopsies and scans with liquid biopsies to monitor cancer treatment efficacy, disease progression and recurrence. CancerIntercept Monitor can also be ordered with personalized Clinical Trial Matching for later stage cancer patients.

“Rising levels of tumor DNA may indicate progression of the cancer before there is clinical or imaging evidence of tumor growth” said Dr. Glenn Braunstein, MD and Chief Medical Officer of Pathway Genomics. “Our liquid biopsy tests may also detect new mutations that occur over time and signal that the patient is becoming resistant to current therapy.”

Naturally, Pathway Genomics has produced an very sophisticated animated video to tout the benefits of its new product:

In the press release, Pathway Genomics states that the test can be either ordered through a patient’s own physician or, helpfully, it has an “online physician referral network,” presumably of physicians willing to order the test if the patient’s physician is not. Of note, the $299 price is for patients receiving the test on a “subscription” service, with repeat tests done at quarterly intervals. For just one test, the price is $699; annual, $499, semi-annual, $399. In other words, the company is incentivizing patients to be tested more frequently by accepting a smaller profit margin in return for more frequent testing. As we will see, that there is a severe lack of compelling scientific evidence that quarterly testing with CancerIntercept™ Detect benefits patients more than semi-annual or yearly testing matters not at all. As we will also, that there is an even more disturbing lack of compelling evidence presented that testing with CancerIntercept™ Detect decreases mortality rates from cancer even in high risk patients matters not at all.

A “cancer stethoscope,” dissected

Featured prominently in the promotional video, press release, and company website is a reference to CancerIntercept™ Detect and CancerIntercept™ Monitor as a “stethoscope” for cancer. It sounds like an awesome marketing simile, at least if you don’t think about it too closely. After all, CancerIntercept™ Detect is first a “yes-no” test: Is there DNA containing a cancer-specific mutation in the blood or is there not? Then it is—if you accept the company’s advertising materials—a diagnostic test. Which cancer-associated mutation(s) is there in the blood and at what level? A stethoscope, on the other hand, simply amplifies what can be heard without it? Before stethoscopes existed, doctors could simply put their ear to a patient’s chest or back. Moreover, interpreting heart sounds and breath sounds is a skill that requires a great deal of practice to master. It’s an essential skill for primary care physicians and many other specialties. Of course, it’s quite clever of Pathway Genomics to liken its test to this essential physician tool, but it’s a very imperfect analogy.

Be that as it may, let’s look at some of the specific claims made by Pathway Genomics. Which claims have merit? From my perspective, only one of the claims might have merit, while the rest are highly questionable at best. To understand which one, you must first know what, exactly, these tests do. Cancer cells release small fragments of DNA into the bloodstream, known as cell-free DNA or cfDNA. For CancerIntercept™ Detect, cfDNA in the blood is tested for the presence of circulating tumor DNA (ctDNA) by screening for specific cancer-associated mutations using polymerase chain reaction (PCR) to amplify both the mutant and wild type DNA, followed by a “specific enrichment of the mutant and simultaneous removal of the wild type DNA by using a proprietary technology,” after which the “mutant DNA is sequenced on Illumina’s next-generation sequencing platform.” Pathway Genetics claims that the test can detect two mutant copies of DNA per 5 ml blood sample. I always get a bit worried when I hear of a “proprietary” method to enrich mutant DNA compared to wild type (i.e., “normal”) DNA, because I can’t evaluate whether it’s an accurate and reliable method or not.

So what does this test detect? The test examines 96 mutation “hotspots” among nine cancer “driver” genes (i.e., genes that, when mutated, can cause cancer or contribute to cancer progression). The genes tested for are involved primarily in breast, ovarian, lung, colorectal cancers, and melanoma and, for those of you with the knowledge and inclination to evaluate them, these specific mutations in the following genes: BRAF, CTNNB1, EGFR, FOXL2, GNAS, KRAS, NRAS, PIK3CA and TP53. You don’t have to know all these genes for purposes of this discussion, but I list them for those who might be interested. Basically, to me it sounds like a shotgun approach to a bunch of mutations without anything resembling adequate clinical validation to justify its recommended use.

For whom is CancerIntercept™ Detect intended?

Helpfully, Pathway Genetics includes a “white paper” that enumerates what its tests do and what, according to the company, the supporting evidence is for their indications. Unfortunately, it’s mighty thin gruel. According to the white paper, CancerIntercept™ Detect can be used thusly:

For preventative surveillance of high-risk populations in order to screen for mutations that could indicate early disease. Examples of high risk populations include, but are not limited to:

  • Significant family history of one of the cancers that are known to harbor the mutations in the genes within the screen.
  • Known genetic predisposition for one of the screened cancer types.
  • Personal history of smoking, or prolonged exposure to second-hand smoke.
  • Exposure to known carcinogens, like radon.
  • Prolonged radiation or UV light exposure.
  • History of hormone use (fertility drugs, progestogen-containing hormone replacement therapy).
  • Certain reproductive and dietary factors.
  • History of certain infectious diseases or chronic health conditions.

(Cancer types included in the screen: breast, colorectal, lung, melanoma, and ovarian cancers).

In a FAQ, Pathway Genomics states that CancerIntercept™ Detect should be considered for basically the same sorts of patients and includes a link to its clinical questionnaire. As a questionnaire to determine the appropriateness of a screening test, it is quite risible. For instance, the very first question is “How would you rate your risk of cancer?” followed by a 1 to 10 scale, with 10 being the highest risk. If there’s one thing that most people don’t have a good handle on, it’s their actual risk for cancer; those at high risk tend to underestimate their risk while those at low risk tend to overestimate their risk. For purposes of a screening test—and, let’s face it, that’s how Pathway Genomics is marketing this test, as a screening test—the patient thinks his or her risk of cancer is really doesn’t matter, except perhaps as a marketing tool for a test like this. What really matters are the parts of the clinical history that are predictive risk factors.

In fairness, the rest of the questionnaire does ask about family history, previous hereditary cancer tests, health conditions associated with a higher risk of cancer, and various environmental exposures, some common (alcohol, smoking), some less so (asbestos, nickel, chromium, silica dust, etc.). The problem is that nowhere on the form or in Pathway Genomics’ online literature is there an indication of a risk level as assessed by the test where CancerIntercept™ Detect wouldn’t be appropriate. If, for instance, a prospective patient were to check no relevant exposures, no family history of cancer, no diseases associated with increased risk, and that he or she was a teetotaler who never touched alcohol or tobacco, would the company refuse to run the test, even though that person is at most at average risk for cancer but actually lower than average risk? Somehow, I tend to doubt it. That is unlike, for instance, the OncoType DX test for breast cancer. If the patient is inappropriate for the test (her tumor is estrogen receptor negative or HER2-positive, for instance), the company will not run the test. Worse, in the white paper, there is no direct clinical trial evidence cited showing that this particular test decreases mortality for cancer or even results in earlier diagnosis. As is frequently the case with various alternative medicine modalities, there are lots of references cited; it’s just that many of them are not directly relevant, nor do they support many of the claims being made, particularly for CancerIntercept™ Detect.

For whom is CancerIntercept™ Monitor intended?

CancerIntercept™ Monitor is a similar test but intended for patients who have already been diagnosed with cancer. With this test the company is on a bit more solid ground than it is with CancerIntercept™ Detect, but still, in my estimation, makes a number of claims that are not fully supported by the evidence. According to the same Pathway Genetics white paper, CancerIntercept™ Monitor can be used thusly:

  • Monitor residual disease in patients with known mutations in the primary tumor.
  • Monitor treatment efficacy in patients.
  • Monitor disease progression and tumor evolution (i.e. development of tumor resistance).
  • Help the physician explore other options of treatment when the patient is resistant to current therapies.
  • Provide an alternative method for biopsy when tissue is difficult to obtain or not available, or when the primary site of metastatic disease is unknown.
  • Provide an alternative method for biopsy when the quantity of tissue obtained in a biopsy sample is limited and traditional molecular genotyping is requested.
  • Provide prognostic information for some patients.

I can see the potential utility of genomic tests applied to “liquid biopsies” of tumors. So can a lot of other investigators. It is true that, if a primary tumor has already been diagnosed, monitoring the mutation-containing DNA fragments in the blood might well be useful for identifying potential driver mutations and following response to therapy by following a blood test rather than other more difficult tests. That’s why liquid biopsies are being tested in clinical trials. Indeed, Pathway Genomics lists a number of such clinical trials examining the prognostic value of various mutations screened for by the CancerIntercept™ Monitor and Detect tests in terms of recurrence, survival, and response to treatment, as well as correlation with the actual presence or absence of the mutation in the tumor itself. These tests could potentially be used to support the utility of a test like CancerIntercept™ Monitor in identifying specific mutations in patients with an already diagnosed cancer of a type that often harbors mutations tested for by the test.

My concern, however, is the lack of specific evidence that this specific test does what the company claims it does and is useful for the indications in patients with cancer that the company lists. Again, given that the enrichment process is proprietary, it’s impossible for me—and any other scientist with a molecular biology background—to satisfy ourselves that the methodology is sound, at least not without seeing some rather specific evidence from each step in the assay to show that it does what is claimed for a large number of samples and doesn’t over- or under-enrich for ctDNA.

The FDA steps in

Not surprisingly, the Food and Drug Administration (FDA) took an interest in Pathway Genomics’ claims after the splash it made with its announcement earlier this month, so much so that it sent a letter last week to Pathway Genomics Founder and CEO Jim Plante. Its letter doesn’t mention CancerIntercept™ Monitor, likely for the reasons I mentioned above, but it does express a considerable amount of concern regarding CancerIntercept™ Detect. Specifically, in its letter the FDA expresses the very same concerns that I did:

We have conducted a review of our files and have been unable to identify any Food and Drug Administration (FDA) records reflecting the approval, clearance, or listing of these devices. We have also examined published literature and have not found any published evidence that this test or any similar test has been clinically validated as a screening tool for early detection of cancer in high risk individuals. We have reviewed the information presented on your website in the white paper, entitled “Liquid Biopsy for the Detection and Monitoring of Cancer: Analysis of 96 Hotspot Mutations via Plasma Derived Circulating Tumor DNA,” dated September 2015. It is unclear how the literature that you cited, addressing the presence of circulating tumor DNA (ctDNA) in already-diagnosed patients, is adequate to support the expansive claims of screening for early cancer detection using ctDNA in undiagnosed patients for up to 10 different cancers with the CancerInterceptTM Detect.

I agree. The literature cited by Pathways Genomics is in no way adequate to support the claims made for CancerIntercept™ Detect. I’d also add that the literature cited would not be adequate (to me, at least) to support the claims made for CancerIntercept™ Monitor, either, although for CancerIntercept™ Monitor the disconnect is much less egregious. Be that as it may, screening an asymptomatic population is a very different thing from monitoring a tumor marker in an already-diagnosed patient with cancer.

There are a number of perils and pitfalls in using tumor markers to follow cancer patients for response to treatment and recurrence. It’s not as though we don’t have considerable experience with them. Indeed, the scientific literature surrounding CEA and PSA, which have often been used for this purpose, is replete with the difficulties and complexities of following just a single molecule for a single cancer known to produce it. What does a rising level of a ctDNA with one or more of the mutations tracked by CancerIntercept™ Monitor mean? What should a clinician do? How sensitive is the test for detecting recurrences of the cancers covered by the test? How specific? How do you use the information to guide treatment, or do you? After all the hype, precision medicine is in its infancy and a recent clinical study (SHIVA) published in The Lancet Oncology failed to find a survival benefit using genomic profiling and targeted treatment in patients with advanced cancer (perhaps a topic for another post).

As for following a patient successfully treated for cancer for recurrence, perhaps Pathway Genetics should consider that, of the original “Choosing Wisely” guidelines from the American Society of Clinical Oncology, one of the guidelines against scientifically supported treatment stated, “For individuals who have completed curative breast cancer treatment and have no physical symptoms of cancer recurrence, routine blood tests for biomarkers and advanced imaging tests should not be used to screen for cancer recurrences”—exactly the indication Pathway Genomics proposes for CancerIntercept™ Monitor, particularly given that in 2013 ASCO widened the recommendation to avoid advanced imaging as routine followup for pretty much all cancers unless there is high level evidence supporting it.

These issues are complicated enough when monitoring a patient known to have cancer and whose ctDNA mutation profile might agree with the mutation profile of his or her cancer, but start screening an asymptomatic population, even a “high risk” population, for ten cancers using a test like CancerIntercept™ Detect, and the issues and complexity skyrocket.

We know that our bodies are always producing cells with various mutations that could grow into cancer. Usually, these cells either die or the body eliminates them. Often, these tiny cancers never progress beyond a tiny cancer because they don’t acquire the ability to induce the body to provide them with a blood supply. Without a blood supply, they remain limited by how far oxygen will diffuse in plasma (less than 1 mm) and never grow larger. As I described a long time ago, most men over 80 have tiny prostate cancers. Thyroid cancer is an uncommon cancer, but a Finnish study found evidence of papillary thyroid cancer in 36% of adults in an autopsy series. We’re constantly producing tiny cancers that either don’t progress beyond microscopic size or regress. How often does CancerIntercept™ Detect detect these tiny cancers in normal people?

More importantly, what do we do if these ctDNA fragments with cancer-associated mutations are found in an asymptomatic patient who just got the test because the company’s marketing made it sound as though he should? These mutations are not cancer type-specific. They’re found in many kinds of cancer. A clinician would have little idea where to look, particularly for the more “promiscuous” mutations found in many types of cancer. Will clinicians do PET scans, whole body CT scans, and/or MRIs in a frantic search for a tumor that might never harm the patient? Would finding tumors, be they from breast, prostate, the GI tract, ovaries, or elsewhere result in lower mortality from those cancers, or would we see a massive wave of overdiagnosis, with subsequent overtreatment, based on these findings. I don’t know for sure, but my prediction is the latter. Think of it this way. We have significant overdiagnosis and overtreatment from far less sophisticated and sensitive tests, like mammography and PSA. Imagine how much more we would be likely to see from a test like CancerIntercept™ Detect.

Pathway Genomics just doesn’t “get it”

Does Pathway Genomics “get” these issues? If its response to the FDA is any indication, the answer is a resounding no:

We are carefully considering the concerns of the FDA as stated in their letter, and we will be responding to that letter. We assure that there is physician involvement in the ordering, review and follow-up of CancerIntercept™ testing. We believe that CancerIntercept™ Detect is a laboratory developed test and, as a CLIA and CAP certified clinical laboratory, we are offering it as such. While Pathway Genomics is involved in educating and marketing the tests to physicians and consumers, we do not believe this is a direct-to-consumer model. We believe we have performed appropriate validation of the test as a laboratory developed test, and we are in the process of performing additional studies.

Now you know why Pathway Genetics has its own network of physicians for this test, to avoid the “direct-to-consumer” model while still being able to do the test for pretty much any consumer who wants it. Moreover, while Pathway Genomics might believe that it’s “validated” its test sufficiently as a “laboratory-developed test” (LDT), in my opinion it hasn’t validated its test anywhere near adequately as a screening test for the general population, “high risk” or not.

Why is Pathway Genetics emphasizing that it considers its test a “laboratory-developed test” in a CLIA- and CAP-certified clinical laboratory? Dr. J. Leonard Lichtenfeld, Deputy Chief Medical Officer for the American Cancer Society, describes in a blog post that echoes many of the concerns I have about these tests:

The test in question is only done by this one company, measuring over 90 genetic abnormalities in the blood sample. And, since this is a proprietary laboratory test it can be offered directly to the public and the company can make whatever claims it chooses to consumers and health professionals–who may not even be aware there is no oversight by the Food and Drug Administration to verify the claims made for the test. (The Centers for Medicare and Medicaid services oversees the general quality of the laboratories offering these tests, but does not do specific review of a test in these situations).

This is basically the situation right now, but the FDA’s policy towards these tests could well be changing, as its regulations are from an era before tests like CancerIntercept™ Detect and CancerIntercept™ Monitor. As the described on its website, the FDA “does not consider diagnostic devices to be LDTs if they are designed or manufactured completely, or partly, outside of the laboratory that offers and uses them,” explaining, “While the uses of an LDT [laboratory developed test] are often the same as the uses of FDA-cleared or approved in vitro-diagnostic tests, some labs may choose to offer their own test. For example, a hospital lab may run its own vitamin D assay, even though there is an FDA-cleared test for vitamin D currently on the market.”

In other words, back in the day, LDTs were generally simple tests, such as for vitamin D levels, electrolyte levels, or other commonly measured parameters. They were not complex genomic tests involving enrichment of plasma for specific types of DNA and then next generation sequencing of the resulting fraction. As a result, the FDA has provided draft guidance for the development of a regulatory framework for LDTs, invited public comment, and held a public workshop earlier this year for public input.

Tests used to diagnose or guide treatment of a disease, particularly cancer, should have strong scientific evidence supporting their indications, accuracy, and efficacy. Barring that, results from tests like the ones marketed by Pathway Genomics can confuse far more than illuminate our decisions on how to treat patients. As Dr. Lichtenstein puts it, “Take an abnormal result from this test to your doctor and the real possibility exists they will have no clue what to do with it.” Exactly so.

He also notes, as I’ve noted before, that there will be testimonials that this test saved people’s lives. Of course, as I’ve described so many times before, just because a patient believes a test (such as thermography for breast cancer) or a treatment (such as Stanislaw Burzynski’s antineoplastons) saved her life, that does not make it so.

Tests like CancerIntercept™ Detect demonstrate just how urgent the need is for the FDA to modernize its regulation of laboratory-developed tests. Maybe Pathway Genetics is the perfect test case. Liquid biopsies will very likely be validated as a means of guiding therapy in cancer patients, but it’s way, way too early to consider using them as screening tests for cancer in asymptomatic patients. Our experience with much simpler screening tests like mammography and PSA screening should tell us that much. The potential of genomic tests is huge, but such tests need to be validated by science before being offered to patients on a large scale.

And Pathway Genomics is far from alone in this field.

Categories: Medicine, Skepticism

The Enigma of Chiropractic: A Brief Review with a Perspective on Chiropractic as a Specialty

Science Based Medicine - Sun, 09/27/2015 - 10:15

Subluxation-based chiropractic care is sustained more by faith than by facts


Much of what is discussed in this article has been said before in previous articles I have written for Science-Based Medicine. But since the audience for SBM has greatly increased over the past few years, some subject matter should be repeated for the new readers and researchers coming to this site for reliable information on health care.

Many consumers now search SBM for articles dealing with controversial alternative treatment methods that have been shown to be ineffective or to be loaded with fraud and quackery. Chiropractic in particular continues to be problematic for its failure to renounce the scientifically indefensible, nonfalsifiable subluxation theory that defines the profession as a whole. A review of chiropractic web sites reveals that many chiropractors continue to base their treatment methods on subluxation theory, encompassing a broad scope of health problems. Some chiropractors are now including use of “functional medicine” which uses “natural tools” to treat diabetes, thyroid disease, neuropathy, and other diseases best treated by conventional medical care. Most alarming of all is the treatment of infants and children by “pediatric chiropractors.” Chiropractors are being certified in 10 different specialties, including a diplomate in Diagnosis and Internal Disorders.

As long as chiropractic is licensed as a health-care profession based on subluxation theory or some other unscientific approach, it will continue to be subjected to scrutiny and criticism by the science-based community. It is, in fact, the moral and ethical responsibility of science-based practitioners to oppose any form of unscientific health care, wherever it might exist, separating sense from nonsense without being influenced by politics, special interest, pseudoscience, or belief systems.

Legal recognition vs. science

The vertebral subluxation theory that defines the chiropractic profession has been rejected by the scientific community. Yet, chiropractic has gained public acceptance and licensure as a profession capable of treating both physical and organic ailments. Some chiropractors claim to be primary care providers, despite use of a limited treatment method. Chiropractic’s primary treatment, the spinal adjustment, is described as a modality used to improve health by correcting vertebral subluxations that are interfering with nerve supply to the body’s organs. While spinal manipulation might have value as a complementary procedure or as a treatment option in the care of mechanical-type neck and back problems, a distinction should be made between appropriate use of generic spinal manipulation and the questionable use of chiropractic adjustments to restore and maintain health.

Legal recognition of chiropractic as a health-care profession has generated considerable confusion in the public’s perception of the role of manual therapy in health care. Subluxation theory defining use of manipulation by chiropractors has allowed the proliferation of practitioners who promote a variety of nonsensical treatment methods that are the antithesis of generally accepted medical care. Separated from the mainstream of health care, chiropractic is being presented as a form of alternative medicine, competing with primary care physicians as well as with physical therapists who offer manual therapy for musculoskeletal problems. In the absence of any apparent movement by the chiropractic profession to police its ranks, it is important that the general public be made aware of the controversy surrounding subluxation-based chiropractic care.

The implausibility of subluxation theory

There is no credible evidence to support the contention that a vertebral subluxation, a joint dysfunction, or compression of a spinal nerve can cause nerve interference that will affect general health or cause organic disease.1,2 A simple review of anatomy and the nervous system seems to provide enough evidence to refute subluxation theory.

Spinal nerves are commonly compressed by bony spurs and herniated discs. Compression of a spinal nerve can cripple supplied musculoskeletal structures but does not cause organic disease. In the absence of pathology such as disc herniation or osteophyte formation, vertebral misalignments rarely affect spinal nerves. The body’s organs are supplied primarily by autonomic nerve ganglia and plexuses located outside the spinal column and by autonomic cranial and sacral nerves that pass through solid bony openings,3 providing overlapping nerve supply that is unaffected by slight misalignment of a vertebra or by a dysfunctional spinal segment.

Defining chiropractic

The chiropractic profession continues to cling to the theory that gave it birth and independence. State laws defining chiropractic as a method of restoring and maintaining health by adjusting vertebral subluxations to remove nerve interference remain unchallenged.4

According to a 2015 publication by the National Board of Chiropractic Examiners in the United States:

The specific focus of chiropractic practice is known as the chiropractic subluxation or joint dysfunction. A subluxation is a health concern that manifests in the skeletal joints, and through complex anatomical and physiological relationships, affects the nervous system and may lead to reduced function, disability, or illness.5

Some definitions of chiropractic avoid use of the word “subluxation,” referring instead to nerve interference as a cause of disease. Such interference is often attributed to a “vertebral subluxation complex” involving changes in nerve, muscle, connective tissue, and vascular tissues without actual displacement of a vertebra.6 Although chiropractic subluxation theory has evolved from a bone-on-a-nerve theory to a more complex description involving “a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health,” 7 the theory is no less implausible. An asymptomatic chiropractic subluxation alleged to be a cause of disease (not to be confused with a real orthopedic subluxation that causes musculoskeletal symptoms) is generally considered to be an imaginary lesion.

It is important to remember that subluxation-based chiropractors often genuinely believe that they can restore and maintain health by adjusting the spine and will often advise their back-pain patients that every member of the family needs regular spinal adjustments to stay healthy. For this reason, physicians and science-based chiropractors should openly advise against subluxation-based chiropractic care, especially when recommending chiropractic care for back pain. Unfortunately, chiropractic associations might be reluctant to renounce the nerve interference aspect of subluxation theory, which would require a change in legislation that supports the licensure and livelihood of thousands of chiropractors.

If the mission of chiropractic colleges is not changed sufficiently to produce a chiropractic majority that opposes subluxation theory, laws and the belief system defining the practice of chiropractic will not change.

Appropriate use of spinal manipulation

Systematic reviews of the literature on the use of manipulation in the treatment of back pain indicate that spinal manipulative therapy may not be any more effective than other recommended therapies.8,9 A 2012 systematic review of the effectiveness of spinal manipulation provided by physical therapists in the treatment of low back pain concluded: “Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice. Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain.”10

I suspect that future research will identify specific mechanical-type back problems for which judicious use of spinal manipulation might be the treatment of choice in relieving pain and restoring mobility. Some back-pain patients simply prefer the pleasurable, relaxing effects of hands-on manipulation and massage. Patient satisfaction coupled with the immediate, albeit temporary, effects of spinal manipulation is reason enough to support inclusion of spinal manipulative therapy as complementary care or as a treatment option in the physical treatment armamentarium of any therapist or practitioner who treats back pain — without subluxation theory, of course.

Unfortunately, the Chiropractic Paradigm of the Association of Chiropractic Colleges, which “focuses particular attention on the subluxation,”7 is echoed in a 2015 survey of North American chiropractic students, “a majority of whom would like to see an emphasis on correction of vertebral subluxations.”11 Regardless of scientific developments in the use of spinal manipulation, it appears that subluxation-based chiropractic will be perpetuated as a belief system.

Back-care specialty, an opportunity missed

While opinions describing chiropractic range from “quackery” to “miracle healing,” many people think of chiropractors as back doctors since they manipulate the spine for what is commonly believed to be a vertebra out of place. A 2015 Gallup poll (Americans’ Perceptions of Chiropractic) reported that the majority (61%) of American adults agree that chiropractors are effective at treating neck and back pain.

“When given a choice of five different healthcare providers they might see about neck and back pain, regardless of cost, slightly more than half of adults (54%) say a medical doctor would be their first choice, followed by 29% saying they would most like to see a chiropractor. Less than 10% would prefer to see a physical therapist, massage therapist or acupuncturist for neck or back pain.”12 Although a majority agreed that chiropractic is an effective treatment for neck and back pain, only 29% of polled respondents would choose chiropractic for such care, perhaps reflecting low confidence in treatment provided by chiropractors.

Despite the public’s perception that chiropractors treat neck and back pain, and the fact that back pain and musculoskeletal problems are the No. 1 and No. 2 causes of disability worldwide,13 chiropractic has failed to fill a niche as a specialty providing conservative care for mechanical-type back pain. There are some good chiropractors who use generic manipulation appropriately in a practice limited to care of back pain and related musculoskeletal problems, and they can offer a service of value. It appears, however, that the chiropractic profession as a whole may have missed an opportunity to abandon subluxation theory and make the changes needed to become a legitimate mainstream musculoskeletal back-care specialty based on science, the common denominator that unites mainstream health-care professionals. An increasing number of physical therapists are now being trained in the use of science-based spinal manipulation, offering an alternative to subluxation-based chiropractic manipulation.

Some chiropractors identify themselves as spine specialists, a designation often used by orthopedists who have the facilities and the means to handle any kind of spine problem. Since chiropractors cannot offer medication to relieve acute back pain and do not have access to the hospital facilities needed to treat a serious, incapacitating back injury or to diagnose back pain of unknown origin, chiropractic care cannot always be appropriate for back pain or a spine problem. A science-based chiropractor who offers conservative care for uncomplicated back pain would be compelled to refer certain acute back-pain patients to medical providers for pain relief, for hospitalization, or for a hospital-based diagnostic procedure. A correct diagnosis indicating disease, infection, or neurological complications would require immediate referral to a medical specialist.

A chiropractic “spine specialist,” subluxation-based or not, is obviously not capable of independently handling back pain across the board. No specialty can function in the best interest of the patient without the cooperation of mainstream health-care professionals, a position unattainable by chiropractic in its present form.

Chiropractic specialties vs. medical specialties

Despite the limitations of chiropractic treatment methods and the isolation of chiropractic from mainstream health care, the American Chiropractic Association (ACA) endorses 10 post-graduate programs offering diplomate certification in specialties for chiropractors:

  • Chiropractic Pediatrics
  • Chiropractic Physical and Therapeutic Rehabilitation
  • Chiropractic Acupuncture
  • Diagnosis and Internal Disorders
  • Diagnostic Imaging
  • Neurology
  • Nutrition
  • Occupational Health
  • Sports Physician
  • Orthopedics

Certification in these specialties is obtained by attending 300 to 400 hours of classroom instruction in 26 sessions of 12-hour weekends over a period of 3 years.14 Such part-time classroom instruction cannot begin to compare with a full-time residency program in a hospital setting that lasts 3 to 7 years after graduation from medical school, depending upon the specialty. An additional 1 to 3 years of training is required for a subspecialty.15

Resisting what the chiropractic profession considers to be a demeaning identification as a back specialty, it appears that the profession has taken the untenable position of competing with medical specialties, using spinal adjustments as the primary treatment method. According to an executive of the ACA’s Council on Diagnosis and Internal Disorders, a chiropractic internist with a DABCI certification (Diplomate American Board of Chiropractic Internists) can treat everything from allergies to thyroid problems to fatigue as a primary care physician:

We do laboratory workups, blood chemistries, adrenal and hormone testing, GI function studies, EKGs. We treat everything from allergies to thyroid problems to fatigue. It makes us more of a family doctor, not in the sense that we always take care of the whole family, but we can take care of all that ails them….If I’m adjusting somebody and not getting them better, [my training] gives me a broader range of things to look at as to what it might be.14

While post-graduate study offered to chiropractors is commendable for its value in expanding the knowledge base of the individual practitioner, specialty certification in a chiropractic classroom cannot compare or compete with a board-certified hospital-based medical specialty that requires thousands of hours of training. A chiropractic specialty certainly does not justify or excuse use of chiropractic adjustments based on vertebral subluxation theory, and it is no less questionable under the label of alternative medicine or integrative medicine.

State laws defining chiropractic as a method of adjusting vertebral subluxations do not permit chiropractors to use many of the tests and procedures implied to be part of a chiropractic specialty. Medicare coverage of chiropractic services, defined by federal law, is specifically limited to manual manipulation of the spine to correct a subluxation (demonstrated to exist) causing a related neuromusculoskeletal problem; no other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor’s order is covered.

As we men of medicine grow in learning we more justly appreciate our dependence upon each other. It has become necessary to develop medicine as a cooperative science, the clinician, the specialist and the laboratory workers uniting for the good of the patient. The people will demand, the medical profession must supply, adequate means for the proper care of patients, which means that individualism in medicine can no longer exist.16

Dr. Will Mayo (1861-1939)

  1. The College of Physicians and Surgeons of Quebec. The Scientific Brief Against Chiropractic. The New Physician. 1966. (Accessed August 19, 2015)
  2. Mirtz, TA, Morgan L, Wyatt LH, Greene L. 2009. An epidemiological examination of the subluxation construct using Hill s criteria of causation. Chiropr Man Therap. 17:13. (Accessed August 30, 2015)
  3. Homola S. Chiropractic: History and Overview of Theories and Methods. Clin Orthop Relat Res. 2006. 444:236-242.
  4. Bellamy JJ. Legislative alchemy: The U.S. state chiropractic practice acts. Focus Alternat Complement Ther. 2010 Sept;15(3):214-222.
  5. Christensen MG, Hyland JK, Goertz CM, Kollasch MW, Shotts BL, Blumlein NL, et al. Practice Analysis of Chiropractic 2015. National Board of Chiropractic Examiners. Greeley, Colorado. May 2015. p5. (Accessed September 21, 2015)
  6. Rosner AL. The Role of Subluxation in Chiropractic. 1997. Foundation for Chiropractic Education and Research. p2
  7. Association of Chiropractic Colleges. Chiropractic Paradigm. (Accessed August 30, 2015)
  8. Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review. Spine. 2011; 36(13):E825-46. (Accessed September 21, 2015)
  9. Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for acute low back pain: an update of the Cochrane review. Spine. 2013; 38(3):E158-77.
  10. Kuczynski JJ, Schwieterman B, Columber K, Knupp D, Shaub L, Cook CE. Effectiveness of physical therapist administered spinal manipulation for the treatment of low back pain: a systematic review of the literature. Int J Sports Ther. 2012;7(6):647-662. (Accessed September 21, 2015)
  11. Gliedt JA, Hawk C, Anderson M, Ahmad K, Bunn D, Cambron J, et al. Chiropractic identity, role and future: a survey of North American chiropractic students. Chiropr Man Therap. 2015;23.4. (Accessed August 30, 2015).
  12. English C, Keating E. Majority in U.S. say chiropractic works for neck, back pain. Gallup. September 8, 2016. (Accessed September 8, 2015).
  13. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012; 15;380(9859):2163-96.
  14. American Chiropractic Association. Chiropractic Specialties on the Rise. (Accessed August 28, 2015).
  15. American Medical Association. Requirements for Becoming a Physician. (Accessed August 30, 2015).
  16. Clapesattle, Helen. The Doctors Mayo. Garden City Publishing Company. Garden City, New York, 1943.

Sam Homola is a retired chiropractor who has been expressing his views about the benefits of appropriate use of spinal manipulation (as opposed to use of such treatment based on chiropractic subluxation theory) since publication of his book Bonesetting, Chiropractic, and Cultism in 1963. He retired from private practice in 1998. His many posts for are archived here.

Categories: Medicine, Skepticism

A “Natural Cure” for Eczema Leaves a Young Child in Agony…..

Science Based Medicine - Fri, 09/25/2015 - 08:00

“I swear I had nothing to do with this!”

A short post today, for me at least, but an important one to file away for the next time somebody asks “What’s the harm?” during a discussion on the use of irregular medicine in the care of pediatric (or any) patients.

The case

The September 2015 issue of Pediatrics in Review, the official American Academy of Pediatrics source for continuing medical education, contains a case report that should be of particular interest to readers of Science-Based Medicine. The authors, pediatricians at Children’s Hospital at Albany Medical Center, describe the ordeal of a six-year-old boy, previously healthy except for eczema, suffering with lower extremity pain to the point of crying with attempts to walk or to even bear weight. For those of you who don’t have experience with children of this age, it takes a considerable amount of discomfort or disability to interfere with their determination to remain in a near constant state of motion. Refusal to bear weight is a red flag that we take very seriously as the cause in a young child is often serious, ranging from traumatic injuries and severe infections of the bones or joints to diagnostic dilemmas such as leukemia and juvenile rheumatoid arthritis.

In addition to his pain, which had been steadily worsening over the twelve days prior to seeking care at the authors’ facility, his family was concerned about his malaise (extreme fatigue), nausea, poor appetite, and unusually dry lips that were cracked and bleeding. A preliminary evaluation by his primary care pediatrician at the onset of his symptoms was reasonable, ruling out the more common possible etiologies, yet was ultimately unfruitful.

The eventual finding of a significantly elevated serum calcium level, as well as the overall presentation of his symptoms, was concerning for cancer but labs and imaging, including bone marrow biopsy, CT of the brain, and MRI of the spine, were normal. A nuclear medicine study called a bone scan revealed abnormally elevated uptake of technetium-99m in his long bones, which was a clue for a endocrine abnormality. This led to additional but also unhelpful laboratory tests.

Meanwhile, initial attempts to treat the child’s increased blood level of calcium with hydration and a medication that inhibits the indirect bone resorbing activity of parathyroid hormone failed. His calcium level, and thankfully his symptoms, did respond once he was treated with a bisphosphonate and a strong diuretic. Bisphosphonates bypass parathyroid hormone and directly inhibit the activity of osteoclasts, cells vital to the healthy maintenance of our bones and in regulating levels of important minerals in our blood. It’s not a commonly prescribed medication in kids.

The reveal

Although the patient was recovering, it appears that the team was at a loss until the child’s parents revealed a game-changing piece of information later in the admission. Six months before his pain and other worrisome symptoms began, they had sought treatment for his eczema from a “natural health practitioner.” He had been prescribed a number of supplements containing vitamin A, one with a whopping 39,000 IU per pill. He had vitamin A toxicity.

Vitamin A toxicity in a healthy child living in the United States is rare as hen’s teeth. I doubt that the team would have figured it out without the (better late than never) disclosure by the family. Even checking vitamin A levels in the blood, which would normally result in a discussion of which member of the genus Equus is most likely to be the source of audible hoofbeats, might not have led to a lucky catch because they don’t correlate well with tissue levels.

The recovery

The patient responded to medical management, cessation of his dangerous supplement regimen, and a diet that limited his calcium and vitamin D intake. His recovery was not easy, however, as he needed physical therapy for persistent weakness that lasted for months. During his hospitalization, he underwent numerous blood draws and aspiration of his bone marrow for testing. He was also exposed to significant amounts of ionizing radiation and likely required sedation for either his bone marrow biopsy, his spine MRI (which can take over an hour), or both. He was treated with medications having significant, although unlikely, potential side effects. All of this because some irresponsible and poorly-educated quack thought it appropriate to prescribe supplements to a young child.

Vitamin A, what is it good for?

Vitamin A is an interesting chemical, and one traditionally associated with vision in the minds of the public and medical professionals. The ancient Egyptians first made the association between improved vision at night and eating animal liver but Swiss researchers first isolated and named vitamin A. We now recognize two primary forms of the compound: provitamin A carotenoids found in green leafy vegetables and carrots, beta-carotene being the only one metabolized by mammals, and the more active preformed vitamin A found in animal sources such as liver and egg yolk. Preformed vitamin A compounds, such as retinol and retinoic acid, are also typically used in drugs and supplements like the ones taken by the poor victim in the above case.

Provitamin A, even when ingested in large quantities, is generally felt to be incapable of causing toxicity. Our bodies must convert beta-carotene into active vitamin A, a process which is tightly regulated such that intake above a certain level causes a negative feedback inhibition. I once cared for a young infant who was being fed only 100% carrot juice because of religious beliefs pertaining to proper nutrition. The diffusely edematous and orange infant had a severe deficit in protein despite adequate calories, a condition known as kwashiorkor, but did not suffer any ill effects related to excessive vitamin A intake. Animal or synthetic sources of preformed vitamin A on the other hand are already highly active and can easily lead to toxic effects because there is no mechanism of feedback inhibition.

Vitamin A plays an important role in numerous biological functions, with vision being the most well known. Appropriate levels of vitamin A prevent pathologic dryness of the eye and surrounding tissues, a condition known as xerophthalmia, which is a leading cause of preventable blindness in developing countries. Vitamin A is also pivotal in the process of phototransduction, the conversion of light into electrical signals to the brain. Two photoreceptor cells, rods (motion and nightvision) and cones (light and color vision in bright light), require derivatives of vitamin A for proper function. Vitamin A is also important in cell health and growth, particularly in the skin and bone marrow, as well as immunity, bone metabolism, reproduction, and prenatal development.

Deficiency of vitamin A isn’t something we deal with much in the United States and other developed nations, although conditions that can result in poor absorption of fat, such as cystic fibrosis and Crohn’s disease, put some patients at risk. Sadly, deficiency is far from a rarity in the rest of the world where each year half a million infants and toddlers lose their vision because of a lack of dietary sources. Many of these children die. Efforts at providing supplementation to at-risk children are ongoing, but there are misinformed activists fighting against our most promising advances in the prevention of blindness and death in resource-poor regions.

Too much of a good thing

Excessive vitamin A intake leading to toxicity is also rare, and is likely even less common than deficiency in developed countries although data on prevalence is lacking. There are no disease states that predispose patients to toxicity. As stated earlier, we get vitamin A from our diet in the form of certain plants (provitamin A) and animal products (preformed vitamin A), but it is difficult to overdose through diet. It isn’t impossible though. Vitamin A is primarily stored in the liver, and consumption of that organ harvested from some animals, such as polar bears and seals, can cause severe acute illness and even death.

How much vitamin A we should get daily is a bit complicated because it depends on where it comes from. A much smaller amount of preformed vitamin A from animal organs or supplements is acceptable compared to a relatively large amount of plant-derived beta-carotene, which must be converted to an active form. Just giving an amount in international units (IU) can be confusing if you don’t know the source. Daily allowances are usually measured in micrograms of retinol activity equivalents (RAE) that take into account biologic activity. Since beta-carotene really never leads to toxicity, we only have to worry about preformed compounds that come in supplements and drugs.

Toxicity, when it occurs, usually results after the ingestion of vitamin supplements containing amounts well above the recommended intake for long periods of time. Although the amount that will consistently result in symptoms is variable from person to person, as expected it takes less to cause damage in children than in adults. Daily intake of 3,000 IU or 900 micrograms RAE is considered the upper limit for safe daily intake in a 6-year-old child. Intake of 1,500 IU/kg body weight of preformed vitamin A (recommended daily allowance would be around 1,000 IU total in kids if all they got was the preformed compound) would be very likely to lead to toxicity in our patient, who received almost 2,000 IU/kg every day for six months from his bogus eczema treatment.

Acute toxicity can cause nausea and vomiting, dizziness, and blurry vision. Severe cases can result in effects on the central nervous system with resulting excessive tiredness and headache. The skin is also often involved in acute toxicity, becoming dry, sometimes painfully so, with cracked lips that can bleed. Longer term excess intake tends to affect the liver, bone, brain, and muscle leading to a variety of impairments including the presentation seen in the above case.

Vitamin A for eczema?

Vitamin A does play a role in the health of our skin. A deficiency can cause overgrowth of the outer layer of the skin and loss of hair follicles. But it doesn’t cause eczema. And even if it did, deficiency is extremely rare here in the United States.

Extremely high oral doses of chemicals closely related to vitamin A called retinoids are frequently used to treat severe cystic acne and psoriasis. Although the mechanism of action isn’t fully understood, the hypothesis is that the retinoids induce the death of sebaceous glands and a reduction in the amount of sebum, an oily secretion believed to play a large role in the pathophysiology of acne. The side effect profile of these medications is rough and as expected includes extremely dry and fragile skin. It is, essentially, purposeful and controlled vitamin A toxicity.

The use of megadoses of vitamin A to treat eczema, an allergic condition infamous for its pathologically dry and irritated skin manifestations, is absurd and potentially very dangerous. High-dose topical formulations of vitamin A derivatives, such as Retin-A, are also used to treat acne and can also cause severe skin reactions that would mimic and certainly exacerbate existing eczema. And there is no good evidence to support even the use of lower dose vitamin A-containing moisturizers for eczema in children.

Yet there are multiple online “resources” recommending the use of vitamin A for eczema, such as this nonsense from a nutraceutical company informed by a “team of naturopathic physicians.” WebMD lists eczema as a condition treated with vitamin A as well. And Orthomolecular Hall of Fame member Patrick Holford BSc, DipION, FBANT, NTCRP (I kid you not) loves vitamin A for eczema. There are so many more but I’ll stop there.

Conclusion: Harmful nonsense is harmful

There is a reason why Science-Based Medicine comes down so hard on practitioners of alternative medicine. And naturally we are particularly concerned about those who feel that they have the expertise to care for pediatric patient. This case is a perfect example.

Young children don’t have the ability to understand the complex variables involved in healthcare decisions and are helpless when their caregivers make poor choices based on misinformation and unscientific world views. This child should not have had to go through such an ordeal because there should not have been a “natural health practitioner” allowed to take part in his care. Unfortunately, fixing that problem is an uphill if not unwinnable battle so we must focus instead on education of the public and the prevention or removal of legislation that places children at greater risk.



Categories: Medicine, Skepticism

44 Reasons Creationists are Deceptive, Final Installment

Neurologica Blog - Thu, 09/24/2015 - 12:48

This week I have been making my way through a list of old and debunked creationist arguments put together by Michael Snyder (a young-earth creationist), giving the old arguments new life on social media. As science communicators we often have to play this game of whack-a-mole, persistently addressing points that have already been refuted. Each time is an opportunity to educate more people about the real science of evolution, about logic and critical thinking, about science in general, and the vacuous and deceptive arguments of the science deniers.

This is the fourth and final installment of this series of posts. You can find the others here: Part I, Part II, and Part III.

The next five points that Snyder raises are all variations on the same theme:

#30 Which evolved first: blood, the heart, or the blood vessels for the blood to travel through?

#31 Which evolved first: the mouth, the stomach, the digestive fluids, or the ability to poop?

#32 Which evolved first: the windpipe, the lungs, or the ability of the body to use oxygen?

#33 Which evolved first: the bones, ligaments, tendons, blood supply, or the muscles to move the bones?

#34 In order for blood to clot, more than 20 complex steps need to successfully be completed. How in the world did that process possibly evolve?

Snyder, of course, is asking a false question, one with an unstated major premise that is wrong, or at least misleading. The implication he is trying to make is essentially the debunked notion of irreducible complexity – that complex structures or biological systems could not have evolved because they could not have simpler functional states.

Every example brought up to support irreducible complexity, however, has been falsified.

The questions themselves are misleading because no one component had to evolve first. They co-evolved from simpler yet fully functional systems. Sometimes one mentioned component did arise before the others, but in a system that did not yet require the others.

For example, animals evolved to use oxygen before lungs evolved, even before gills, or before a circulatory system to distribute the oxygen. In the simplest oxygen-using creatures, they relied upon simple diffusion – oxygen would directly diffuse through tissue. This works, but only for small creatures. Insects still use this basic approach.

Oxygen carrying fluid can then evolve in an open circulatory system, where the fluid simply bathes the tissue. This fluid can be progressively isolated from other tissue by endothelium, which eventually evolves into vessels. Of course the endothelium would need to be thin enough to allow oxygen to diffuse across, as in modern capillaries.

We have not fully fleshed out the evolution of every organ system in the body, but we have made great progress in understanding many of the big steps. The diversity of extant life on Earth allows us to see examples of simpler systems that still work, providing a plausible pathway for such evolution to occur. Genetic and fossil evidence then tell us about the actual path that evolution took.

The same is true of blood clotting. There are simpler systems in nature, like the lobster’s clotting system, that work fine. The vertebrate clotting system is more complex, but simpler versions do work also, just not as efficiently. Complexity evolves over time, tweaking the system to optimize function – but this does not mean it could not function prior to the development of that complexity.

The bottom line, however, is that Snyder’s question is based upon the persistent creationist misunderstand that modern complex systems and structures had to evolve directly to their complex form. This is clearly not the case, and is not what evolutionary biologists claim. The evidence, rather, indicates that complex forms evolved from simpler but fully functional forms.

#35 DNA is so incredibly complex that it is absolutely absurd to suggest that such a language system could have “evolved” all by itself by accident…

This is just another naked argument from personal incredulity. All that is necessary is for a molecule that can make a crude copy of itself. Once you have replication, variation, and differential survival and reproduction, you have evolution. This did not happen “by accident.” DNA is the end result of an incremental evolutionary process that probably took tens of millions of years.

Once again Snyder is completely ignoring the science that indicates that complex systems can spontaneously arise. Snyder could avail himself of one of the many resources for the layperson on spontaneous complexity in self-organizing systems.

#36 Can you solve the following riddle by Perry Marshall?…

1) DNA is not merely a molecule with a pattern; it is a code, a language, and an information storage mechanism.

2) All codes are created by a conscious mind; there is no natural process known to science that creates coded information.

3) Therefore DNA was designed by a mind.

If you can provide an empirical example of a code or language that occurs naturally, you’ve toppled my proof. All you need is one.

This is not a proof. It merely assumes its conclusion when it states as a premise, “All codes are created by a conscious mind.” That is actually the question, isn’t it?

This is a rigged challenge, because it is designed to make any example impossible. What creationists do is dismiss any example that involves life, because life uses DNA. They dismiss any example that does not involve life because it does not contain a coding and decoding system (even though complex information may be spontaneously stored in a natural process). In other words, it does not contain the kind of complexity we only see in life.

The deeper point is that the challenge itself is bogus. It does not have to be answered. DNA evolved so that the order of nucleic acids determines which amino acid is added to a polymer to make a protein. Let’s say that is the only example in the universe of such a system evolving naturally. So what? Just because something is unique that does not mean it did not evolve, or that it is impossible to have occurred spontaneously without deliberate design.

The premise is flawed.

Of course, it’s possible that we may find examples of life that evolved elsewhere, and they may contain DNA or something other than DNA that serves the same purpose. I have no doubt that such examples will do nothing to dissuade creationists from this line of faulty argument.

#37 Evolutionists simply cannot explain why our planet is so perfectly suited to support life.

This is another iteration of the anthropic principle. Actually Snyder has it backwards – it is not that the Earth is so perfectly suited for life, it’s that life is so perfectly suited to Earth. This is because life evolved on Earth and adapted to it’s environment.

This is known as the puddle fallacy – it is similar to a puddle of water being amazed at the fact that the hole it is in is so perfectly shaped to hold it, when obviously it is the water that is conforming to the hole. I write about this more extensively here.

#38 Shells from living snails have been “carbon dated” to be 27,000 years old.

Ah, the radiocarbon gambit again. No one dating method is perfect. In order to apply it properly you have to understand how it works. Radiocarbon dating is based on the spontaneous radioactive decay of carbon 14, an unstable isotope of carbon that spontaneously decays into carbon 12 or 13, which are stable isotopes. Carbon 14 is created in the upper atmosphere from cosmic rays crashing into nitrogen 14, which then gets into the carbon cycle of the planet as CO2.

When creatures are alive and breathing the atmosphere they incorporate a certain percentage of carbon 14 into their tissue. When they die they no longer are breathing and so are not incorporating any new carbon 14. Their carbon 14 then radioactively decays at a predictable rate. We can therefore use the ratio of carbon 14 to total carbon to date how long it has been since the creature died.

Once you understand how radiocarbon dating actually works you can then understand why it does not apply in all situations. I already discussed the fact that this dating method is useful to about 20,000 years ago. For older samples the amount of carbon 14 remaining is so little that any signal is lost in the noise.

There is another way, however, that this dating method breaks down. If you are a mollusk, for example, that lives in water which is particularly lacking in CO2 from the atmosphere, you will incorporate less carbon 14 into your tissue. This lower amount of carbon 14 will then make it look like you are older than you are. It may even make the shell from a living mollusk look like it is thousands of years old – because the starting point of carbon 14 is lower than for creatures breathing in carbon 14 from the atmosphere.

This is yet another example of Snyder throwing out an isolated factoid without putting it into the context of the actual science.

#39 If humans have been around for so long, where are all of the bones and all of the graves?

Snyder quotes Don Batten who calculated that there should be billions of human skeletons buried around the world. This, of course, assumes that all or most human remains would survive for tens of thousands of years. Batten glosses over this assumption by stating that older bones have been found, implying that therefore all younger bones should still be around.

However, whether or not bones are preserved depends highly on the conditions in which they end up. Most bones do decay over time, unless specific cultural practices or lucky conditions resulted in preservation. Batten has an out for that explanation also, writing: “However, even if the bodies had disintegrated, lots of artefacts should still be found.”

You know, there is an entire field of science dedicated to finding and digging up artifacts of past human civilization, called archaeology. There are vast numbers of archaeological finds all over the world, complete with large numbers of artifacts. Batten makes no attempt at a scholarly analysis of the density and number of archaeological finds compared to how many one would expect to find, given the extent of searching that has happened. He is just shooting from the hip and confirming his own bias based on nothing but ignorance.

Give me a peer-reviewed scholarly analysis and I’ll take it seriously.

#40 Evolutionists claim that just because it looks like we were designed that does not mean that we actually were.  They often speak of the “illusion of design”, but that is kind of like saying that it is an “illusion” that a 747 airplane or an Apple iPhone were designed.  And of course the human body is far more complex that a 747 or an iPhone.

This is the “design inference” gambit. Snyder is attempting to address the scientific response, but is only doing a terrible job of addressing a straw man version. The design inference is that because there is the appearance of design in nature, then nature was intelligently designed.

However, this is asking the wrong question. Scientists do not actually doubt the appearance of design in nature. It is not the “illusion of design” – it is actual design. But it is a bottom-up evolutionary design, not a top-down intelligent design.

That there is design is not questioned, it is the nature of that design that is at issue. Evolution is not a random process. It is a creative process, although without any evidence to suggest that there is anything guiding the creative process. If we ask the actual question – does life look like it was designed by a spontaneous bottom-up process, or a deliberate top-down process, the answer is overwhelming and obvious. The design of life looks evolved, not intelligent. I discuss this distinction in more detail here.

#41 If you want to be part of the “scientific community” today, you must accept the theory of evolution no matter how absurd it may seem to you.  Richard Lewontin of Harvard once made the following comment regarding this harsh reality…

We take the side of science in spite of the patent absurdity of some of its constructs, . . . in spite of the tolerance of the scientific community for unsubstantiated commitment to materialism. . . . we are forced by our a priori adherence to material causes to create an apparatus of investigation and set of concepts that produce material explanations, no matter how counterintuitive, no matter how mystifying to the uninitiated. Moreover, that materialism is absolute, for we cannot allow a Divine Foot in the door.

This is wrong on multiple levels.  Science is not a priesthood – you don’t have to accept any particular conclusion of science in order to be accepted as a scientist. What you have to do, however, is demonstrate that you understand how science works.

Scientists propose new ideas that go against current beliefs all the time. That is how they make their careers, by discovering new stuff.

Scientists are dedicated to the scientific method. Scientists are judged by how rigorous their methods are, how valid their logic, and how sound their conclusions. If evolution were not true, as Snyder believes, then a scientist should be able to find evidence against evolution, or in favor of an alternative. If they had the evidence and logic, they could make their case. Other scientists could replicate their work.

What Snyder is demonstrating is nothing but his abject ignorance of science and scientists.

Lewontin’s statement is similarly problematic. I reject his assertion that scientists accept absurd conclusions out of nothing but a dedication to materialism. Scientists question everything. But we also have come to understand that our intuitions don’t always accord themselves accurately to the universe. Why should they?

At the core of Lewontin’s claim, which has become standard in the ID community, is that the game of science is rigged against “divine” causes. This is misleading, as it implies that this choice is arbitrary and unfair. As I have discussed extensively here before, methodological naturalism is a necessary premise for science. Science cannot function otherwise.

You cannot test a miracle. Supernatural notions do not lend themselves to falsification. Science can therefore not operate with such ideas. Science has to follow methodological naturalism by definition, or else it is not science.

Lewontin might as well complain that youth is wasted on the young, or that democracy gets bogged down in all those elections.

We haven’t had a quote taken out of context in a while, so here ya go:

#42 Time Magazine once made the following statement about the lack of evidence for the theory of evolution…

“Yet despite more than a century of digging, the fossil record remains maddeningly sparse. With so few clues, even a single bone that doesn’t fit into the picture can upset everything. Virtually every major discovery has put deep cracks in the conventional wisdom and forced scientists to concoct new theories, amid furious debate.”

The link Snyder provides does not go to the Time article, but an article by the Institute for Creation Research, which itself does not bother to provide the primary reference or even mention the author. I had to dig up the primary reference myself, which is an article by Michael D. Lemonick in 1994. The quote, therefore, is not even from a scientist but a science journalist, and is 21 years old.

It is also taken out of context. What the ICR is doing here is another common form of creationist misdirection. There are at least three main aspects to the science of evolution: the fact of common descent, the proposed mechanisms for evolutionary change, and the history of what evolved from what and when.

The article is specifically about human evolution. The main point it is making is that the history of hominins is one of a diverse branching bush of adaptive radiation.  Out of this complex web we have a few pieces here and there. If you count Homo naledi. there are now 9 known species in the genus Homo. There are also three genera closely related to humans after the split with chimpanzees – Kenyanthropus, Australopithecus and Paranthropus.

The picture is slowly coming into focus, but we are still at the point that a new fossil find adds significant complexity to our understanding of human evolution. Twenty-one years ago, when the article was written, there were far fewer known species, and it was even more true that each new discovery was redrawing the family tree.

Creationists are committing two levels of confusion. First they are confusing the details of evolutionary history with the fact of common descent. Each new fossils adds to our total evidence for common descent, and strengthens our understanding of the evolution of humans. Creationists pretend that each new discovery calls into question the underlying basic fact of common descent when they don’t.

They are also making the classic science denier mistake of pretending that arguments over the details call into question the bigger picture. Scientists can argue about whether or not Homo naledi is really its own species, and whether or not modern humans evolved from naledi, habilis, erectus, or some other species – without calling into question the bigger picture that all these species represent a diverse family tree of hominins that are closely related to modern humans.

#43 Malcolm Muggeridge, the world famous journalist and philosopher, once made the following statement about the absurdity of the theory of evolution…

“I myself am convinced that the theory of evolution, especially the extent to which it’s been applied, will be one of the great jokes in the history books of the future. Posterity will marvel that so very flimsy and dubious an hypothesis could be accepted with the incredible credulity that it has.”

A quote from a creationist criticizing evolution is worth literally nothing. Muggeridge is just invoking the unassailable authority of the future. Such appeals to the future cannot be directly countered, because everyone is free to project their own biases onto the future without the fear of being contradicted, at least anytime soon. Muggeridge gives himself even more protection by not giving any time frame.

I, of course, can find quotes to support whatever position I want. I can quote Michael Palin who said of Muggeridge:

“He was just being Muggeridge, preferring to have a very strong contrary opinion as opposed to none at all.”

Snyder concludes:

#44 In order to believe the theory of evolution, you must have enough blind faith to believe that life just popped into existence from nonlife, and that such life just happened to have the ability to take in the nourishment it needed, to expel waste, and to reproduce itself, all the while having everything it needed to survive in the environment in which it suddenly found itself. Do you have that much blind faith?

This is complete nonsense. No blind faith is required to accept the scientific consensus regarding the fact of evolution. The evidence is overwhelming. Snyder’s characterization is, typically, a straw man. No one believes that life just “popped into existence.” There is active research going on regarding the development of life from possible precursors. There was likely a period of chemical evolution prior to organic evolution.

It is also a non sequitur to say that life “just happened” to have the ability to take in energy, expel waste, and reproduce – these are characteristics of life. Living systems evolved over time, nothing just “popped into existence.” Life also did not just “find itself” on Earth – it evolved on Earth and therefore was adapted every step of the way to its environment.

Equating a well-established scientific theory to “blind faith” lies somewhere between abject intellectual dishonesty and complete ignorance about the nature of science.


Snyder actually has an epilogue to his 44 reasons – a challenge for anyone to lay out the evidence for evolution. This is also a completely disingenuous challenge. He can just put out the challenge, pretend that the evidence does not exist by simply ignoring it, and then claim victory.

If Snyder wants to see the evidence for evolution, he can start with Darwin’s Origin of Species. Darwin actually makes a very compelling argument. There are many more updated sources, however. He can read Why Evolution is True by Jerry Coyne.

Here is a free online reference that lays out the evidence for macroevolution. It is a slam dunk. He could even listen to the Evolution 101 podcast by Zachary Moore.

Snyder, of course, does not want to genuinely engage with scientists or the actual scientific evidence for the various aspects of evolutionary theory. Creationism is not a coherent belief system, and it is certainly not a science. It is nothing more than a campaign of doubt and confusion, trying to muddly the waters of the public understanding of evolution as much as possible.

As I have carefully documented over these four essays, they accomplish this goal of confusion by lying about the facts, giving partial information, quoting scientists and others out of context, and heavily employing logical fallacies.

What they never do is make a coherent scientific argument that accounts for the actual evidence and the current claims of scientists. They don’t do this because they can’t. That is because evolution is true, and creationism is not science.

By doing such a horrible job of attacking evolution, Snyder actually demonstrates how solid a scientific theory it is. If evolutionary science had any real weakness or vulnerabilities, creationists would be gleefully pointing it out.

I will end with a counter-challenge to Snyder. I will happily engage with him on any or all of his 44 reasons. He can simply respond in the comments, or send me a response which I will publish. It would probably be best to pick one or a few related points so that we can do a detailed analysis. He can choose. I have corrected him on many clear factual errors. Let’s see if he has the intellectual integrity to admit any of them.

Categories: Medicine

An aspirin a day to prevent heart attacks, strokes, and cancer?

Science Based Medicine - Thu, 09/24/2015 - 09:30

Low dose aspirin is now recommended to prevent heart disease and stroke.

Despite the remarkable advances in medicine over the past 20 years, cardiovascular disease and cancer will still kill half of us. Beyond the deaths, millions survive heart attacks, strokes and cancer, but many are left with disability and a reduced quality of life. While lifestyle changes can improve our odds of avoiding these diseases, they do not eliminate our risk. Finding ways to medically prevent these diseases before they occur, a term called “primary prevention”, is a holy grail in medicine. Primary prevention can be a tough sell, personally and medically. It means taking medicine (which may cause side effects) when you’re well, with the hope of preventing a disease before it occurs.

The US Preventative Services Task Force (USPSTF) released draft guidelines on the primary prevention of cardiovascular disease and colorectal cancer last week. The USPSTF is now recommending daily aspirin use in those at average risk of cardiovascular disease. This isn’t the first guideline that’s recommended aspirin for primary prevention of cardiovascular disease, but it is the first major guideline to endorse aspirin to prevent colorectal cancer. Given these recommendations will apply to millions of people, they have attracted considerable controversy. Is this strategy going to reduce deaths and disability? Or are are we about to start “medicalizing” healthy people inappropriately?

Why take Aspirin?

Aspirin or acetylsalicylic acid (ASA) has a long history of use with origins in a natural remedy, where willow bark was used as medicine as far back as 3000-1500 BCE. The active ingredient in willow is salicin which, after being isolated, was modified chemically in an attempt to improve the side effect profile. The ASA chemical structure was invented in 1899 by the pharmaceutical company Bayer, which still retains the right to the trademarked brand name “Aspirin” in some countries. ASA is generic, inexpensive, and one of the most widely used drugs in the world.

The analgesic and pain-relieving effects of ASA are well known. At high doses, ASA can be used to treat inflammatory diseases like rheumatoid arthritis. ASA appears to reduce the risk of heart attacks and strokes through mild anti-inflammatory effects as well as anti-platelet effects (reducing their “stickiness”). The effectiveness of ASA in preventing cardiovascular disease was demonstrated back in the 1980’s, with considerable research occurring since them on the optimal dose and conditions for use. The role of ASA in the prevention of a second heart attack or other cardiovascular “event” after the first one has occurred is now well established. In this population, the benefits tend to greatly outweigh the risks, and daily ASA therapy is standard treatment. As supporting evidence has emerged, there has been growing enthusiasm for its use in primary prevention, with some guidelines now (cautiously) endorsing its use. Steven Novella reviewed the evidence in a past post, noting that the potential benefit, being small, needs to be weighed against the real risk of side effects.

How ASA prevents colorectal cancer isn’t clear, but it does appear to work. It may also be due to effects on inflammation, possibly reducing the formation of tumors in the colon. But effects on platelets have also been proposed.

What did the USPSTF do?

The USPSTF commissioned three systematic reviews and a decision analysis model to develop its recommendations. Using benefit and harm data, they they estimated overall benefits to different groups. The model started by assuming a population that was not already taking non-steroidal anti-inflammatory drugs (NSAIDs), and with no risk factors for gastrointestinal bleeding. They used a risk calculator to predict the 10-year risk for a heart attack, stroke, or other death due to heart disease. They then considered the likelihood of benefit (cardiovascular events and cancers avoided) versus the risk of harms (e.g., gastrointestinal ulcers, and strokes caused by bleeding in the brain), and how that changed over time.  The effects were modest but for some groups, a net benefit found. ASA can reduce the risk of heart attacks and strokes by about 22%, although effects on all-cause mortality (any reason for death) are more modest (6% based on pooled data). Data on the effectiveness in reducing the risk of colorectal cancer was also observed. However, it takes 10 years or more before a benefit is seen – which can be up to 40%, with a 33% mortality benefit. The longer your life expectancy, the greater chance you have to to experience benefit.

The net benefits and risk were then summarized for different age groups.

What are the expected benefits of daily ASA consumption?

Deciding about risks and benefits is ultimately a personal decision. In this case, you must weigh your perceptions about the benefit of avoiding colorectal cancer, heart attacks and ischemic strokes against the risks of harms from ASA. The USPTF concluded there was sufficiently good evidence to conclude with “moderate certainty” that the benefits outweigh the risks for those aged 50-59 who are not at an elevated risk of bleeding:

The USPSTF recommends low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer in adults ages 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.

The were also supportive, but with somewhat less confidence, of daily ASA used in those aged 60-69:

The decision to use low-dose aspirin to prevent CVD and colorectal cancer in adults ages 60 to 69 years who have a greater than 10% 10-year CVD risk should be an individual one. Persons who are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years are more likely to benefit. Persons who place a higher value on the potential benefits than the potential harms may choose to use low-dose aspirin.

I’m under 50 or over 70 years old. Why did the USPSTF say the evidence was “insufficient”?

The USPSTF concluded the evidence was insufficient to assess benefits and harms of primary prevention if you are younger than 50 or over the age of 70.

In those under the age of 50, the risk of cardiovascular disease is lower, and the expected benefits have not been well studied. Given the lower risk, the harms likely outweigh any expected benefits. People with shorter life expectancy are less likely to obtain an overall benefit from ASA therapy. That’s why the USPSTF was more supportive of starting ASA in those aged 50-59.

Evidence of benefit in older (>70 years) is also lacking. While the risk of cardiovascular disease is much higher, so is the likelihood of harm from ASA. There is also less expected benefit in terms of protection from colorectal cancer in this age group. Consequently, any decision to treat requires a careful evaluation of expected benefits and potential risks.

Why do I need to take ASA for 10 years? Is there any benefit to taking it occasionally?

The overall benefits of ASA are due to effects on cardiovascular disease and cancer. The evidence suggests you need to take ASA daily for at least 10 years before there’s a meaningful benefit on your risk of colon cancer, which is an important contributor to the overall benefit of the therapy.

What’s the proper dose of ASA for primary prevention?

There’s no clear evidence supporting any single dose. The 81mg tablet is widely available and used regularly. There’s no persuasive evidence that enteric-coated tablets or “buffered” tablets reduce the side effects of ASA. One tablet daily is the usual dose.

What are the possible risks of daily ASA therapy?

The biggest risk of ASA treatment is gastrointestinal (GI) bleeding. The risk of a GI bleed increases with age. Any other conditions or medications that raise that risk (e.g., history of GI ulcer) need to be considered in the overall decision.  There is also the risk that the benefits will be reduced if the medication isn’t taken. A decision to start ASA to prevent disease should be considered a 10 year commitment. Sticking with daily medication use can be challenging, particularly when you’re not actually ill.

I don’t want to take ASA. What can I do to reduce my risks?

You can dramatically reduce your risk of cardiovascular disease through lifestyle changes:

  • Don’t smoke.
  • Maintain a healthy body weight
  • Exercise regularly
  • Eat a healthy diet

You can also add to this:

  • Prevent and treat diabetes, high blood pressure and high cholesterol, using the best evidence.

Do as many of these as possible and you will significantly reduce your risk of cardiovascular disease.

There’s less evidence to suggest that lifestyle changes can prevent colorectal cancer, but a healthy diet and the advice above will probably be helpful. Screening program are effective, and should be considered at the appropriate age (usually age 50).

Praise and Criticism

Taking ASA for primary prevention is requires a close evaluation of known risks and expected benefits. The new USPSTF guidelines try to clarify the place in therapy. Probably the biggest argument against primary prevention with ASA is the fact that there is limited randomized data that’s examined this specific question. This has led to different interpretations of the evidence. As recently as May, the FDA denied a request from Bayer to approve the marketing of Aspirin for primary prevention. Some criticize the guidelines for their complexity, suggesting that some may consider self-medicating without implementing more important (and effective) lifestyle changes or accessing screening programs.

 What’s the Bottom Line?

Given the risks, is the evidence strong enough to recommend ASA for primary prevention? For those in the 50-69 age group, there is likely to be a modest, but real benefit. But this benefit comes with some risks. On an individual basis, the incremental benefit needs to be considered in the context of everything that you’re doing to prevent cardiovascular disease and cancer. Calculate your own cardiovascular risk. Think about what you personally value, your own lifestyle choices, and the risks you’re willing to accept. Then speak with your primary care provider about your preferences.


Photo from flickr user Mike Mozart used under a CC license.

Categories: Medicine, Skepticism

44 Reasons Creationists Are Deceptive further cont.

Neurologica Blog - Thu, 09/24/2015 - 08:13

This is the third post dealing with a recent aggregation of old creationist arguments that has been making the rounds on social media,.44 Reasons Why Evolution Is Just A Fairy Tale For Adults.  The author, Michael Snyder, has shown a typical level of horrific scholarship and reasoning. Post 1 is here, and post 2 is here.

In the last article I discussed the claim that the Coelacanth is a “living fossil” (a term I despise because it is ripe for confusion). Essentially Snyder and other creationists treat the Coelacanth as if it is a specific species, when in fact it is an order of fish. An order surviving for hundreds of millions of years is not at all unusual.

In the next of Snyder’s reasons he commits the same mistake:

#18 According to evolutionists, the Ancient Greenling Damselfly last showed up in the fossil record about 300 million years ago.  But it still exists today.  So why hasn’t it evolved at all over the time frame?

This claim is entirely wrong, demonstrating sloppy research. Actually I suspect that Snyder did no research (and here I am just referring to looking up reliable references). He seems to have just swallowed a creationist meme whole from the Institute for Creation Research, specifically an article by their “science writer” Brian Thomas.

Thomas claims that there are fossils of the Ancient Greenling Damselfly, unchanged from the modern species, that are 300 million years old. This is simply not true, and Thomas provides no primary references to back up his claim.

I spent some time digging up primary references to find out what is really going on. The Ancient Greenling Damselfly is the sole surviving species of a rare family of Damselfly, the Hemiphlebiidae. Damselflies in turn are closely related to dragonflies, the most obvious difference being that when dragonflies are at rest their double wings are spread out, creating the iconic shape of a dragonfly, while damselflies fold up their wings flat against their body.

Briefly, the order Odonata includes the suborder Anisoptera (dragonflies) and Zygoptera (damselflies), which in turn contains many families, one of which is the Hemiphlebiidae, which includes the Ancient Greenling Damselfly. There are at least two fossil species of Hemiphlebiidae, Parahemiphlebia and Cretarchistigma , from the Lower Cretaceous of England and Brazil.

These species date to as old as 140 million years ago, not 300 million years. Further, while they are in the same family as the extant Ancient Greenling Damselfly, they are in different genera. But Thomas writes:

“But this particular insect is part of another tale, for the same species has been found fossilized from Brazil to Siberia.”

This is wrong – it is not the same species. It is a different species, different genus, but same family.

The bigger point here is that creationists often use apparent stability of living groups over long periods of time to argue against evolution. However, large successful groups (like the Odonata) can be relatively stable over tens or even hundreds of millions of years. However, we will still see adaptive radiation and evolution at lower taxonomic levels, like families, genera, and species.

#19 Darwinists believe that the human brain developed without the assistance of any designer.  This is so laughable it is amazing that there are any people out there that still believe this stuff.  The truth is that the human brain is amazingly complex.  The following is how a PBS documentary described the complexity of the human brain: “It contains over 100 billion cells, each with over 50,000 neuron connections to other brain cells.”

This is the argument from personally incredulity, otherwise known as the, “Aw, shucks, that sure is complicated,” fallacy.  The human brain is certainly complex (I can say this with some authority, being a neurologist). Actually the best current estimate is that there are about 86 billion neurons in the adult human brain, but this is a minor point.

The claim here is that complexity on this order of magnitude could not arise without a designer, but that is a vacuous claim without scientific support. Self organizing systems following relatively simple rules can generate fantastic amounts of complexity. The vertebrate brain, for example, has a great deal of repetition in its anatomy, with millions of cortical columns comprised of 100 or so neurons. The brain also undergoes what is called somatotopic organization during development – sensory input and feedback from the body follows simple rules to produce a mapping of the brain onto the world and the body.

The brain, in other words, looks like something that evolved from the bottom up, not something that was designed from the top down. Either process can produce complexity. In fact, bottom up organization is associated, if anything , with greater potential complexity.

Time for another quote from a scientist taken entirely out of context:

#20 The following is how one evolutionist pessimistically assessed the lack of evidence for the evolution of humanity…

“Even with DNA sequence data, we have no direct access to the processes of evolution, so objective reconstruction of the vanished past can be achieved only by creative imagination.”

Again Snyder does not provide any primary reference, just a secondary creationist source. This does contain the primary reference, however: A Genetic Perspective on the Origin and History of Humans, by N. Takahata. In this fairly narrow technical paper Takahata is attempting to use molecular genetics to infer the branching order of gorillas, chimpanzees, and humans and to estimate their historical population sizes. The point he is making in that quote is simply that we cannot directly observe what was happening in these populations in the past, but we can infer what happened by testing hypotheses (generated through his poetically referenced imagination) with objective molecular data. Wow, how devastating.

Also, imagine the quote-mining they must be doing to select that one quote from that one obscure and narrow technical paper.

#21 Perhaps the most famous fossil in the history of the theory of evolution, “Piltdown Man”, turned out to be a giant hoax.

Piltdown is famous for being a hoax. There are other famous fossils, such as Lucy and the Berlin specimen. Fossil fame, however, is irrelevant. The creationists are never going to let go of Piltdown man, because they can use it to make the implication (often without stating it outright) that fossils in general are fake. This, of course, is an absurd claim and is not true.

The scientific community was indeed punked by Piltdown in 1912. Paleoanthropology was a very young science, with few specimens, and they were presented with a carefully crafted hoax that confirmed all their current biases. As more and more human fossils were discovered, however, Piltdown man became progressively sidelined and ignored, because it did not fit with the rest of the evidence. Eventually this conflict prompted a reexamination of the original specimen, and they were found in 1953 to be a modern hoax. Science was a bit slow this time, but in the end it self-corrected.

There are plenty of online resources cataloguing the growing list of human fossils. Homo naledi was just added to that list. Once again Snyder just puts out an isolated factoid without putting it into any context.

The next two points are essentially the same:

#22 If the neutron were not about 1.001 times the mass of the proton, all protons would have decayed into neutrons or all neutrons would have decayed into protons, and therefore life would not be possible. How can we account for this?

#23 If gravity was stronger or weaker by the slimmest of margins, then life sustaining stars like the sun could not exist. This would also make life impossible. How can we account for this?

This is the anthropic principle. There are many physical constants that, if they were even slightly different, the universe could not exist as it does. This, of course, has absolutely nothing to do with evolution. Whatever the reason for the current physical laws of the universe, they allow for evolution, and the evidence strongly suggests it did happen. I write more about the anthropic principle, and why it is not an argument for god, here.

Every few points, apparently, he has to throw in a quote out of context. This one, however, is worse than usual:

#24 Why did evolutionist Dr. Lyall Watson make the following statement?…

“The fossils that decorate our family tree are so scarce that there are still more scientists than specimens. The remarkable fact is that all of the physical evidence we have for human evolution can still be placed, with room to spare, inside a single coffin!”

Watson is not an evolutionary scientists. He had no science degree. He is an author of dubious supernatural books who was writing in a popular magazine (Science Digest) and not in the peer-reviewed literature. He is most famous for his “hundredth monkey” theory, which is complete nonsense. Further, the claim is just wrong. Again – here is a partial list. It is way more than Watson said.

I am starting to get repetitive, but that is because Snyder is repetitive – what Snyder is doing is quoting a secondary hostile creationist source, which in turn quoted a pseudoscientist, in order to make a claim about the state of human fossils. He did not research how many fossils of human ancestors we have or link to actual scientific or reliable sources.

#25 Apes and humans are very different genetically.  As explains, “the human Y chromosome has twice as many genes as the chimpanzee Y chromosome and the chromosome structures are not at all similar.”

Wrong (again, notice his source), we are genetically very similar.  I wrote about the science of comparing human and chimp DNA here. Read that article for a full treatment. Bottom line – if you make the correct kind of comparison, one that is meaningful for degree of evolutionary separation, then humans and chimps share 96% of their DNA. This fits well with the fossil evidence about time of divergence, of about 8 million years ago.

Using the Y chromosome as evidence for divergence is highly misleading. It is true that human and chimp Y chromosomes are divergent, but it is misleading to imply from this that we are not genetically similar overall. Chromosomes are capable of massive reorganization, and even in a single generation they can fuse or split. The Y chromosome is also special, because of its role in determining sex. It is particularly subject to gene loss and alterations. Read the technical reference if you want the details.

#26 How can we explain the creation of new information that is required for one animal to turn into another animal?  No evolutionary process has ever been shown to be able to create new biological information.

This is the information argument that intelligent design creationists are so fond of. It is nothing but a lie. There are known mechanisms to create new information. Gene duplication is the most obvious – one gene can be duplicated during reproduction, now you have two copies of the same gene. While one gene continues its original function, the second gene is free to evolve in novel directions. You just doubled the genetic information of that gene. In fact, there is tremendous evidence of analysis of the gene structures of many species that gene duplication is a primary mechanism of increasing genetic information. This has been known since 1930, so Snyder is only 85 years behind the times.

There are other mechanisms as well, such as horizontal gene transfer. The DNA from a virus can get stuck in the DNA of a host organism, and then become part of the genomes. These insertions actually make up a significant portion of our DNA (about 8%), and sometimes they can be used for raw material for the evolution of new genes.

I would also add that mutations create new biological information.

#27 Evolutionists would have us believe that there are nice, neat fossil layers with older fossils being found in the deepest layers and newer fossils being found in the newest layers.  This simply is not true at all

The fossil layers are not found in the ground in the nice neat clean order that evolutionists illustrate them to be in their textbooks. There is not one place on the surface of the earth where you may dig straight down and pass through the fossil layers in the order shown in the textbooks. The neat order of one layer upon another does not exist in nature. The fossil bearing layers are actually found out of order, upside down (backwards according to evolutionary theory), missing (from where evolutionists would expect them to be) or interlaced (“younger” and “older” layers found in repeating sequences). “Out of place” fossils are the rule and not the exception throughout the fossil record.

This is once again partial information crafted to deceive.  The Earth is geologically active. Land is being moved around all the time, heaving up, eroding away, crashing into each other, etc. However, there are different geological strata, with different geological characteristics and different fossils. These different strata and their fossils do consistently occur in in ordered layers. However, they get moved around a lot.

The result is like a puzzle – but we can put the pieces of that puzzle together to construct an entire geological column. Because a complete column does not occur all in one place is irrelevant. For example, we may find the following sequences in different locations: A-B-C-D; J-K-L-M-N; D-E-F-G-H; G-H-I-J-K-L, etc. We can use the overlaps in the sequences to place them in order. Also, don’t forget, we can directly date many layers so we can use their ages to sequence them also.

Further, the overwhelming fact is that fossil species do exist in the various strata in a consistent order. We never ever see dinosaur fossils in strata younger than the K-Pg boundary 65 million years ago, for example. The only exceptions are when there are obvious geological processes that caused mixing of layers. We simply construct the geological column from areas where mixing has not occurred.

If you want to see nice neat geological layers then visit the Grand Canyon.

#28 Evolutionists believe that the ancestors of birds developed hollow bones over thousands of generations so that they would eventually be light enough to fly.  This makes absolutely no sense and is beyond ridiculous.

That is not even an argument, it is a statement of personal incredulity. The probable implication he is trying to make is that birds could not fly until they had evolved hollow bones over thousands of generations, but this is simply not true. Here it is clear that Snyder simply does not know what he is talking about, and made not effort to educate himself on bird bones as an adaptation of flight.

First, bird bones are not necessary lighter than mammalian bones. Some bird bones are light, some are heavier, and overall there is not much of a difference. Bird bones, however, have becomes highly specialized for flight. They are stiffer, stronger where they need to be, and have been simplified to eliminate bones where possible. They also demonstrate varying degrees of “pneumatization” – air sacs like in the lungs, which do make them hollow in places. This adaptation provide more oxygen to the blood quicker, which is an advantage for flight.

What we see with bird evolution is the slow adaptation of the theropod skeleton to the bird skeleton, with multiple optimizations for flight.

It seems that the core misunderstanding of Snyder is the false premise that birds could not fly at all until their skeletons were optimized for flight, but there is no reason at all to suppose this. Archaeopteryx could fly, and yet lacked many modern bird adaptations for flight. Function is not all or nothing. Often species will do something poorly, because it is still useful, and then will evolve adaptations to optimize the function.

#29 If dinosaurs really are tens of millions of years old, why have scientists found dinosaur boneswith soft tissue still in them?

The finding of soft tissue inside the fossilized bones of T-rex has been highly controversial, for obvious reasons. While there is interesting evidence to support the claim, I don’t think we are there yet. Even if we acknowledge the presence of soft tissue in dinosaur bones tens of millions of years old, that does not mean their age is incorrect. There are already findings that can help explain this extreme preservation, such as the presence of iron which can act as a preservative.


As we work our way through these 44 creationist arguments, the patterns become more and more clear. In each case Snyder (who is just copying standard creationist arguments) is not referencing scientific sources or giving a reasonable overview of the actual evidence. In each case he is giving a highly selected tiny slice of the picture, crafted to create a deceptive implication. Sometimes his claims are outright incorrect.

There is a simple reason why creationist arguments are so transparently terrible – they have no good arguments.



Categories: Medicine

NPR and the False Choice of Alternative Medicine

Science Based Medicine - Wed, 09/23/2015 - 08:01

A recent segment on NPR is an excellent representation of some of the mischief that promotion of unscientific medical treatments can create. The title is a good summary of the problem: To Curb Pain Without Opioids, Oregon Looks To Alternative Treatments.

The entire segment is premised around a false dichotomy, between excess use of opioids and unproven alternative treatments. It is clear that the reporters didn’t even speak to a pain specialist who relies upon science-based treatments, or if they did the specialist was completely ignored because an SBM approach did not fit into the narrative of the report.

Opioids and Pain

The problem addressed by the segment is real – the current technology of pain control is limited. I don’t want to sell pain-management short, we have an array of powerful and effective treatments. There are limitations, however, and many patients are inadequately treated.

Acute pain from trauma, surgery, or illness is usually not a problem. We can give powerful drugs to stop pain over the short term. The bigger challenge is chronic pain. There are also two types of pain, neuropathic and nociceptive. Neuropathic pain arises from the nervous system itself, a nerve misfiring, for example, and producing pain signals in the absence of any tissue damage. Nociceptive pain involves pain arising from outside the nervous system due to chronic tissue pathology, such as arthritis.

Neuropathic pain does not respond well to pain medication. Instead it is treated with neuropathic pain prophylaxis, which are drugs that essentially calm down the overactive nerve or neurons through a variety of mechanisms. These drugs work, but not always. Some neuropathic pain syndromes can be challenging to control.

Nociceptive pain responds to pain killers, which are called analgesics. However, nociceptive pain also has an underlying tissue cause, by definition, and this can be addressed also. If the source of pain is the muscles that massage, physical therapy, moist heat, and muscle relaxants may help. If there is inflammation involved then anti-inflammatories are appropriate. If the joints, ligaments, and tendons are involved then mobilization, bracing, exercises, and other interventions may help.

Many patients, however, have chronic pain that is challenging to control. There are limited options for outpatient chronic treatments. NSAIDS (non-steroidal anti-inflammatory drugs, like aspirin) are a mainstay of treatment, but can cause stomach upset, and in severe cases even lead to ulcers. They also cause stress on the kidneys. Some patients may not be able to take NSAIDS for a variety of reasons. There is acetaminophen, which does not affect the stomach or kidneys, but can affect the liver. Without NSAIDS options quickly become limited.

There are migraine-specific medications for migraines (called triptans) but they don’t work for other pain syndromes. There are a variety of patches and creams, such as a lidocaine patch, that can be helpful for localized pain.

After that we are essentially down to centrally acting drugs, such as opioids. There is also a drug called tramadol which is centrally acting but non-narcotic. Opioids are very effective at pain relief. They not only reduce the pain, they affect the brain so that pain does not hurt, meaning they suppress the negative emotional response to pain.

The core problem with opioids is that they are both addictive and have tolerance. Tolerance means that over time the medication is less effective, you need a higher dose to get the same effect. Even worse, there is evidence that chronic opioid use makes patients more sensitive to pain at baseline. Addiction means that chronic use results in drug seeking behavior and negative symptoms from withdrawal – the addiction is both psychological and emotional.

The dilemma for practitioners is that opioids work (at least in the short term) and no one wants to see their patients in pain when we have effective treatment. Patients suffering from chronic pain can get quite desperate and demanding. Further, once they experience the effect of opioids, the freedom from the negative emotional response to pain, they may become effectively spoiled for any other pain control strategy.

The False Choice

This is where the poor reporting from NPR comes in. They report:

David Eisen, executive director of the Quest Center, is Keene’s “Dr. Dave.” He is board-certified in traditional Chinese medicine and acupuncture, and he says doctors need to stop thinking of opioids as a first-line defense against pain.

“There should be an array of things for people to choose from,” Eisen says, “whether it be chiropractic care, or naturopathic care, or acupuncture, nutrition, massage. Try those things — and if they don’t work, you use opioids as a last resort.”

Dr. Dave is presenting a false dichotomy, between using opioids as a first choice or using alternative treatments. There is, of course, a third science-based approach (completely ignored in this report). In my opinion, a good approach to chronic pain does not use opioids as a first line treatment, but as a last resort and in a limited and carefully monitored way.

Prior to resorting to opioids for chronic pain (again, distinguishing this from acute severe pain and also terminal pain), a practitioner should identify and address any underlying cause of the pain. This includes treating any neuropathic component and addressing any muscular, joint, and soft-tissue sources of pain. Physical therapy and all of its associated methods are often effective and science-based approaches to tissue pain. Lifestyle factors, such as weight, exercise, and exacerbating factors, also need to be addressed.

Within the marketing fiction of the alternative medicine world, however, mainstream medicine is all drugs and surgery. They contrast themselves to a fictional straw man version of science-based medicine, which is exactly what the NPR report did, giving listeners a distorted view of the modern practice of pain management. The purpose of this, of course, is to divert patients to ineffective but expensive “alternative” treatments.

The only hint of skepticism was in the final paragraph:

Oregon has not found overwhelming evidence that acupuncture, yoga or spinal manipulation work better than other options. But, as Taray points out, these alternatives don’t involve drugs.

Neither does physical therapy, exercise, and lifestyle changes – which are not “alternative” despite often being lumped in with pseudoscientific practices in order to lend legitimacy to the false category of “alternative” medicine.

Acupuncture for Pain

One of the modalities that is perhaps most prominent in terms of alternative pain management is acupuncture. The degree to which this pseudoscientific treatment has penetrated mainstream medicine is disturbing, and its promotion is based entirely on misdirection.

Acupuncture involves sticking thin needles into acupuncture points. Various possible mechanisms are proposed, none proven. The traditional explanation is that the needles alter the flow of “chi” or life energy. This is pure pre-scientific superstition. Modern defenders have tried to dress up acupuncture in more scientific language by invoking more plausible mechanisms, but there is nothing that is specific to acupuncture or that necessary results in practical pain control.

After thousands of studies there are a few things we can say with a very high degree of scientific confidence – acupuncture points do not exist, and as a result it does not matter where you stick the needles. In fact it also does not matter if you actually stick needles through the skin or just poke the skin randomly with dull needles or toothpicks.

In short – acupuncture does not work. It is nothing more than an elaborate placebo with clinically insignificant results. It is a medical dead end that should be entirely abandoned. If there turns out to be some sliver of a real effect from tissue manipulation or electrical stimulation, these things are not acupuncture in any case. Acupuncture adds nothing to our understanding of pain or how to control it.

Acupuncture for low back pain, the treatment specifically mentioned in the NPR report, demonstrates all the problems with the acupuncture literature. The best controlled studies, such as the 2009 study, show no difference between “real” acupuncture, sham acupuncture using the wrong points, and placebo acupuncture using dull toothpicks.

Systematic reviews are often wishy washy, trying to put a positive spin on the data, but they often give the game away. The latest systematic review concludes:

Systematic reviews of variable quality showed that acupuncture, either used in isolation or as an adjunct to conventional therapy, provides short-term improvements in pain and function for chronic LBP. More efforts are needed to improve both internal and external validity of systematic reviews and RCTs in this area.

In other words, there are good studies, and not-so-good studies, with inconsistent results. Results only seem to be present when there is an unblinded comparison, or when blinding is uncertain, and they tend to be short-lived and of dubious clinical significance. They also often mix in “electroacupuncture,” muddying the waters with electrical stimulation, which has its own effect. This pattern of results is most consistent with background noise, not a real clinical effect. If it is this difficult to tease out a tiny clinical effect, perhaps it is not real.


The NPR report demonstrated one of the marketing strategies for dubious but highly profitable medical treatments – brand them as “alternative” and then compare them to a straw man of bad medical practice.

There are many opportunities for this approach because medicine is complex and imperfect. We face many challenges, our scientific information is incomplete, and there are many conditions for which we lack effective treatments or where hard trade-offs need to be considered.

Instead of taking a rigorous scientific approach to slowly improve our knowledge and the practice of medicine, the “alternative medicine” world offers magic solutions and false promises. In addition they poison the well of mainstream medicine by spreading misleading negative stereotypes about their competition.

Categories: Medicine, Skepticism

44 Reasons Creationists Are Deceptive cont.

Neurologica Blog - Tue, 09/22/2015 - 08:11

Part II: Sudden Appearance

This is a continuation of my blog post from yesterday, deconstructing 44 alleged reasons to doubt evolutionary theory. In Part I I addressed the claim that there are no transitional fossils, which is a bold creationist lie they maintain despite the copious evidence and the fact that their misinterpretations have been publicly corrected.

The next series of “reasons” #7-12, attempt to support the claim that species appear suddenly, as if they are created. Snyder begins:

If the theory of evolution was true, we should not see a sudden explosion of fully formed complex life in the fossil record. Instead, that is precisely what we find.

Once again we see the creationist tactic of giving partial selected information, rather than putting the entire picture into perspective. They are not looking for proper perspective – they are looking for deception.

I assume by this statement he is referring to the Cambrian “explosion.” This explosion represents the first appearance of multicellular creatures in the fossil record, at least those that lead to extant life. There is also the Ediacaran fauna which immediately predate the Cambrian. It is not clear if these creatures were an evolutionary dead-end or if they had descendants in the Cambrian. The Cambrian period lasted from about 540 to 490 million years ago, 53 million years. In the early Cambrian we “suddenly” (in geological terms) see many multicellular creatures. Of course “sudden” in this context means millions of years.

The Cambrian explosion represents a genuine period of rapid evolutionary change. This makes perfect evolutionary sense – prior to the Cambrian the world was occupied entirely by single celled and colony creatures, but no multi-cellular creatures. When cells starting to specialize and form complex organisms, this new strategy had tremendous potential and evolution took off in many directions. Further, because basic body plans had not yet been worked out evolutionary change was not constrained, and so was free to experiment in many directions.

Another reason for the suddenness of the Cambrian explosion is likely an artifact of the fossil record. Soft part don’t fossilize well – they only leave behind trace fossils. But hard part do fossilize. When hard parts, like shells and bones, first evolved this would suddenly “turn on” the fossil record.

Finally, Snyder uses the term “complex” without ever putting it into perspective. Cambrian fauna was complex, but not relative to modern life. We don’t see horses in the Cambrian, we see relatively small creatures with a relatively simple body plan. Some creatures are clearly the ancestors to later groups, while others seem to have left no descendants behind. Again – it’s pretty much what you would expect to find (broadly speaking, not in detail) with the first appearance of multicellular life.

Snyder then follows with more quotes taken out of context, including one from Richard Dawkins:

“It is as though they [fossils] were just planted there, without any evolutionary history. Needless to say this appearance of sudden planting has delighted creationists. Both schools of thought (Punctuationists and Gradualists) despise so-called scientific creationists equally, and both agree that the major gaps are real, that they are true imperfections in the fossil record. The only alternative explanation of the sudden appearance of so many complex animal types in the Cambrian era is divine creation and both reject this alternative.”

As I discussed in part I, evolutionary biologists are still debating about gaps in the fossil record and whether or not they are entirely due to the imperfection of the fossil record or represent the general pace of evolution (punctuated equilibrium). That is the context of this quote from Dawkins. He is saying that the gaps are due to the imperfections in the fossil record.

And again Snyder never makes a coherent argument. He never discusses what the fossil record actual looks like, or addresses the scientific explanations for the data. If we look at the overall fossil record what we see are continuous changes over time in an exquisitely evolutionary pattern – meaning that the relationship between fossil species maps out in time and geological range in a pattern that support evolution. Species survive for a while then disappear. New species appear that always have plausible ancestors.

All of the debate is about the fine level of detail, not the broad picture. When you get down to a single species over a short period of time geologically speaking, 1-2 million years, we see that most species (not all) are relatively stable over their life on earth. Dawkins would say this is a limitation of the fossil record, Gould would say this is punctuated equilibrium, but both agree (with almost all other scientists in the world) that the big picture is obviously one of evolution.

We can also discuss what we don’t see in the fossil record. We don’t see species out of sequence – no horses in the Cambrian, no dinosaurs surviving past the Cretaceous period. In fact, the periods and epochs of the Earth are defined by what fossils we find there, because it is very predictable. If evolution were not true, fossils would not be so neatly organized by period and location, with clear lines of ancestors and descendants (again, broadly speaking).

We also don’t see the sudden appearance of creatures that have no possible ancestors. Once basic body plans were worked out in the Cambrian, we continue to see those same body plans in later evolution. We don’t suddenly see six-limbed terrestrial vertebrates.

In fact, in those lines in which we have good fossil evidence, we seen in small detail the evolutionarily contiguous nature of anatomy. We see specific body parts evolving into other body parts. We don’t see new parts arising and disappearing willy-nilly.

And still we are just talking about one line of evidence for evolution – the fossil record. The evidence from genetics is even stronger. There is also evidence from developmental biology, and also from modern observation, which brings us to the next point. The flip side of the claim that species appear “suddenly” is that “macroevolution” has never been observed.

Nobody has ever observed macroevolution take place in the laboratory or in nature.  In other words, nobody has ever observed one kind of creature turn into another kind of creature.  The entire theory of evolution is based on blind faith.

This may have something to do with the fact that speciation takes thousands of years. No one has observed the formation of a planetary system from a cloud of dust either, the raising of mountains through tectonic activity, or the carving of a canyon by a river. Some natural processes take thousands or millions of years to occur, so we cannot observe them happening in real time. But we can infer they happened through other lines of evidence.

I would also add that evolutionary change has been directly observed.

Part III: Misc. 

Snyder next makes some individual points, all incoherent but let’s take a look.

#13 Anyone that believes that the theory of evolution has “scientific origins” is fooling themselves.  It is actually a deeply pagan religious philosophy that can be traced back for thousands of years.

This is a non-sequitur, specifically the genetic fallacy – judging something by its origins. It actually doesn’t matter what the origins of the idea of evolution were. Proto-evolutionary thinking does go back to the ancient Greeks, who pretty much came up with every idea. Evolution as a scientific theory predates Darwin. Darwin’s main contribution was to propose variation and natural selection as the mechanism for evolutionary change. He also is credited with making a persuasive argument for evolutionary theory, and essentially convincing the scientific community.

So what? Chemistry has its roots in alchemy. Astronomy has its roots in astrology. Modern medicine developed from Galenic medicine (the four humors), which is pure pseudoscience. None of this says anything about the scientific status of evolutionary theory today.

#14 Anything that we dig up that is supposedly more than 250,000 years old should have absolutely no radiocarbon in it whatsoever.  But instead, we find it in everything that we dig up – even dinosaur bones.  This is clear evidence that the “millions of years” theory is simply a bunch of nonsense

From the NCSE:

Very simply. Radiocarbon dating doesn’t work well on objects much older than twenty thousand years, because such objects have so little C-14 left that their beta radiation is swamped out by the background radiation of cosmic rays and potassium-40 (K-40) decay. Younger objects can easily be dated, because they still emit plenty of beta radiation, enough to be measured after the background radiation has been subtracted out of the total beta radiation. However, in either case, the background beta radiation has to be compensated for, and, in the older objects, the amount of C-14 they have left is less than the margin of error in measuring background radiation.

There are many many lines of evidence supporting an ancient Earth and the age of life on Earth. Radiocarbon dating is one method that is often a target of creationists, because it is a limited method. It is only reliable in certain conditions and only out to about 20,000 years. We don’t use radiocarbon dating to date fossils or anything older than 20,000 years. This is another great example of how creationists tend to provide only some information without ever giving the entire picture – because the big picture does not support their pseudoscience.

#15 The odds of even a single sell (sic) “assembling itself” by chance are so low that they aren’t even worth talking about.

This is a straw man. Evolutionary theory does not require that a single cell assembled itself by chance. A single celled creature living today is the result of several billion years of evolution – that’s billion. So I agree – this is not worth even talking about.

#16 How did life learn to reproduce itself?  This is a question that evolutionists do not have an answer for.

This is a vague question. What type of reproduction? Mitosis? The strategy here, however, is to say that because current evolutionary theory does not have a specific explanation for every evolutionary development, that calls the theory into question. No one ever claimed that we have an explanation for everything, down to the arbitrarily tiniest detail. Inferring how a slow and complex process worked millions of years ago is very difficult. It’s amazing we can infer as much as we do.

This is yet another logical fallacy – confusing unexplained with unexplainable. Scientists are making progress understanding the evolution of sexual reproduction. We don’t have a full explanation. This does not mean evolution is impossible, as creationists would like to suggest.

#17 In 2007, fishermen caught a very rare creature known as a Coelacanth.  Evolutionists originally told us that this “living fossil” had gone extinct 70 million years ago.  It turns out that they were only off by 70 million years.

The Coelacanth was first known from fossils, with the most recent being from about 65 million year ago. It was not until 1938 that a living specimen was found. This is because they are a deep sea fish and are rarely encountered.

The implication here is that because the Coelacanth survived into modern times that… Well, there really isn’t a coherent point here. It is just trying to imply something vague to sow confusion. If we try to extract a coherent point it could be that Coelacanths survived for millions of years, therefore they did not evolve.

Snyder, however, is implying a common confusion, likely because he is confused on the facts himself. The Coelacanth is not a specific species of fish. It is an order of fish. An “order” is a level of taxonomic classification that is fairly high up the chain. Primates are an order. So the modern Coelacanth has roughly as much of a relationship to the fossil Coelacanths as lemurs do to humans. To clarify – the modern living Coelacanth is not the same species as the fossil Coelacanths. They are just in the same order, the way that monkeys and gorillas are in the same order.


I’m not even half way there. As you can see, it takes much more space to correct a misconception than to create it. This is what leads to the “Gish gallop” – a term named for Duane Gish, who would debate scientists about evolution and overwhelm them with a rapid series of misconceptions that the scientist could not hope to counter in the time allowed.

Snyder has created a Gish gallop of creationist nonsense in his list of 44 reasons. Answers to his claims are already out there, and I linked to some good resources in the first two parts of my posts. I do think it is useful, however, to have a thorough response in one location, social media being what it is.

Categories: Medicine

Keep Naturopathy Out of the VA!

Science Based Medicine - Tue, 09/22/2015 - 03:00

Let’s not change the eagle into a duck

AMVETS has joined with The American Association of Naturopathic Physicians in seeking to “promote natural, non-pharmacological approaches to treating patients suffering from chronic pain.” They are petitioning Congress and the VA to authorize bringing licensed NDs into the VA system. As a veteran myself, a retired Air Force Colonel and an MD, I find this appalling. During my twenty years service in the U.S. Air Force as a family physician and flight surgeon, I took pride in the high-quality science-based medical care my colleagues and I were able to provide. This proposal would jeopardize the welfare of our veterans by exposing them to substandard care with irrational, untested, and potentially harmful treatments. Letting naturopaths into the VA would be a grave mistake.

Their argument

Many of our veterans suffer from chronic pain, and there have been problems with overdosing and abuse of pain medications. The press release says naturopathic physicians are

well suited to help our veterans, since they are specially trained in natural, non-pharmacological approaches that facilitate the body’s self-healing ability. Approximately 4,400 NDs are licensed to practice naturopathic medicine, having earned their degree from 4-year postgraduate naturopathic medical schools accredited through the US Department of Education. The approaches studied include nutritional counseling and stress reduction, botanical medicine, therapeutic manipulation, and oriental medicine. A strong emphasis is placed on disease prevention and educating patients on proactive self-care to maintain wellness. Resolutions passed by the US Senate have urged Americans to learn more about this “safe, effective, and affordable form of health care.

This might sound good to the uninitiated, but it is a very biased, deceptive description of naturopathy. The AANP has bamboozled the AMVETS and now it hopes to bamboozle Congress and the VA. This is a blatant ploy by naturopaths to get a foot in the door. They had to resort to political lobbying because their dubious brand of alternative medicine couldn’t hope to succeed on its own merits.

A rebuttal

• Yes, the schools are accredited, but accreditation only means that the school has met certain standards of administrative methods. Accreditation does not indicate that what is being taught is valid or even that it has any connection to reality. In fact, naturopaths are in charge of accrediting their own schools.
• Yes, students of naturopathy learn about science and some valid treatment methods, but they also learn a lot of arrant nonsense. They are taught that homeopathy is valid, that dissolved oxygen can be absorbed through the skin in appreciable quantities, that goldenseal cures strep throat, that a stroke should be treated with wet compresses, and that “craniosacral rhythms” exist and can be altered by pressing on the skull. One of their standard textbooks devotes 2 full pages to describing the physical manifestations of the four humors, a medieval concept that was discarded long ago. It recommends asthma be treated with hydrogen peroxide baths and gems worn as jewelry or placed around the home in special places. For heart disease, it recommends unproven herbs and chelation, and omits any mention of proven treatments known to lower blood pressure and prevent heart attacks. For HIV infection, it recommends naturopathic treatments while admitting there are no clinical studies of effectiveness, and it fails to even mention the effective HAART medications that prevent progression to AIDS and give patients a near-normal life expectancy. The AIDS Research Center at Bastyr, the most prestigious school of naturopathy, recommends over 100 dubious remedies for AIDS, including “acupuncture detoxification auricular program,” cranioelectrical stimulation, and colloidal silver.
• Naturopaths say they place a strong emphasis on disease prevention, but studies have shown that the patients of naturopaths are actually less likely to get immunizations and preventive screening tests like mammograms.
Naturopaths’ education is far inferior to that of medical doctors, physician assistants, and nurse practitioners. Their education does not equip them with the experience needed to treat patients with serious illnesses requiring hospitalization or to recognize the indications and complications of pharmaceuticals, and they have been known to miss crucial diagnoses and to treat patients for diseases that do not exist.
• They say naturopathy is safe and effective, but that can’t be substantiated. Much of what they do has never been tested for safety and effectiveness, and they continue to use treatments that have been tested and proven not to work, like homeopathy, a mainstay of naturopathy.
• They say it is affordable, but if any treatment is ineffective, it’s no bargain.

The history of naturopathy

As George Santayana said, “Those who cannot remember the past are condemned to repeat it.” In 1910, the Flexner Report surveyed American medical schools and found that educational standards were sadly lacking, and many schools taught whole bogus systems of medicine. Flexner called for them to adhere strictly to the protocols of mainstream science, and as a result, American medicine was reformed. Nearly half of existing medical schools closed, and the remaining ones were those that were grounded in science.

Naturopathy was the brainchild of Bernard Lust, who became enamored of natural treatment methods after he was treated for TB in Germany with a “water cure.” He advocated massage, hydrotherapy, herbal medicine, nude sun-bathing, and avoidance of caffeine and alcohol. The heyday of naturopathy was in the early 20th century. At its peak of popularity it was licensed in 25 states. By 1958 it was only licensed in 5 states. But with the rise of so-called “alternative medicine,” it has managed to sneak back in. Today it is licensed in 17 states but is still prohibited by law in two states: South Carolina and Tennessee. It was de-licensed in Idaho this year.  Licensing bills that have been brought up in other states have been repeatedly rejected: 10 times in Massachusetts and 8 times in New York. Naturopaths would have us believe there is a public demand for their services, but only a miniscule three tenths of one percent of American adults consulted a naturopath in 2007.

Naturopaths say they reject drugs, but the natural remedies they use meet the definition of drugs, and they have sought and obtained full prescribing rights for prescription drugs in two states (Washington and Oregon), a tacit admission that their natural methods are inadequate. In the 31 states where naturopaths are not licensed, they are subject to prosecution for practicing medicine without a license.

Naturopathy’s basic principles

Naturopathy is a belief system, not a legitimate scientific discipline. It claims to be unique, but most of its avowed principles are no different from those of conventional medicine.
• First do no harm. This has been a foundational principle of all medicine since the ancient Greeks. Naturopaths interpret it to mean, “don’t use drugs because they might have side effects.” Conventional medicine interprets it to mean, “Make sure the treatment doesn’t do more harm than good.”
• Physician as teacher. Physicians have always been teachers; they share expert knowledge with patients. Naturopaths teach patients things that are not true.
• Treat the whole person. That is what every good clinician does. The standard medical history includes a section for social history, reminding the physician to consider everything about the patient that might have an influence on health outcomes, from psychology and lifestyle to family and finances.

• Healing power of nature. MDs have always known that the body heals itself. Science-based treatments facilitate known physiologic healing processes by rational means, like eliminating harmful bacteria with antibiotics. Naturopaths try to facilitate a mythical vitalistic healing force, the vix medicatrix naturae, by irrational means.
• Prevention. Conventional doctors invented prevention and have always held that prevention is the best cure. They have always emphasized vaccines, screening tests, and advice about diet, exercise, alcohol, tobacco, etc. And naturopaths have not demonstrated that what they do is effective in preventing disease; in fact their patients are less likely to get effective prevention measures like vaccines and screening tests,  and children who receive naturopathic care are more likely to be diagnosed with a vaccine-preventable disease. Their ideas of prevention are often bizarre; here’s how a professor at Bastyr told a patient she could reduce her risk of breast cancer: “Keep your breasts happy and healthy. Love them and yourself. We often develop illnesses because of our own unresolved feelings and lack of love for ourselves…Deal with any unresolved maternal, nurturing, and relationship issues so they’re not lurking in your breasts.”

Treat the cause. Doctors have always treated the cause. They don’t just treat symptoms with painkillers for appendicitis or cough syrup for pneumonia. Naturopaths treat bogus causes like dietary sugar/fat/gluten, epidemic candidiasis, intestinal “dysbiosis,” vertebral misalignments, and imbalances of qi.

Health consumer advocate Stephen Barrett says,

I believe that the average naturopath is a muddlehead who combines commonsense health and nutrition measures and rational use of a few herbs with a huge variety of unscientific practices and anti-medical double-talk.

In essence, what naturopaths do that is good is not different from what medical doctors do, and what they do that is different is not good.

AMVETS was hoodwinked

AMVETS is one of America’s leading veterans service organization with over 250,000 members. It has a laudable goal: to put vets first and improve the VA system. But in this case, their misguided proposal would make VA care worse, not better. Unfortunately, with no doctors or scientists on their staff, they were easily misled by the deceptive propaganda of the AANP.

Congressman Mark Pocan said, “Our veterans deserve access to all possible forms of health care.” Really? All possible forms? Including those that have been proven not to work? Including quackery? Bloodletting? Perkins’ tractors? Hulda Clark’s zappers? Psychic surgery? I think not. I think they deserve access to all legitimate, effective forms of health care.

Part of their argument is a fallacious appeal to popularity. They did a survey and found that “nearly two-thirds of veterans (64%) would prefer a doctor who prescribes natural therapies before considering drugs or surgery, and that nearly three-quarters of veterans (73%) would consider seeing a ND if he or she were on staff at a nearby VA facility.” Medical care is not a popularity contest. The patients expressed those preferences without knowing all the pertinent facts. How many patients would prefer a doctor who prescribes natural therapies if they knew that none of those natural therapies had been tested and shown to work, and that some of them had been tested and shown not to work? Calling something “natural” doesn’t justify a double standard: drugs are drugs, whether they come from an herb garden or a pharmaceutical manufacturer. If a new remedy were proposed by a pharmaceutical company, would anyone be clamoring to put it on the market before it had been tested? Do patients know best? Patients may think they know what they want, but they would do well to seek the advice of doctors who have expert knowledge about what will really benefit them.

Scientific medicine has progressed by leaps and bounds. It has had outstanding successes, from antibiotics to organ transplants. Alternative medicine hasn’t. There is really no such thing as “alternative” medicine; there is only medicine that has been tested and proven to work and medicine that hasn’t. There is no evidence that naturopathy is effective in treating chronic pain. If naturopathy had effective treatments to offer and had bothered to properly test them, they would have become part of mainstream medicine and could no longer be called “alternative.”

Naturopaths may offer non-drug treatments for chronic pain that other science-based practitioners already offer, like massage, heat packs, exercise, stretching, and physical therapy. Naturopaths rely heavily on marijuana as a pain management tool, but they could not use it in the VA because it is prohibited by federal law. Other naturopathic specific treatments for chronic pain include herbs like kava that are suspected of causing fatal liver damage and that have yet to be evaluated in populations with chronic health conditions like hepatitis and PTSD.

Naturopathy would have us turn back the clock to the early 1900s. Its vitalistic concepts and its irrational treatment choices have no place in the 21st century.

How about a more rational solution?

The VA has had enough problems with access, long waits for appointments, and bureaucratic snafus. Our vets have enough problems with chronic pain, PTSD, traumatic brain injuries, and other service-related problems. We want to solve those problems, not make things worse. We all want the best for those who have served our country.

Our veterans deserve ready access to cutting edge treatments for chronic pain. Modern medicine offers pain treatment centers that combine rational strategies from various health care specialists working as a team. The VA could work to improve access to the best of those programs for our vets.

It could establish immediate access to care with hotlines and could eliminate waiting for appointments. It could make veterans’ care more personal by providing convenient phone or e-mail access to their own designated patient advocate who would get to know them as individuals and help insure they got the best, most timely care. It could hire more science-based health care providers and adapt the system so providers could spend more time with patients at each appointment.


Naturopaths do not belong in the VA. As Steven Novella has pointed out,  this proposal appeals to “health care freedom” but goes beyond the issue of health care freedom. It calls for health care irresponsibility and asks for taxpayer dollars to be spent on unproven and pseudoscientific treatments. Our veterans (and our taxpayers) deserve better. This proposal is gravely misguided. It would hold medical care hostage to self-serving lobbyists and misinformed public opinion. Rather than putting veterans first, it would put science last.

Harriet A. Hall, Col, USAF (Ret)

Categories: Medicine, Skepticism

44 Reasons Creationists Are Deceptive

Neurologica Blog - Mon, 09/21/2015 - 10:59

Part I: Transitional Fossils

Creationists are an endless source of material for skeptical analysis. The reason for this is that modern creationism is what I call “sophisticated nonsense.” It is an elaborate system of motivated reasoning crafted to defend a particular religious view.

The energy, time, and resources that some creationists put into this endeavor is astounding, resulting in a mountain of false claims, half-truths, misdirections, unsound arguments, and misinterpretations.

Creationists are engaged in science denial – denying evolutionary science. The purpose of denial is doubt and confusion, so they don’t have to create and defend a coherent explanation of the origins of life on Earth. They don’t have to provide an explanation for all the available evidence. All they have to do is muddy the waters as much as possible.

This behavior is absolutely clear when you examine their arguments and their methods. One of the hallmarks of creationist arguments is that they don’t change, or they change only slowly and minimally. They continue to use arguments that have been demolished decades ago. That is a sure sign of intellectual dishonesty – even when corrected on a factual error, they don’t seem to care. They continue to spread the misinformation.

One recent example is called, “44 Reasons Why Evolution Is Just A Fairy Tale For Adults.” The author, Michael Snyder, is the worst kind of creationist in my opinion – a polemicist for creationism who boldly and even condescendingly spouts utter nonsense.

His “44 reasons” are not actually 44 separate reasons – he spreads out a single point into multiple “reasons.” He also likes to use the old creationist method of taking quotes out of context. This is another sure sign of intellectual dishonesty. You will see what I mean. (It takes a lot more time to correct a misconception than to create one, so I will have to break this up into multiple posts.)

Reasons 1-6: Transitional Fossils

The first six reasons are essentially the same point, that there is a lack of transitional forms in the fossil record. This, of course, is a complete lie. Snyder, however, maintains this lie with two common misconceptions among creationists that relate to how we define “transitional fossil.”

Creationists, of course, do not provide and then use one consistent definition of the term. They rely upon shifting definitions to sow their confusion. Evolutionary biologists consider a transition fossil any fossil that gives us information about the evolutionary connection between two groups. These two groups can be descendants and ancestors, or two descendants with a common ancestor. The two groups can also be at any taxonomical level – two orders, two families, or two species. This is a broad definition, which allows for creationist mischief.

When scientists discuss the fossil record they will often discuss specific aspects of the record, and their points can easily be taken out of context, especially if you allow yourself a fluid definition of “transitional.” First let me explain, in broad brushstrokes, what the fossil record actually shows, and then we can see how they exploit the details to confuse.

We now have an enormous fossil record containing numerous transitional forms – species that are clearly in between extant species or that clearly fall between extant groups. To give some common examples:

There are now many transitional whales, such as Pakicetus, that are part way between terrestrial mammals and full whale, with stubby legs and nostrils still toward the front of their skull.

Archaeopteryx was the first fossil species part way between theropod dinosaurs and birds, but now we have discovered numerous examples of feathered dinosaurs, and part birds.

Tiktaalik is part way between fish and amphibians.

We have excellent documentation of the evolution of reptiles to mammals, including therapsids and cynodonts. This includes many steps in the transition from a reptilian to mammalian jaw and inner ear.

And of course there is excellent documentation of the hominin group – species that are between modern apes and modern humans. This includes the recently discovered Homo naledi, 15 nearly complete specimens of a creature that is about as close to half-way between apes and humans as you can get.

Here are a list of some other transitional forms.

While this is impressive, the fossil record is admittedly patchy. We are getting narrow glimpses into the past – into a 550 million year history of the evolution of hundreds of millions of multicellular species. Scientists try to understand the patterns in evolutionary history as well as the small details of what exactly evolved from what and when, from this patchy record. Scientists frankly discuss the limitations of this record and will often argue with each other about how to interpret it.

This is where creationists step in – to exploit this discussion and pretend as if a disagreement over the details calls into question the bigger picture, that there is massive evidence that evolution happened. Three of those details are most commonly exploited: the difference between species-level transition and group-level transition, the extent and meaning of stasis in the fossil record, and the difference between a transitional form and an actual ancestor.

Generally we have better documentation of group-level change than species-level change. This is a matter of the resolution of the fossil record. We can see changes that happened over millions of years much easier than changes that occurred over thousands of years. Although when we get closer in time to the present, the resolution of the fossil record improves and we get more species-level data. For example, we are fleshing out the evolution of early humans down to the species level.

Stasis in the fossil record simply means that species tend to arrive in the record, remain relatively stable for their existence, and then disappear. They are not constantly slowly changing. This lead Gould and Eldredge to propose the theory of punctuated equilibrium, which is now generally accepted. This means that selective pressure tends to keep a species in an optimal relationship with their environment. However, this stability is punctuated by often rapid change when that environment changes or something disturbs the stability. “Sudden” in the fossil record, of course, can mean 50 thousand years – enough time for a speciation event.

In order to understand the third point about actual ancestors you need to understand that evolution does not progress in a straight line toward some end. Rather, adaptive radiation results in species evolving in multiple direction, in a branching bushy pattern.  For example, theropod dinosaurs hit upon feathers as an adaptation, and there were many species of feathered theropods. They were not evolving into birds, just adapting to their niche. One branch of theropods started using those feathers in a way that led to flight, a rather significant adaptation. They branched out in many directions, only one twig of which ultimately lead to modern birds.

So – when paleontologists find a fossil of a half-bird, half theropod (like Archaeopteryx), that is a transitional fossil because it represents the morphological space between birds and theropods, and is a definite evolutionary connection. However, we have no way of knowing if the specific individual discovered was an actual ancestor to modern birds, or was from a closely related branch. This again gets to the resolution of the fossil record. Also, without DNA it is impossible to confirm actual ancestry. Fossils alone will never do it. This doesn’t mean that the form is not transitional, however.

Now, let’s get to Snyder’s claims and see how he exploits the complexity of the science to sow confusion. He writes:

#1 If the theory of evolution was true, we should have discovered millions upon millions of transitional fossils that show the development of one species into another species. Instead, we have zero.”

Forgetting the lack of the subjunctive, the core problem with this statement is that it refers to “species” without putting that into context. We do have some evidence of species to species evolution, but not much. Most of the fossils we have demonstrate genus or higher level transitions. He is simply wrong that we should (given the state of the fossil record) have “millions” of fossils that are transitional at the species level. He never explains this either because he is confused on this fact, or he simply wants to create confusion.

Point #2 is simply that Darwin admitted there were no transitional fossils during his time – this is irrelevant since we have discovered numerous transitional forms in the last 150 years.

#3 Even some of the most famous evolutionists in the world acknowledge the complete absence of transitional fossils in the fossil record. For example, Dr. Colin Patterson, former senior paleontologist of the British Museum of Natural History and author of “Evolution” once wrote the following

“I fully agree with your comments about the lack of direct illustration of evolutionary transitions in my book. If I knew of any, fossil or living, I would certainly have included them …. I will lay it on the line – there is not one such fossil for which one could make a watertight argument.”

OK – this requires some explanation. Fortunately, Lionel Theunissen has already done so. First, the comments in question were made in 1979 (a fact Snyder does not disclose). Relying upon a 36 year old quote about the current state of the scientific evidence is always dubious.

From reading the full quote, and knowing that Patterson accepts evolution, it seems obvious that he was referring to the third point I discuss above – the difference between a transitional fossil representing the morphological (and I would add temporal and geographic) space between two groups and proving that a specific specimen is an actual ancestor. Theunissen suspected this also, and so he wrote a letter to Patterson asking him if this is the correct interpretation. Patterson replied:

“I think the continuation of the passage shows clearly that your interpretation (at the end of your letter) is correct, and the creationists’ is false.”

(Follow the link for the full letter.) It cannot be more clear than that. Patterson directly says that the creationist interpretation of his quote is false, and that he was only referring to the difference between being transitional and being an actual ancestor. Despite this iron-clad revelation, creationists continue to use this out-of-context quote, and even dispute Patterson’s own explanation of what he meant.

Of course, all of this is also a misdirection – it is not a discussion of the actual evidence of transitional fossils. It is a discussion about a quote from one scientist from 36 years ago and about what, exactly, they meant. I suspect part of the reason (other than misdirection) that creationists like this tactic is that they are used to citing a book as authority. So when they argue against evolution they follow their form, and make arguments from authority, specifically how to interpret a particular passage of the speech or writings of a scientist. Very telling.

In fact this form of misdirection is so common that TalkOrigins has a page dedicated to exposing creationist “quotemining.” On that page you will find Snyders next two examples.

Stephen Jay Gould, Professor of Geology and Paleontology at Harvard University, once wrote the following about the lack of transitional forms…

“The absence of fossil evidence for intermediary stages between major transitions in organic design, indeed our inability, even in our imagination, to construct functional intermediates in many cases, has been a persistent and nagging problem for gradualistic accounts of evolution.”

As talk origins explains:

“This is a rather unspectacularly predictable mined quote, as everyone who has had a few hours exposure to Gould’s writings on evolution can instantly see that he’s arguing against gradualism and probably in favor of punctuated equilibrium, a theory that he co-originated with Eldredge in 1972. Contrary to possible first impressions of the uninformed, Gould is presenting a problem FOR gradualist evolution, and countering WITH solutions to this apparent “problem” later in the paragraph.”

Gould and other scientists argue about gradualism vs punctuated equilibrium. Essentially this is a debate over whether or not the admitted gaps in the fossil record are an artifact of the spotty record or do they reflect the actual pace of evolution – long periods of stasis with rapid change in small populations?

Gould is not arguing against evolution, but against gradualism. This is a common denialist tactic – to confuse debate over the details as if it calls into question the bigger claims.

Snyder finishes this section with the following claim:

#6 If “evolution” was happening right now, there would be millions of creatures out there with partially developed features and organs.  But instead there are none.

This is the crocoduck gambit. In fact evolution does not predict the existence of “partially formed features and organs.” Rather, each form is complete for what it is.

To use a technological analogy, Snyder would have you believe that in the 1700s farmers were dragging half-constructed modern tractors behind their horses, or that the absence of such half-built tractors in the 1700s means that modern farming sprung up whole without any antecedents. Rather, pre-industrial farmers were using fully formed (but far simpler) plows.

Likewise, the predecessors to any modern biological structure were not partly formed, but were a fully formed something else. Creationists never seem to get this simple evolutionary concept. The entire pseudoscience of “irreducible complexity” is built upon this misunderstanding.


Snyder is an aggressive creationist whose writing is dripping in equal measures with condescension and abject ignorance, with a heavy helping of intellectual sloppiness and/or dishonesty (it can be sometimes difficult to tell the difference, but it doesn’t really matter).

He is raising no new points – no points that have not already been demolished long ago. This is because creationists have no new points. They also have no evidence or science on their side.

Evolutionary science, meanwhile, continues to progress nicely. The gaps in the fossil record are slowly being filled in. Recent finds show transitions in turtle evolution, for example. What evolutionary theory predicts is that we would find fossils that fit into a coherent evolutionary history of life on earth, with nestled hierarchies of related creatures. That is exactly what we find.

The pace and tempo of evolution is a detail. Creationists exploit both limitations of our understanding of tiny details, and scientists debating over these details, as if they refute or call into question the massive evidence for the big picture – that all life on earth is the result of common descent.


Categories: Medicine

Donald Trump and the dangerous vaccine politics of the 2016 Presidential race

Science Based Medicine - Mon, 09/21/2015 - 03:00

I’ve been writing about vaccines and the antivaccine movement since the turn of the millennium, first in discussion forums on Usenet, then, beginning in 2004, on my first blog (a.k.a. the still existing not-so-super-secret other blog), and finally right here on Science-Based Medicine (SBM) since 2008. Vaccines are one of the most important, if not the most important, topics on a blog like this because (1) arguably no medical intervention has prevented more deaths and suffering throughout history than vaccines; (2) few medical interventions are as safe and effective as vaccines; and (3) there is a vocal and sometimes effective contingent of people who don’t believe (1) and (2), blaming vaccines for all sorts of diseases and conditions to which science, despite many years of study, has failed to link them. The most prominent condition falsely linked to vaccines is, of course, autism, but over the years I’ve written about a host of others, including sudden infant death syndrome, shaken baby syndrome, autoimmune diseases, and even cancer. In a similar vein, antivaccine activists will try to claim that vaccines are loaded with “toxins” or even tainted with fetal “parts” or cells because some vaccines’ manufacturing process involves growing virus in two cell lines that were derived from aborted fetuses many decades ago. Even the Catholic Church doesn’t say that Catholics shouldn’t use these vaccines, but that doesn’t prevent some antivaccine groups from portraying vaccines as virtually being made by scientists cackling evilly as they grind up aborted fetuses to make vaccines. (I exaggerate, but not my much.)

On a strictly scientific, medical level, antivaccine claims such as the ones described above are fringe, crank viewpoints. There is no serious scientific support for any of them and lots of scientific evidence against them, particularly the most persistent myth, namely that vaccines cause autism. It also used to be the case that, politically, antivaccine views tended to be those of the fringe. Unfortunately, in the current election cycle, those fringe views seem to be coming to the fore among prominent candidates for the Republican Presidential nomination, when Donald Trump spewed antivaccine tropes and neither of the two physicians also running for the Republican nomination mounted a vigorous defense of vaccines. Even candidates who have previously issued strong statements defending vaccines (Senator Marco Rubio and Louisiana Governor Bobby Jindal) remained silent.

(Video of the exchange can be found here.)

How did we get to this point? And why is it that antivaccine views, which in the past were stereotypically associated with crunchy lefties in the mind of the public, seem now to have also found a comfortable home among small government conservatives, including the man who currently appears to be the frontrunner for the Republican nomination? In the days that followed the debate, there have been many discussions of Donald Trump’s antivaccine views, but none that take the long view, none. All seem to flow from the idea that it’s mainly just Donald Trump and his wacky views, rather than Trump being part of a more widespread phenomenon. I’ve frequently said that antivaccine beliefs tend to be the pseudoscience that knows no political boundaries, occurring with roughly equal frequency on the left and the right. However, it’s virtually inarguable that right now, in 2015, the most prominent politicians expressing antivaccine views (or antivaccine-sympathetic views) are Republicans. Yes, Robert F. Kennedy, Jr. is back in a big way, partying like it’s 1999 with Bill Maher over thimerosal-containing vaccines and autism, but neither he nor Bill Maher holds public office or is currently running for office. The uber-liberal website The Huffington Post might have been promoting antivaccine propaganda since its inception, but its writers are not running for office, either.

Antivaccine politics over recent years

When I first started blogging, arguably the most prominent politician expressing strong antivaccine views (while claiming, of course, that he was for “vaccine safety”) was Representative Dan Burton (R-IN). Back in the day, as chair of the House Committee on Oversight and Government Reform, Burton regularly used to hold hearings designed to “investigate” links between vaccines and autism. Usually this involved dragging CDC officials in front of his committee to harangue them about what they were doing to investigate this nonexistent link. He interfered in other ways, as well. For instance, in 2000 he wrote a letter urging the director of the FDA to recall all thimerosal-containing vaccines. In 2007, tried to insert himself into the Autism Omnibus hearings on the side of the “vaccine-injured,” using typically awful antivaccine studies as his “evidence.” Until his retirement at the end of 2012, Burton maintained on his official House website a page that was a veritable cornucopia of antivaccine fear-mongering disguised as autism advocacy, a common misrepresentation, along with a blunt statment to the effect that “Based upon my own research, I believe that the mercury-based preservative thimerosal – contained in 7 of the 9 vaccines that my grandson received in one day shortly before he was diagnosed with autism – may have been a contributing cause of his condition.”

Burton was a Republican, and a true believer that vaccines (particularly thimerosal-containing vaccines) caused an “autism epidemic.” He, at least, is somewhat understandable for the same reasons that antivaccine beliefs in some parents of children with autism are understandable. He has a grandson with autism, and he confused correlation with causation with respect to vaccination and the onset of his grandson’s first symptoms of autism. More frequently, politicians tend to pander. Indeed, in the 2008 Presidential election campaign, three major candidates did just that. First, responding to a question from the mother of a boy with autism at a town hall meeting, John McCain was quoted thusly:

McCain said, per ABC News’ Bret Hovell, that “It’s indisputable that (autism) is on the rise amongst children, the question is what’s causing it. And we go back and forth and there’s strong evidence that indicates that it’s got to do with a preservative in vaccines.”

McCain said there’s “divided scientific opinion” on the matter, with “many on the other side that are credible scientists that are saying that’s not the cause of it.”

Yes, scientific opinion was about as “divided” on this issue as it is on whether creationism is a valid explanation for how the diversity of life on earth developed.

Sadly, it didn’t take long for both Hillary Clinton (who was still challenging Barack Obama for the Democratic nomination) and Barack Obama himself to issue statements that, while not as bad as McCains, were pretty bad. Both issued statements that were a mixture of vacuous politician-speak plus implicit agreement with for ideas that are pillars of the antivaccine movement, specifically claims that:

  • There is an autism “epidemic.” (Arguably, there is very likely not.)
  • There is a scientific controversy over whether vaccines cause autism. (There really isn’t; it’s a so-called manufactured controversy. There is no good evidence that vaccines cause autism. Multiple large epidemiological studies have failed to find even a hint of a convincing link.)
  • Vaccines are somehow unsafe or that children are “overvaccinated” and eceive too many vaccines. (Again, there is no good evidence that either of these is the case.)

As antivaccine “journalist” David Kirby crowed at the time:

Senator Hillary Clinton, in response to a questionnaire from the autism activist group A-CHAMP, wrote that she was “Committed to make investments to find the causes of autism, including possible environmental causes like vaccines.” And when asked if she would support a study of vaccinated vs. unvaccinated children, she said: “Yes. We don’t know what, if any, kind of link there is between vaccines and autism – but we should find out.”

And now, yesterday, at a rally in Pennsylvania, Barack Obama had this rather surprising thing to say:

We’ve seen just a skyrocketing autism rate. Some people are suspicious that it’s connected to the vaccines. This person included. The science right now is inconclusive, but we have to research it.

(Note: The Washington Post reports that when Obama said “this person,” he pointed to someone who had asked an autism question).

So there you have it, our next President will share the views of such radical fringe crazies as, well, me, Democrat Robert Kennedy, Jr., Republican Joe Scarborough, former NIH and Red Cross chief Bernadine Healy, and several researchers at Harvard, Johns Hopkins, the Universities of California and Washington and elsewhere.

Of course, RFK, Jr. is a fringe crazy on the issue and has been ever since before he wrote his conspiracy-laden Deadly Immunity story for and Rolling Stone. On the issue of vaccines, so was Bernardine Healy, her having served as NIH director in the 1990s notwithstanding. As I said at the time, I realize that Clinton and Obama are politicians and that they didn’t want to anger the group that sent them the questionnaire. I also realize that politicians will pander. The problem is that pandering to antivaccine groups like A-CHAMP can have serious consequences.

After the 2008 election, there appeared to be less pandering to antivaccine groups by major politicians. Certainly, I don’t recall anything major during the 2012 Presidential election campaigns or either the 2010 or 2014 midterm elections. I strongly suspect that this was largely due to the epic discrediting in 2010 of one of the architect of the MMR scare, Andrew Wakefield, who in rapid succession in the course of a year was stripped of his UK medical license, saw his 1998 Lancet paper that started the scare retracted, forced to resign his position as medical director of the quack clinic he helped found, and saw highly convincing evidence of his fraud published by investigative journalist Brian Deer, who pithily referred to it as “Piltdown medicine.” As much as I would prefer that rejection of antivaccine beliefs were based on science and evidence alone, it is undeniable that the public discrediting and humiliation of Andrew Wakefield provided a handy shorthand for rebutting antivaccine beliefs by referring to his fraudulent research. Today, as we all know, except to committed antivaccine activists for whom he is “Nelson Mandela and Jesus Christ rolled up into one,” Andrew Wakefield is a joke, a punchline, a headliner on a “Conspira-Sea Cruise”—no, seriously, that’s what it’s really called!—so chock full of cranks, quacks, and conspiracy theorists that it must have taken considerable financial dispensation for Wakefield to swallow his pride and commingle with New World Order conspiracy theorists, crystal healers, HIV/AIDS denialists, and crop circle mavens.

Enter Donald Trump

If you were to peruse the front page of the antivaccine website Age of Autism, you’d rapidly find articles with titles like an article by AoA founder J.B. Handley entitled Trumps Stands with my Son, I Stand with Trump, in which Handley declares, “Donald Trump is the best thing that has happened to our kids in a very long time and I hope we can all lay down our issues and stand with him.” Other enthusiastic articles include ones by Dan Olmsted exulting how Vaccine Injury Gets an Audience and, as a “granola-cruncher,” praising Trump for “embracing our issues.” In fairness, not all AoA denizens were so impressed, with Dan Burns, who after attending a Trump rally expressed genuine and appropriate concern at Trump’s dark “us versus them,” “winners versus losers” rhetoric.

The first time I learned of Donald Trump’s antivaccine proclivities was way back in 2007 after he spoke at an Autism Speaks fundraising event. What was he saying back then? This:

“When I was growing up, autism wasn’t really a factor,” Trump said. “And now all of a sudden, it’s an epidemic. Everybody has their theory. My theory, and I study it because I have young children, my theory is the shots. We’ve giving these massive injections at one time, and I really think it does something to the children.”


“When a little baby that weighs 20 pounds and 30 pounds gets pumped with 10 and 20 shots at one time, with one injection that’s a giant injection, I personally think that has something to do with it. Now there’s a group that agrees with that and there’s a group that doesn’t agree with that.”

Referring to his and his wife Melania’s 22-month-old son Baron, Trump continued: “What we’ve done with Baron, we’ve taken him on a very slow process. He gets one shot at a time then we wait a few months and give him another shot, the old-fashioned way. But today they pump the children with so much at a very young age. We do it on a very, very conservative level.”

So, yes, back in 2007, Trump was already parroting the antivaccine pseudoscience that at that time I had been deconstructing for seven years and blogging about for nearly three. It was a performance—and, let’s face it, everything Trump does in public is performance art, if you can call it that—that was brilliantly parodied at Autism News Beat as The art of the schlemiel. In any case, I’m hard pressed to come up with any time when a baby gets 10 or 20 shots at a time, and that’s even assuming that Trump was ignorantly conflating the number of diseases vaccinated against in combination vaccines with “shots.” For example, the DTaP vaccinates against diphtheria, tetanus, and pertussis, or three “shots,” to use Trump’s apparent parlance, and MMR vaccinates against measles, mumps, and rubella, or three more “shots.” That’s six, so far, but in only two real shots. You get the idea. Trump seems to think that each vaccine in combo vaccines is a single shot, or at least he talks as though that’s what he believes. I use the present tense, because he’s still doing it, and this 2007 interview was just the first example of which I’m aware in which he did that.

Four years later, Trump was still at it. On Fox and Friends, he repeated once again that he had a “theory” about vaccines, and that was:

In a Monday interview on Fox News, the reality star explained that a series of casual observations had led him to the conclusion that “monster” vaccinations cause autism.

“I’ve gotten to be pretty familiar with the subject,” Trump said. “You know, I have a theory — and it’s a theory that some people believe in — and that’s the vaccinations. We never had anything like this. This is now an epidemic. It’s way, way up over the past 10 years. It’s way up over the past two years. And, you know, when you take a little baby that weighs like 12 pounds into a doctor’s office and they pump them with many, many simultaneous vaccinations — I’m all for vaccinations, but I think when you add all of these vaccinations together and then two months later the baby is so different then lots of different things have happened. I really — I’ve known cases.”

The video can still be viewed here.

Tellingly, when he was challenged on this by Gretchen Carlson, who noted that “the studies have said that there is no link” and that there hadn’t been any mercury in vaccines for years, Trump would have none of it:

“It happened to somebody that worked for me recently,” he added. “I mean, they had this beautiful child, not a problem in the world, and all of the sudden they go in and they get this monster shot. You ever see the size of it? It’s like they’re pumping in — you know, it’s terrible, the amount. And they pump this in to this little body and then all of the sudden the child is different a month later. I strongly believe that’s it.”

All because of what Donald Trump calls a “monster shot.” This is what those of us who pay attention to these things refer to as the “too many too soon” gambit. All spreading out vaccines accomplishes is to increase the period of time that a child is vulnerable to infectious diseases for no real benefit of reducing the chance of autism because there is no link between vaccines and autism.

More recently, Trump has become a Twitter sensation, with over 4 million followers, where he has expressed similar ideas. Here is but a sampling:

Massive combined inoculations to small children is the cause for big increase in autism….

— Donald J. Trump (@realDonaldTrump) August 23, 2012


If I were President I would push for proper vaccinations but would not allow one time massive shots that a small child cannot take – AUTISM.

— Donald J. Trump (@realDonaldTrump) March 27, 2014


Healthy young child goes to doctor, gets pumped with massive shot of many vaccines, doesn't feel good and changes – AUTISM. Many such cases!

— Donald J. Trump (@realDonaldTrump) March 28, 2014


No more massive injections. Tiny children are not horses—one vaccine at a time, over time.

— Donald J. Trump (@realDonaldTrump) September 3, 2014


I am being proven right about massive vaccinations—the doctors lied. Save our children & their future.

— Donald J. Trump (@realDonaldTrump) September 3, 2014


I'm not against vaccinations for your children, I'm against them in 1 massive dose.Spread them out over a period of time & autism will drop!

— Donald J. Trump (@realDonaldTrump) September 4, 2014


So many people who have children with autism have thanked me—amazing response. They know far better than fudged up reports!

— Donald J. Trump (@realDonaldTrump) September 4, 2014


You get the idea.

Basically, like Robert F. Kennedy, Jr., Donald Trump subscribes to a notion that has been massively discredited from a scientific standpoint. Mercury in vaccines does not cause autism. I realize that criticizing Donald Trump for being an antiscience idiot is rather akin to criticizing water for being wet or Donald Trump’s hair for having a life of its own—particularly when he’s preoccupied with real science.

This time it’s different, though.

In all the times before, Donald Trump was nothing more than a billionaire with a flair for reality TV and self-aggrandizement. True, in 2012 he did flirt with running for President but never actually went through with it to the extent that he has this time. Now, he’s been the top of the polls in the race for the Republican Presidential nomination for weeks. Now that he’s gotten this far, not surprisingly public health advocates are worried, given this sort of rhetoric Trump trotted out in response to a question by conservative radio talk show host Hugh Hewitt:

HH: If a group of scientists came to you and said look, The Donald, that’s just, that’s not right, you’re giving out misinformation, would you change your mind if presented with facts on that?

DT: Well, I’ve seen babies that were totally healthy that weren’t healthy, and I’m not asking for anything. All I’m doing is saying spread it out over a period of time. I’m not saying don’t get inoculated, don’t get the shots, don’t get the vaccines. I’m saying spread it out over a period of time. It doesn’t hurt anybody other than probably the pharmaceutical companies, because they probably make more money putting it into one shot. Maybe it hurts the doctors. I don’t know. But I can say this. Everybody would get the vaccines. They just, they wouldn’t be pumping these massive amounts of liquid into a child.

As you can see, although Trump has changed his positions on several issues over the years there is one issue about which he has been remarkably consistent, and that’s his belief that vaccines cause autism. He’s been just as consistent as characterizing vaccine shots as “monster shots” with a “massive shot of fluid” that do something to babies to cause autism. Of course, most vaccines are in 0.5 ml to 1.0 ml per dose (for comparison, one ounce is 30 ml), which is not a lot, even for a newborn, but Trump makes it sound as though babies receive gallons of fluid toxic with each round of vaccines, enough to overload them with…something.

Vaccines at the Republican debate

It’s almost unnecessary for me to quote what Trump said about vaccines in the second Republican debate last Wednesday because it was virtually identical to what he’s been saying about vaccines since at least 2007 if not before. Still, it’s useful to set up the context. The question that provoked The Donald’s repetition of his oft-repeated antivaccine tropes from the last eight years was not actually directed at him. After making a reference to the measles outbreak that started at Disneyland earlier this year, moderator Jake Tapper actually asked Ben Carson this question: “Dr. Carson, Donald Trump has publicly and repeatedly linked vaccines—childhood vaccines—to autism, which, as you know, the medical community adamantly disputes. You’re a pediatric neurosurgeon. Should Mr. Trump stop saying this?”

It was obvious that Tapper was trying to provoke an argument between Trump and Dr. Carson. Otherwise, he would have just asked Trump directly about his previous statements about vaccines and autism. It was a golden opportunity for Dr. Carson to defend vaccines, given that earlier this year, Dr. Carson had been quoted strongly defending school vaccine mandates:

“Although I strongly believe in individual rights and the rights of parents to raise their children as they see fit, I also recognize that public health and public safety are extremely important in our society,” Carson, a retired pediatric neurosurgeon, told The Hill in a statement.

“Certain communicable diseases have been largely eradicated by immunization policies in this country and we should not allow those diseases to return by foregoing safe immunization programs, for philosophical, religious or other reasons when we have the means to eradicate them,” he added.

That’s right. Back in February, Dr. Carson opposed religious and personal belief exemptions to vaccine mandates. Last winter, he published an extensive statement in which, while acknowledging the issue of personal freedom, nonetheless came down on the side of vaccine mandates, stating

I am very much in favor of parental rights for certain types of things. I am in favor of you and I having the freedom to drive a car. But do we have a right to drive without wearing our seat belts? Do we have a right to text while we are driving? Studies have demonstrated that those are dangerous things to do, so it becomes a public safety issue. You have to be able to separate our rights versus the rights of the society in which we live, because we are all in this thing together. We have to be cognizant of other people around us and we must always bear in mind the safety of the population. That is key and that is one of the responsibilities of government.

I am a small-government person, and I greatly oppose government intrusion into everything. Still, it is essential that we distinguish between those things that are important and those things that are just intruding upon our basic privacy. Whether to participate in childhood immunizations would be an individual choice if individuals were the only ones affected, but as previously mentioned, our children are part of our larger community. None of us live in isolation. Your decision does not affect only you — it also affects your fellow Americans.

This was an eminently reasonable position, acknowledging the balance between individual rights and how they can be constrained when an individual’s choices affect other people. Now, fast forward to September and Carson’s response to Tapper’s question:

Well, let me put it this way. There has — there have been numerous studies, and they have not demonstrated that there is any correlation between vaccinations and autism… This was something that was spread widely 15 or 20 years ago and it has not been adequately, you know, revealed to the public what’s actually going on…

This was technically correct. Tepid, but technically correct, although I don’t know what the heck Carson meant about “this” not having been “adequately revealed to the public what’s actually going on.” It’s not as though it hasn’t been widely publicized that science does not support the claim that vaccines cause autism and that Andrew Wakefield’s research was fraudulent. Then, whether it’s because he didn’t want to attack Trump or didn’t want to upset the Republican base (perhaps both) Carson went to undermine what he just said:

Vaccines are very important. Certain ones. The ones that would prevent death or crippling. There are others, there are a multitude of vaccines which probably don’t fit in that category, and there should be some discretion in those cases.

First of all, as Tara Haelle pointed out, all the vaccines on the current CDC schedule prevent death and severe morbidity. Which ones does Dr. Carson consider “discretionary”? I’d love to hear his answer. Later, after Trump once again channeled Jenny McCarthy and her “too many too soon” misinformation, in which it is claimed that children are receiving too many vaccines at too high a dose at too young an age (or, as Trump has put it, “monster shots”) and it is advocated that vaccines be delayed and spread out, Carson actually bought into this antivaccine gambit, saying, “But it is true that we are probably giving way too many in too short a period of time, and a lot of pediatricians now recognize that and, I think, are cutting down on the number and the proximity in which those are done.” The only pediatricians who “recognize that” are antivaccine pediatricians like “Dr. Bob” Sears and antivaccine-sympathetic pediatricians like Dr. Jay Gordon. Delaying and spreading out vaccines just prolongs the time when children are susceptible to vaccine-preventable diseases without any benefit.

Basically, Dr. Carson flubbed a chance to hit a home run defending vaccines. Whether it was his fear of Trump or his fear of his own base, he equivocated, parroted one antivaccine talking point (“too many too soon”) and in the end refused to tell Trump to his face to stop spewing antivaccine misinformation. It was an epic fail.

The Disneyland measles outbreak versus “parental rights”

Why did Ben Carson fail? Why did Carson flip-flop so blatantly, given his strong past support for vaccines? From my perspective, the answer comes from one other statement Dr. Carson made during his response to Tapper:

But, you know, a lot of this is—is—is pushed by big government. And I think that’s one of the things that people so vehemently want to get rid of, big government.

Bingo! If you want to know why antivaccinationism has found another home among small government conservatives and why neither of the two physicians (Ben Carson and Rand Paul) standing on the stage with Donald Trump was willing to tell him in no uncertain terms that he should stop spreading misinformation about vaccines, there you have it right there. It’s the distrust of government. Vaccine mandates come from government, and resistance to vaccine mandates resonates strongly among the Republican base. Antivaccine views are relatively uncommon, regardless of politics, but the concept of “health freedom” provides a banner that antivaccinationists can wave that will draw support from small government conservatives. Thus, freedom from vaccine mandates becomes conflated with “freedom.”

All of this might have remained fairly quiescent, lurking under the surface in Republican politics but not bubbling up, were it not for two factors: The Disneyland measles outbreak and, of course, Donald Trump. Given the concern over pockets of low vaccine uptake, mostly in affluent areas, California had been for years trying to tighten up its requirements for exemptions from school vaccine mandates. California Bill AB 2109, for example, was passed a couple of years ago and required parents seeking personal belief exemptions to school vaccine mandates to be counseled by a physician or certain other allied health professionals about the risks of leaving their child unvaccinated. The idea was to make it just a bit more difficult than signing a sheet of paper for parents to claim a personal belief exemption. Unfortunately, Governor Jerry Brown, no conservative he, neutered the law by adding a signing statement requiring the California Department of Public Health to allow parents claiming a religious exemption simply to sign the form without a physician’s signature.

Then came the Disneyland measles outbreak.

Alarmed at this outbreak, California Senators Richard Pan (D-Sacramento) and Ben Allen (D-Santa Monica) introduced SB 277, a bill designed to eliminate all non-medical exemptions. When it was first introduced, I didn’t think it had a prayer of passing. This was, after all, California, home to many antivaccine celebrities and pediatricians, not to mention entitled affluent elites who don’t think their children are vulnerable to vaccine-preventable disease. Yet pass it did this summer. It is now law.

There’s no doubt that the Disneyland measles outbreak produced a seismic shift in attitudes toward vaccine mandates, but it also had the unintended and potentially damaging effect of recasting the question of school vaccine mandates as an issue of “freedom” and big government such that what happened in the Republican debate and what various Republicans have been saying about vaccine mandates have taken a disturbing turn. For instance, at the debate itself, Rand Paul was asked to respond to Trump, and this is what he said:

…So I’m all for vaccines. But I’m also for freedom. I’m also a little concerned about how they’re bunched up. My kids had all of their vaccines, and even if the science doesn’t say bunching them up is a problem, I ought to have the right to spread out my vaccines out a little bit at the very least.

Earlier this year, Rand Paul got in a very testy exchange with an CNBC reporter (only the first 2:20 min are about vaccines):

Notice how sarcastically Paul starts out, sneering, “I guess being for freedom would be really unusual.” Personally, I think Paul’s most telling remark comes near the end of the vaccine segment, when, clearly irritated by the reporter’s insistence on pursuing questions about vaccine choice, Rand Paul replies with petulant annoyance, “The state doesn’t own the children. Parents own the children, and it is an issue of freedom.” See what Rand Paul let slip? It’s an attitude that is all too common, namely that the parents own the children and that parental “rights” trump any rights children might have as autonomous beings. The right of the child and any public health considerations are subsumed to parental “freedom to choose” and “parental rights,” with children viewed, in essence, as their parents’ property, to do with as they will.

As for the rest of the interview, it’s the same old antivaccine nonsense. There’s the antivaccine trope against the birth dose of hepatitis B vaccine as being not indicated because it’s a sexually transmitted disease, even though hepatitis B is transmitted by more than just sex. The trope is an obvious ploy to outrage parents by telling them that they’re being “forced” to have a vaccine for a sexually transmitted disease as though they were immoral. We also learn that Paul delayed vaccines for his children, thus leaving them vulnerable to childhood diseases longer than they needed to be, just like many vaccine averse. He even repeats his claim that vaccines cause neurologic injury, even though, as a physician, he should know damned well that this question has been studied time and time and time again, with the overwhelming scientific consensus being that vaccines do not cause autism, neurodevelopmental disorders, or “profound mental disorders.” And through it all, to Paul vaccine “choice” is all about “freedom.” I also think that he holds antivaccine views, but not to the same extent and depth (if you can call it that) as Donald Trump.

As a result of these sorts of attitudes, several of the Republican candidates express similar views on school vaccine mandates. New Jersey Governor Chris Christie, for instance, has sounded a lot like Ben Carson in advocating a “balanced” approach to vaccination in which “not every vaccine is created equal and “not every disease type is as great a public health threat as others.”

Meanwhile, Carly Fiorina believes:

No, I don’t believe the federal government should mandate immunizations. But I think that state governments can allow public schools to say that a child who hasn’t been immunized against an infectious disease that poses a public health risk can’t come to school. And of course there’s some immunizations that don’t have anything to do with public health. Not all immunizations are the same. There’s a big difference between an immunization for measles and HPV.

She repeated similar sentiments as recently as last month, along with ignorance in general about vaccines on the CDC schedule.

In any event, the federal government does not “mandate” school immunizations. The CDC simply publishes recommendations; it is individual states that decide which vaccines are required for school. But note how she’s sounding like Ben Carson as well in equivocating about some vaccines without actually stating which ones she’d support not making mandatory.

Again, in fairness, several of the Republicans come down strongly in support of school vaccine mandates, including Gov. Bobby Jindal, Sen. Marco Rubio, Sen. Ted Cruz, and Gov. Scott Walker. Unfortunately, the top two candidates at the time of the debate do not, and one of them (Trump) is a longtime antivaccine loon.

The politicization of school vaccine mandates?

Support for vaccination used to be a solidly bipartisan affair, with politicians of all political stripes strongly supporting it. To a large extent, it still is a solidly bipartisan affair, and that’s a good thing. For instance, in my own state, there was generally solid bipartisan support for a rule change similar to California AB 2109 requiring counseling by a local health worker for parents seeking personal belief exemptions, particularly from our Republican Governor Rick Snyder. However, the conflation of “personal freedom” and “parental rights” with the “right” to refuse vaccinations for one’s children by the antivaccine movement has been one of the most effective rhetorical tools wielded thus far by antivaccinationists, so much so that it has percolated its way up from below to affect the statements and positions of Republican Presidential candidates. I even find that my very own state senator, Patrick Colbeck, panders to antivaccinationists.

Donald Trump is antivaccine. Of that there is no doubt. Given his current popularity, his presence makes it easier for other candidates to mouth less extreme variants of the same nonsense that he does and appear “reasonable” by comparison. Unfortunately, however, over the last several years antivaccinationism has found a home among conservatives and libertarians such that when Ronald Bailey of wrote an article supporting vaccine mandates the backlash from his libertarian allies was swift and harsh. Meanwhile, antivaccine advocates like “Dr. Bob” Sears routinely invoke the same sort of language of “freedom” in opposing SB 277, even going so far as to liken vaccine mandates to Hitler’s fascism.

Partisan politics can never be eliminated completely from any issue of importance to society. It’s the nature of our government and society. However, certain issues have garnered a strong bipartisan consensus because of their extreme importance to society. Vaccination policy has traditionally been one of those issues. What worries me about the conflation of school vaccine mandates with “big government” and of personal belief exemptions to “freedom” and “parental rights” is that, in the current political climate, it threatens to undermine that bipartisan consensus by making support for vaccination mandates more a partisan issue than a public health one. If that happens, we’ll all suffer, starting with our children.

That‘s why the Republican debate scared me.

Categories: Medicine, Skepticism
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