One of the new realities of social media is that old news can be dredged up and spread around. In this way old memes can keep coming back to life like the Terminator, and we have to kill them over and over again.
The antivaccine crowd, for example, has their narrative of conspiracy and evil and their cherry-picked factoids to support their narrative. In their world vaccines don’t work and are all bad all the time, and only corporate evil and public malfeasance can support them. They scour the internet for anything to support their beliefs, and then splash it around as if it’s news.
In this case, they have resurrected a terrible survey from 1992. The survey was conducted in New Zealand by the Immunization Awareness Society. Unsurprisingly, when this anti-vaccine group surveyed their own anti-vaccine members, they found a higher incidence of disease among vaccinated children compared to unvaccinated children.
The Free Thought Project declares this to “prove without a doubt” that unvaccinated children are healthier. I don’t think they understand what the words “prove” or “doubt” mean.
Survey are, of course, highly problematic as scientific evidence. They are uncontrolled and subject to overwhelming confounding factors and bias. These can be minimized by being very rigorous in technique. No rigor is evident in this survey which relies upon a self-selected and biased population. We don’t even have access to the actual survey used, so really no conclusions can be drawn from the results.
By contrast, here is a published study that gathered information on over 17,000 subjects (compared to several hundred in the above survey), using a representative population, with full details disclosed. They found that the only health difference between vaccinated and unvaccinated children is that unvaccinated children had more vaccine-preventable diseases. That’s it. The study, however, only looked at allergies and other infections, but increases in allergies and infections is part of the anti-vaccine claim.
The second study quoted in the Free Thought article is also a survey, conducted by a German homeopath. Orac already deconstructed this survey, but here are the highlights: This is an online voluntary survey, so a self-selective group. Almost all respondents report that they use homeopaths, naturopaths, or chiropractors as their doctors and favor alternative medicine over mainstream medicine. There is no control group – the survey is just for the “completely unvaccinated.”
On other words – this survey is entirely worthless as scientific evidence. Also, ironically, the data shows an autism rate that is in line with the background rate in the general population. So even this crappy data cannot be used to argue for an association between vaccines and autism.
It is very telling that anti-vaccine groups and alternative medicine sites consistently reference terrible studies in support of their position. The two surveys discussed above are essentially worthless, yet they are touted endlessly by anti-vaccine sites, and I am sure we will see them turn up over and over again.
Scientific evidence is never perfect, especially in a messy area like medicine. The best we can do is look objectively at all the available evidence and try to come to the most reliable conclusion we can.
If you have an agenda, however, there is always plenty of low-quality evidence to cherry pick. Unfortunately, it takes work and some familiarity with the research to recognize cherry picking for what it is.
Social media campaigns spreading lies and misinformation over and over again can therefore be effective, even when they rely upon outdated and terrible information.
All we can do on our end is to continue the game of whack-a-mole, and perhaps hope that the general public will become more critical and savvy over time.
I have argued that HIV treatment is one of the shining examples of the success of reductionist modern medicine. In three decades we went from knowing nothing about a new disease that was almost universally fatal over a few years, to having an extensive understanding of the disease and reducing it to a manageable chronic illness. We still have not created an effective vaccine, nor have we figured out how to cure the disease entirely, but those are both active research programs with promising results.
Recent developments show how sophisticated our technology is becoming. Researchers just published a safety study in the NEJM in which they took the white cells from patients with HIV, treated them to make them resistant to the virus, and then transfused them back into the patients. There was one serious infusion reaction, but otherwise the procedure seemed safe.
HIV enters T-cells (part of the immune system) by attaching to a coreceptor called CCR5. There are rare individuals who have a mutation in the CCR5 gene which makes them resistant to HIV, demonstrating how important the receptor is to the life cycle of HIV. Researchers at the Clinical Cell and Vaccine Production Facility at the University of Pennsylvania used used a zinc-finger nuclease (ZFN) to render the CCR5 gene permanently dysfunctional in the T-cells taken from the patients, and then transfused the cells (about 10 billion of them) back into the patients.
They report that 11-28% of the T-cells were modified by the ZFN. The mean half life of the treated T-cells was 48 weeks, which was longer than for untreated T-cells. While this was primarily a safety and proof of concept study, they did follow some HIV parameters, and report:
“HIV RNA became undetectable in one of four patients who could be evaluated. The blood level of HIV DNA decreased in most patients.”
Again – this is a preliminary study, not a definitive clinical trial. If all goes well it will still take years to develop this technique as a treatment. Also, as is, this is not a cure, but rather another weapon against HIV. It will also be a highly expensive treatment.
The hope is that with this treatment patients with HIV may be able to forgo medications for several years. This will offset the cost of the treatment, and may even make it cost effective. Perhaps combined with medication it may also reduce viral loads more quickly and thoroughly in the early stages of treatment, further reducing morbidity of the disease.
What’s most exciting to me is that this is an entirely new approach to HIV instead of using drugs. The researchers essentially altered the gene function in the T-cells of the patients in order to make those T-cells resistant to HIV. It is also an important proof of concept in terms of the role of the CCR5 receptor, although this has also been demonstrated by previous research.
This suggests the plausibility of using gene therapy to treat HIV. The technology of altering the genes of a human subject has proven, unfortunately, very challenging. Significant safety issues remain, keeping the treatment experimental for now. If, however, we can overcome the safety issues (such as runaway viral infections caused by the viral vectors used to transplant the genes), a world of options opens up.
One of those options could be transplanting variant genes for CCR5 that are resistant to HIV infection, essentially rendering subjects immune to HIV.
It’s exciting to talk about the potential of future technology, but also always highly speculative. Twenty years ago we thought we were on the brink of gene therapy, and there was the general sense that we would have been much further along by now, but reality proved more challenging. There is also the general tendency to overestimate short term scientific advance (benefits of the genome project, stem cell therapy, brain-machine interface, and gene therapy, for example). But also there is the tendency to underestimate long term progress. It may take 20 years longer than we thought, but the eventual benefits of such technologies may end up exceeding expectations. What we can’t predict is which technologies will pan out, and which ones will stall or turn into dead ends.
There is another recent science news item relating to HIV that is quite exciting. About a year ago it was reported that a child born with HIV from her mother was HIV free after receiving high dose anti-retroviral medication shortly after birth. This was presented as a cure of HIV (reasonably so). Now the same researcher reports the apparent cure of a second child with the same technique, high dose medication administered shortly after birth. The technique still needs to be researched for safety and efficacy, but if it pans out it may become routine to cure infants born with HIV.
One of the challenges of being a science communicator is balancing enthusiasm and the “gee-whiz” excitement of new scientific developments, with a cold and sober assessment of the current limitations of what we know and what we can do. This is the “cautious exuberance” approach applied to science reporting. We want people to be excited by science, but to also know where the line is between science and science fiction.
In the case of HIV science and treatment, however, I think the public does not generally appreciate how much of a science success story this is. This is a case where advances exceeded our cautious predictions. I would not have thought earlier in my medical career that at this time patients with HIV would have essentially a normal life expectancy and that we would be dabbling with outright cures.
A new article published in PNAS warns of, Increasing homogeneity in global food supplies and the implications for food security. They reviewed crop production worldwide over the last 50 years and found that:
“The increase in homogeneity worldwide portends the establishment of a global standard food supply, which is relatively species-rich in regard to measured crops at the national level, but species-poor globally.”
In other words, there has been a globalization of crop production, with more nations looking very similar to each other in terms of which crops they grow in what amounts. This has caused a shift to the major energy-dense crops (wheat, corn, rice, potatoes, and sugar) and a relative reduction in more nutrient dense foods. At the national level, species diversity remains high. However local varieties around the world are being displaced by the same energy dense crops internationally.
This has allowed countries around the world to increase their calorie production to help feed a growing human population. However, the trend also raises several concerns discussed by the authors.
One major concern is monoculture – the growing of a great deal of a limited number of varieties of crops. Crops that are ideal in terms of being profitable for farmers, convenient to grow with good yields, good store-shelf appeal, and long shelf life (which allows them to be transported a greater distance) have been favored. Since these traits have been prioritized, other traits have suffered, such as nutrient density, for example. These ideal crops have displaced to some degree local varieties. With the globalization of this process, local varieties around the world are being displaced by a small number of ideal crops.
One major problem of having our food supply increasingly dependent world wide on a smaller number of crops is that of vulnerability to crop failure due to pathogens or other disasters. One blight can wipe out a larger and larger segment of one year’s crop.
The authors are also concerned about the loss of genetic diversity as a source for future breeding of crops. Genetic diversity comes not just from having a wide variety of species and cultivars, but in planting them in sufficient amounts so that further diversity can develop.
One hedge against this problem is the so-called “doomsday vault.” So far the seeds of more than 20,000 species have been sent to this arctic vault to be frozen and preserved in case of emergency. The purpose of this vault is to preserve genetic diversity and ancestral forms as a stock of genetic material for breeding in the future.
The authors also worn about the health effects of having a food supply increasingly dependent on energy-dense rather than nutrition-dense foods. This problem is harder to quantify and connect the dots. The problems of obesity are more complex than just the availability of energy-dense food. Also, at the national level diversity remains high enough to provide varied nutrition, it’s mainly at the international level that diversity has been decreasing. In fact the globalization of the food supply allows for access to a greater variety of fruits and vegetables year round. I’m not saying they don’t have a point, but I don’t think we can make a straight connection between the data in this study and issues of obesity and nutrition.
The authors provide interesting data on the changes of global crop production, documenting what many have suspected – that our food supply is globalizing at the expense of local varieties. I don’t think it is practical to simply reverse this trend by asking farmers not to plant the most productive crops in favor of less productive local varieties. Rather, we need to balance the various demands of our global food production.
It does seem that we need to raise the priority of species diversity in our crops. Market forces seem to be pushing in the directions of increased monoculture and decreased global diversity. There does also appear to be a strong niche market, at least in wealthy countries, for heirloom varieties and other local novelty varieties. This is not enough, however, to offset the risks of major crop failure if a pathogen hit one of the major staple crops.
It is, of course, easier to point out problems than propose solutions. I am not sure what the best solutions would be, and I leave it to the experts to propose fixes. Perhaps incentivising farmers to add more diversity to their staple crops, or perhaps seed breeders to offer greater diversity. These kinds of solutions are always tricky because of the law of unintended consequences. How much would this raise food prices, for example? Any solution is likely to have negative trade-offs, but it seems that our future crop security is worth exploring which trade-offs would be worth making.
Five years ago I wrote a blog post about the product, Your Baby Can Read. I concluded:
While the background concepts are quite interesting, the bottom line is that we have another product being marketed to the public with amazing claims and no rigorous scientific evidence to back them up. This product also falls into the broader category of gimmicky products claiming to make children smarter or more successful academically.
Anxious parents wanting to give their kids every advantage is a great marketing demographic, in that they are easily exploited. But like all gimmicky schemes promising easy answers to complex or difficult problems (weight loss, relationships, or academic success) in the end it is likely to be nothing but a costly distraction from more common sense approaches – like just spending quality time with your kids and giving them a rich and safe environment. What such products often really provide is a false sense of control.
The comments quickly filled with parents who had used the system, which claims to teach even infants how to read, saying that the system worked for them.
I often write about products with claims that are not adequately backed by scientific data. Sometimes there is evidence that the product does not work. Other times there isn’t any research, or the scant research is insufficient to settle the question directly. I can always explore the plausibility of the claims, but without evidence I am left to say that - the claims are not backed by evidence. This is often misinterpreted as me saying that the product does not work, usually followed by attempts to shift the burden of proof to me to prove a claim I actually never made.
As an aside, I often encounter this flawed reasoning, and even catch myself falling into this trap on occasion. We tend to categorize people into various positions, often a false dichotomy. Either you are for or against something. People will then assume that you hold the typical suite of positions held by whichever side they identify you with. This leads to them arguing against your perceived side, rather than your actual position and arguments. The result is people talking past each other – duelling narratives, rather than actual engagement. (Just read the comments to this blog and you will quickly see what I mean.)
I try to be careful with my words, and particularly pay attention to nuances such as the difference between lack of evidence for efficacy and evidence of lack of efficacy. Further, even if I argue that a particular claim is not very plausible, that does not mean I am not open to new evidence. If the evidence clearly shows that it works, I can reassess the plausibility.
With Your Baby Can Read, the claims have a lowish plausibility, but are not crazy. The idea is to start with a whole-word approach to get young children to associate written words with pictures and sounds, and then move on to new words. Certainly children are capable of learning, and perhaps they can learn to read younger than is typical if given the chance.
But – their brains are also still developing. Infants and toddlers develop at their own pace, and within a fairly broad range this is all normal and healthy. The rate at which children develop specific neurological abilities, like language, does not predict their ultimate ability. There is no evidence that you can force early neurological development. Children need enough stimulation to develop optimally, but giving them superstimulation will not, it seems, make them develop faster or better. Further, even if you could get them to develop certain skills ahead of schedule, this does not necessarily mean there will be any long term advantage. If you get your kids to read early they still may end up in exactly the same place at age 10.
Before making specific claims for a product, and before parents commit time, money, and energy to a teaching program for their children, these questions should be sorted out. Otherwise it seems far more likely that parents are going to waste precious time and energy on things that ultimately aren’t helpful.
All of these plausibility and practicality arguments, however, are ultimately not that satisfying. People just want to know – does it work? Now, five years after I wrote that first blog post on the topic, we finally have a direct study looking to see if such reading programs work. Here is the abstract:
Targeted to children as young as 3 months old, there is a growing number of baby media products that claim to teach babies to read. This randomized controlled trial was designed to examine this claim by investigating the effects of a best-selling baby media product on reading development. One hundred and seventeen infants, ages 9 to 18 months, were randomly assigned to treatment and control groups. Children in the treatment condition received the baby media product, which included DVDs, word and picture flashcards, and word books to be used daily over a 7-month period; children in the control condition, business as usual. Examining a 4-phase developmental model of reading, we examined both precursor skills (such as letter name, letter sound knowledge, print awareness, and decoding) and conventional reading (vocabulary and comprehension) using a series of eye-tracking tasks and standardized measures. Results indicated that babies did not learn to read using baby media, despite some parents displaying great confidence in the program’s effectiveness.
Senior author, Susan Neuman, is quoted as saying:
“It’s clear that parents have great confidence in the impact of these products on their children,” Neuman explains. “However, our study indicates this sentiment is misplaced.”
So the one clear effect of this program is to convince parents that it works, despite having no effect on actual reading ability. That does make for an effective marketing strategy, creating the illusion of efficacy, but does not appear to do much for the children.
Of course, one study is never definitive, but this study seems reasonably designed and powered. One study does not “prove” that early child reading programs do not work. What we can say is that what evidence we do have is negative. Combined with the dubious plausibility (although not impossible) this clearly puts the burden on anyone claiming such products do work to provide more and better evidence to back up that claim.
This study also showed that the parents of children who did not display any actual reading ability still had a firm belief that their children had learned to read. This is perhaps the hardest thing to confront as a scientific skeptic – the individual who has been convinced by their personal powerful experience (the, “it worked for me” argument). It takes a fairly extensive understanding of the various mechanisms of self-deception, what I call “neuropsychological humility,” before people will typically accept that their personal experience is misleading.
I get this. It would be incredibly destabilizing to have to confront, all at once, the unreliability of perception and memory and the profound effect of all the various biases in our cognition. Even just fully grasping the power of confirmation bias can be mind-blowing. When I tell a parent who is convinced that their child did not learn to read despite their direct experience that they did, I am not just asking them to surrender this one belief in the name of objective evidence, I am asking them to surrender the basis for how they make sense of reality, and replace it with an entirely different process.
When confronted in this way, the more common response is to maintain one’s belief, which involves rejecting the science. People will not only reject the specific science in the way of their belief, they will often reject science itself. The more they are confronted, the more they must recall and strengthen evidence and arguments that support their belief. The more scientific evidence is in the way, the more they have to reject science. If consensus is in the way, then they reject consensus. This can lead to increasingly bizarre conspiracy theories. The greater the evidence that opposes their belief, the larger the conspiracy must be. I, of course, as the messenger for the science, must be part of the conspiracy (manifesting as the shill gambit).
This is all part of motivated reasoning, and we encounter its full spectrum, from finding fault with a single study, to a full blown conspiracy and anti-science world view. To be clear, parents who falsely believe their children can read are on the very mild end of this spectrum. But the process is the same, and it’s important to understand such processes before they lead farther and farther down the rabbit hole.
Back in 2009 I wrote that companies that market products claiming to teach infants how to read did not have the science to back up their claims. Now I can add that a large and reasonably rigorous clinical trial finds absolutely no benefit from such programs, but do lead to the false belief among parents that their children did learn to read.
At the very least this should caution new parents against readily believing marketing hype about any “baby genius” product. As with many things, it is often better to cover the basics well than to spend lots of time and money on getting a perceived special edge. Spend time with your children, enjoy them, nurture them, bond with them – but don’t feel pressured into drilling them with lessons to make them develop faster or become super children. You’re just paying for motivated reasoning.
The “yoga mat chemical” (azodicarbonamide) is the latest food-based fearmongering, thanks to an unscientific petition by the self-described “food babe,” who apparently feels that she is qualified because she is a computer scientist. (Well, it has the word “science” in it.)
Unfortunately, the “yoga mat chemical” is an effective meme. Who wants to eat something that can be found in a yoga mat? Many journalists, such as Lindsay Abrams, have bought into the meme without any critical analysis. Abrams helpfully provides a list to her readers of “500 more foods containing the yoga mat chemical.”
Here are some other foods her readers might also want to reconsider:
This popular health food can also be found in industrial lubricants, solvents, cleaners, paints, inks adhesives and hydraulic fluid. It is burned as fuel. It is also used to make foam found in, “coolers, refrigerators, automotive interiors and even footwear.” It is used to make carpet backing and insulation.
But the worst part is – it is also used to make yoga mats.
This other “yoga mat” food is also known as soy. So think twice before eating that next tofu burger. (Hat tip to “Ziggy” for bringing up this example.)
The food babe also gives this helpful advice:
“When you look at the ingredients, if you can’t spell it or pronounce it, you probably shouldn’t eat it.”
Let’s see if we can apply this rule of thumb to help us decide what foods are likely to be healthy. Here are some lists of ingredients, see if you can pronounce them:
1- Oleic acid, Linoleic acid, Palmitic acid, Stearic acid, α-Linolenic acid, polyphenols, oleocanthal, oleuropein, aldehydic secoiridoids, flavonoids, acetoxypinoresinol, pinoresinol, hydroxytyrosol
2 – 2,3,5-TRIMETHYLPHENOL, 2-ETHYLPHENOL, 2-METHOXY-4-ETHYLPHENOL, 2,4-METHYLENEPHENOL, DICAFFEOYL-QUINIC ACID, 4-ETHYLPHENOL, 4-METHOXY-4-VINYLPHENOL, ACETALDEHYDE, CAFFEINE, CAFFEOL, CAFFEOYL-3-QUINIC ACID, CAFFETANNIC ACID, CHLOROGENIC ACID, CITRIC ACID, DATURIC ACID, GUAIACOL, HYPOXANTHINE, ISOCHLOROGENIC ACID, PUTRESCINE, SCOPOLETIN, SPERMIDINE, SPERMINE, SUGARS, TANNIC ACID, TANNIN, THEOBROMINE, THEOPHYLLINE, THIAMIN, TRIGONELLINE, XANTHINE
3 – Alpha-Linolenic-Acid, Asparagine, D-Categin, Isoqurctrin, Hyperoside, Ferulic-Acid, Farnesene, Neoxathin, Phosphatidyl-Choline, Reynoutrin, Sinapic-Acid, Caffeic-Acid, Chlorogenic-Acid, P-Hydroxy-Benzoic-Acid, P-Coumaric-Acid, Avicularin, Lutein, Quercitin, Rutin, Ursolic-Acid, Protocatechuic-Acid
I could go on, but you get the point. These are olive oil, coffee, and apples, respectively. Did you know that coffee has putrescine in it? You could, of course, go over each an every chemical ingredient and show that in high enough doses they are deadly toxins, they probably should’t be breathed in, and factory workers might be at risk if directly exposed to the purified or aerosolized form.
When confronted with my criticism that claiming that azodicarbonamide is linked to asthma in the context of a petition to remove it from bread is misleading, because it does not trigger or cause asthma when consumed, it is only a risk to factory workers breathing in the raw chemical, the food babe responded (I’m paraphrasing) – don’t those scientists care about the factory workers? Nice way to move the goalpost.
Of course we care about the safety of factory workers. If it were found that azodicarbonamide could not be safely used, then I would understand and favor its banning. However, industrial workers are potentially exposed to all sorts of harmful chemicals. That is why there are regulations to protect them – requiring proper ventilation, breathers, working under hoods, eye protection, and other safety measures. I also think we should put as much distance between workers and harmful chemicals as possible.
If one is going to make the case that azodicarbonamide should be banned because of its risk to workers, then we need more than just a study showing it is a mild asthma trigger. How is it handled? Are safety measures adequate? Are there any cases of actual harm? How does it compare to other things that workers are potentially exposed to? Many people have pointed out that flour itself is potentially very dangerous (the food babe has no problem with flour, cause it’s natural). Breathing in flour dust is very dangerous, probably more so than azodicarbonamide. Flour dust is flammable. There were 115 reported flour dust explosions between 1994 and 2003.
What the food babe is engaging in is fear mongering of “chemicals” and anything “unnatural.” This is not a rational or science-based position. Everything we eat is made of chemicals (many with long and difficult to pronounce names). Natural vs unnatural does not matter at all.
It is also misleading to think of some chemicals as “toxins.” This is a false dichotomy. Everything is potentially toxic depending on dose and route of administration. I agree that we need scientific evidence and regulations to keep human exposure to substances far below the level where there is any harm to health. I agree with the principle that we should err on the side of caution. I don’t think corporations should have free reign.
What we need is a rational science-based conversation about the evidence and how best to protect human health in our complex industrialized civilization. Fearmongering based on pseudoscience and logical fallacies that fosters a misunderstanding of the relevant science and seeks to replace an evidence-based process with populist movements that are the equivalent of angry mobs with torches and pitch forks, is not the answer.
Hawaii Senate Bill 2571, which is making its way through the legislature, would require that a large non-removable warning label be attached to the back of every cell phone. Originally the warning label was to read, “This device emits electromagnetic radiation, exposure to which may cause brain cancer. Users, especially children and pregnant women, should keep this device away from the head and body.” A revised version of the bill, however, changed the warning to, “To reduce exposure to radiation that may be hazardous to your health, please follow the enclosed product safety guidelines.”
This seems like an example of clear nanny-state overreach, but worse it is not based on science. According to reports every expert consulted by the relevant committees argued against the measure, but the legislators passed it anyway. The measure has one more committee to get through, and then it would go to the House for a vote.
As I have written before (see also here and here) there is no clear link between cell phone use and brain cancer. The plausibility of a link is low but not zero. Non-ionizing radiation is not energetic enough to break chemical bonds, and therefore should not cause DNA damage that could lead to cancer. However, an alternate physical mechanism cannot be ruled out, and biology is complicated, so I don’t think we can rule out a possible connection on theoretical grounds alone. We can just say it’s unlikely.
The National Cancer Institute summarizes the situation thusly:
It is generally accepted that damage to DNA is necessary for cancer to develop. However, radiofrequency energy, unlike ionizing radiation, does not cause DNA damage in cells, and it has not been found to cause cancer in animals or to enhance the cancer-causing effects of known chemical carcinogens in animals.
Epidemiological studies have been a little mixed, as is generally the case with this kind of evidence, but at this point the evidence is fairly solid that there is no link between cell phone use and brain cancer for exposure less than 10 years. The data for >10 years is less certain, but this is mostly because it takes more time to gather this data and we are just getting to the point that there is epidemiological evidence available for long exposures.
The NCI fact sheet also contains an excellent summary of all the relevant studies and the official opinions of various regulatory and health organizations. The bottom line is that there is no clear link. Epidemiological data cannot rule out a small connection, but it is reassuring when no clear signal is evident. This means, at worst, there is a small effect.
As is also often the case there are outliers. In this research I find one research group, Hardell and Carlberg, consistently find an association, at apparent odds with the rest of the scientific community. Some of their studies are also a little odd, like this one looking at brain cancer survival and cell phone use. The results are all over the place, and their choice of statistical analysis seems a bit arbitrary. In other words, the data gives off a whiff a p-hacking. Without consistent independent replication, I usually do not put much weight on such outliers.
One other type of evidence that is relevant is the incidence of new cases of brain cancer. If cell phone use is a significant cause of brain cancer, then we would expect the incidence to be going up over the last 20 years as cell phone use has skyrocketed. However, the incidence has been stable to slightly decreasing. In the last 10 years the incidence of brain and other nervous system cancers has decreased on average by 0.2% per year. This is pretty strong evidence against any significant cell phone effect.
Other types of cancers have also been investigated. A recent study from Denmark showed no association between cell phone use and skin cancer. A possible association between carrying cell phone in one’s bra and breast cancer made the rounds in the media, but this is based on a case series of four patients. This is the most preliminary type of evidence, and should only be used as an indication for further research.
The scientific evidence does not point to any cancer or other health risk from cell phone use (unless you text while driving). The International Agency for Research on Cancer, American Cancer Society, National Institute for Environmental Health Sciences, the FDA, CDC, and FCC have all concluded that there is no clear evidence of any risk, although the IARC considers non-ionizing radiation a “possible” carcinogen.
Despite this Hawaiian politicians feel they know better and that they need to warn the public with a giant sticker on the back of every cell phone. If anything the sticker should warn about the risk of texting or using a cell phone while driving. That is a proven risk.
The evidence does not seem to rise to the level that an intrusive warning is indicated. The unintended negative consequence of such labels is warning fatigue. If the public is constantly bombarded with warnings of marginal or just possible risk, they will tend not to take such warnings seriously. They become part of the background noise. Then, when a warning would be actually beneficial, it is lost in this noise.
In this case, politicians should listen to scientists. If only.
A recent column by political commenter, Charles Krauthammer, attacking the notion that global warming is “settled science,” has been getting a lot of attention. Although perhaps he is making a more nuanced argument than most global warming dissidents, Krauthammer is still largely attacking straw men and engaging in tactics of denial. Up front he says he is not a global warming denier nor a believer, but his arguments are certainly mainstream global warming denial.
“The debate is settled,” asserted propagandist in chief Barack Obama in his latest State of the Union address. “Climate change is a fact.” Really? There is nothing more anti-scientific than the very idea that science is settled, static, impervious to challenge.
To be fair, Krauthammer is talking about the politics of climate change as much as the science, and politicians often open the door to criticism by overstating the case or glossing over complexity and nuance. That does not, however, justify the same sloppiness by Krauthammer. The language above is virtually identical to that used by creationists to attack the position that evolution is a “settled fact” of science. Both arguments erect a straw man about what we mean by settled.
In both cases (evolution and climate change) there is a core scientific claim that is well-established, with less and less certain details about that basic fact. That life on earth is the product of evolution with common descent is established beyond all scientific doubt, sufficient to be treated as a fact. It would take a great deal of rock-solid evidence to push evolution from its scientific perch.
Likewise, that the earth is warming, and that this warming is at least partly due to forcing from human industrial activity, is now a well-established scientific fact. (I would not say it is as solid as evolution, but it’s north of 95% certain, which is comfortably in “fact” territory.)
Calling something an established scientific fact means that it is reasonable to proceed with that fact as a premise, for further research or for policy. It does not mean “static, impervious to challenge.” That is the straw man. Both evolution deniers and climate change deniers use this tactic to misinterpret scientific confidence as an anti-scientific resistance to new evidence or arguments. It isn’t. It does mean that the burden of proof has shifted to those opposing the theory that is now well-established (because it has already met a significant burden of proof).
Next is the confusion of the core facts with less certain implications or predictions:
If climate science is settled, why do its predictions keep changing? And how is it that the great physicist Freeman Dyson, who did some climate research in the late 1970s, thinks today’s climate-change Cassandras are hopelessly mistaken?
If evolution is settled science, then why are scientists always changing their construction of the tree of life, and why can’t they predict the future course of evolution? Same fallacy.
That the globe is, overall, warming due to forcing from increased greenhouse gasses is a highly confident conclusion. The exact implications of this are difficult to predict – how will local climates be affected, how will the ecosystem respond, what will the net effect be of the many feedback systems involved? Uncertainty about the details does not translate into uncertainty about the big picture – just like uncertainty about precise evolutionary relationships does not call into question the basic fact of evolution.
He continues with the “pause” gambit:
Settled? Even Britain’s national weather service concedes there’s been no change — delicately called a “pause” — in global temperature in 15 years. If even the raw data is recalcitrant, let alone the assumptions and underlying models, how settled is the science?
This is a partial fact used to deceive. This is similar to pointing to punctuated equilibrium and focusing on the periods of stability as if they are evidence against evolution (a favorite creationist tactic). Surface temperatures have indeed plateaued over the last 15 years – they have not “regressed to the mean” or behaved in a way that would indicate that there isn’t a real increase in global temperatures. They have remained at their historically high levels but have not continued to further increase at the pace they have been.
However, this is only looking at a subset of the data. The oceans have continued to warm, and scientists believe we are simply in a phase where most of the extra heat in the earth system is going into the oceans, rather than surface temperatures. You have to look at the whole picture, not just the slice that makes your point. Further, a recent study suggests that when the recent trade winds are taken into consideration, this accounts for the discrepancy between climate models and surface temperatures. I also don’t think we have fully answered this question – this is one of those details that will be complex to understand, and new data is likely to shed further light.
Krauthammer, however, is happy to rely upon the notion of a pause, which is so far from settled science it is not even true, rather than the far more robust data supporting the basic fact of climate change.
Accordingly, Obama ostentatiously visited drought-stricken California last Friday. Surprise! He blamed climate change.
OK – he has a point here. Politicians and the media are likely to discuss individual weather events in terms of their relationship to global climate change. This is certainly not scientific – we cannot know the relationship between any specific drought, hurricane, or weather pattern to the long term trend of global warming. Global warming deniers do this too, however, talking about any cold weather as it if calls into question long term climate trends.
But this is the popular abuse or misunderstanding of the science – it is not the science. Don’t confuse the two. In fact, if Krauthhammer had stuck to the point of political abuse of climate change, he could have had a reasonable column that did not stray into science denial.
He does acknowledge that the abuse of science does not invalidate the science, but then slides into another common trope:
None of this is dispositive. It doesn’t settle the issue. But that’s the point. It mocks the very notion of settled science, which is nothing but a crude attempt to silence critics and delegitimize debate. As does the term “denier” — an echo of Holocaust denial, contemptibly suggesting the malevolent rejection of an established historical truth.
I often use the term denial, as I have here, but it is not an attempt to poison the well by making an allusion to Holocaust denial. That is unfair. Rather it is based on an understanding of denialism as a cognitive strategy. I have been writing about denialism for almost 12 years - I have argued that it is an identifiable cognitive strategy with specific features in common. It is the use of tactics of doubt and confusion to attack accepted science. As I have demonstrated here, the tactics of evolution deniers and climate change deniers can be very similar. The same is true of mental illness deniers, vaccine or germ theory deniers, HIV deniers, and yes, Holocaust deniers.
Regarding silencing debate, there is missed nuance here as well. What I consider a legitimate position is to honestly and correctly characterize how confident and robust the scientific consensus is on any particular issue. For a highly robust consensus, minority or dissenting opinions have to be put into their proper context. They may not deserve a place in high-impact scientific journals, or in classrooms. Minority opinions should also not dominate the debate, nor should they be disproportionately represented in the media, because that creates a false impression about the science. Debate and media representation should reflect the consensus. If a 1% minority holds a different opinion, I have no problem with them getting 1% of the attention.
I would never shut out dissenting opinions entirely, and of course they always have the right to express their opinions in their own venues and whatever other venue will have them. But they do not deserve access to premium venues. No one does. That has to be earned by legitimacy.
Such criticisms also confuse quality control with censorship. Journals have standards. News outlets should also set their own standards. Classrooms have standards. Keeping out fringe or minority ideas, or putting them in their proper context and perspective, is not censorship.
But sure, some people miss this nuance and go too far. For example, some people have protested Krauthammer’s article and asked the Washington Post to pull it (which I think is an inappropriate tactic since his is an opinion column). He was then able to exploit this protest to argue that it makes his point.
Climate-change proponents have made their cause a matter of fealty and faith. For folks who pretend to be brave carriers of the scientific ethic, there’s more than a tinge of religion in their jeremiads.
This is just a low blow. The scientific community no more accepts climate change on faith than they do evolution (another common claim). Politicians, of course, always want to make unambiguous clear points. Academic discussions of probability and uncertainty do not play well in the political arena. This, then, opens the door to criticism, in this case portraying a robust scientific conclusion as if it were a tenet of faith. This criticism, ironically, is committing the same fallacy, however, of washing over nuance and complexity in order to make a solid political point.
Krauthammer’s piece, despite his initial protest, is a work of global warming denialism. He uses many of the strategies common to science denial (including denying denialism as a thing) in order to cast doubt on the robust consensus of global climate change. He confuses political posturing for the state of the science, he misrepresents the nature and implications of the “pause,” and he essentially attacks the weakest form of the opposing position.
He also misses a very important point – the true relationship between the science and the policy. Any effective policy that seeks to reduce the impact of manmade climate change will have to act decades before the full impacts are realized. If we are going to do anything, we have to act before we have scientific certainty.
Krauthammer is a physician, so he should understand this principle. In medicine we worry about the threshold of treatment, not the threshold of certainty about a diagnosis. We know there are many situations in which we need to begin treatment before we are certain what the patient has. We continue to keep an open mind, monitor response to treatment, perform more testing if indicated, but sometimes we just have to commit to treatment prior to certainty.
The same is true for climate change. The scientific consensus is that the globe is warming, it is highly probably due at least in part to manmade forcing. Even if we do act now, there will likely be unwanted consequences, although we cannot predict exactly what they will be.
I do not think we should dismantle our economy or take draconian steps that will harm society in a panicked rush to reduce carbon emissions. I do think we need to develop an energy infrastructure that is more sustainable, more efficient, and significantly reduces pollution in addition to carbon emissions. We should be looking for the win-wins, things that we should do anyway, even if there weren’t the issue of global warming. But let’s give this some priority, so we can protect ourselves from a highly probable threat.
This is not about certainty. It’s about probability. Just like all of science, and all of medicine – something Krauthammer should know.
Classification systems are important in science. They often reflect our fundamental understanding of nature, and are also important for efficient and unambiguous communication among scientists. But there is also an emotional aspect to the labels we attach to things.
Perhaps the most famous example of this from recent history is the “demoting” of Pluto from planet to dwarf planet in 2006. There was a great deal of hand wringing about this decision, which ultimate was based on a practical operational definition – a planet needs to be in orbit around the sun, be large enough to pull itself into a spherical shape, and have cleared out its orbital neighborhood. Pluto failed the third criterion, and so was reclassified a “dwarf planet.”
It is very telling that most news reports discussing the category change characterized it as “downgrading” or “demoting” Pluto. Clearly people felt that being a planet was more special or prestigious than being a dwarf planet. This is not unreasonable – planets are generally larger and have a more dominant presence in the solar system. There are currently 8 planets, and that number is now very unlikely to change. There are only 5 named dwarf planets, but that number can climb very high as new Kuiper belt objects are discovered and named.
Still, it is interesting that what should be a technical issue appealing to those who love the Dewey Decimal System became such an emotional controversy for the general public.
The classification of life is also a potentially controversial issue. A new article published in PLOS One proposes a new classification system which is sure to stir some controversy, but first some background. At present there are two classification systems in wide use. The classical Linnaean system is the one most people are familiar with – this is the binomial system labeling all species with a genus and species name (such as Homo sapiens for humans). This system is largely based on phenotypic analysis. It is a hierarchical system, so it does consider relationships among categories of life, but it is not strictly evolutionary (not surprising as it predates Darwin).
The newer system is called cladistics, a system that is based on phylogenetic analysis (evolutionary relationships). A cladistic group is based upon demonstrating features in common because they derive from the most recent common ancestor with that feature.
The two systems have their advantages and disadvantages, which is why they each have their proponents. The advantage of the cladistic system is that it updates our classification system to reflect the main organizing principle of biology, namely evolutionary theory. Understanding exactly where a species fits into the evolutionary tree is critical to understanding the species, and so we might as well classify them based upon this knowledge.
The Linnaean system looks, rather, at the morphology of a species – what it looks like. Of course this results in a system that loosely follows evolutionary relationship – reptiles and mammals, for example, are both Linnaean and cladistic groups. However, interesting differences do emerge. Birds, for example, are a class of vertebrates in the Linnaean system, alongside reptiles, mammals, fish, and amphibians. In the cladistic system, however, birds evolved from one branch of dinosaurs, so their clade is a branch off of one branch of dinosaurs. The Linnaean system considers how different birds are from reptiles (they have feathers, for example), while the cladistic system only considers last common ancestor.
There have been attempts to reconcile the two systems, but they have not worked (at least they have not resulted in anything that is generally accepted). Palaeos summarizes the situation:
Summing up: both Evolutionary/Linnaean and Phylogenetic/Cladistic schemes are complementary rather than exclusive, and both are necessary and useful, each with strong and weak points. Reconciling them however is a nightmare. Monophyletic Linnaean generic and specific taxa can be useful in cladistics, but beyond that the two systems don’t work together very well – many higher taxa have very different meanings in each.
This situation reflects the fact that classification systems often need to make choices regarding what criteria to use and with what priority. There is often no objective right answer, and different choices will have different trade-offs of advantages and disadvantages.
This issue comes up also in medicine and the classification of diseases. Often there are many related diseases without clear demarcations between them. Medical experts get into a “lumper vs splitter” debate – do you use one disease label to describe a variable entity, or do you split the disease into many sub-diseases based upon every variation. If you do split into different diseases how do you prioritize different features, including clinical presentation, demographics of those susceptible, various biological markers, and the results of various diagnostic tests?
There is often no one right answer, and experts argue bitterly in favor of their preferred scheme. But, scientists have to talk with each other (at meetings and in the published literature) so they need a common language, so often a consensus diagnostic scheme emerges that combines various features.
It is also true that as medicine advances new information forces a reclassification of diseases. For example, muscular dystrophies were originally classified based upon their clinical presentation (analogous to the Linnaean system). The advance of genetics, however, made it possible to detect specific genetic mutations occurring in those with muscular dystrophy. Some clinical categories survived reclassification based upon genetics, while others vanished and were replaced by new diagnoses.
Now back to the new PLOS One study – Senior Author, Boris Vanatzer, and his co-authors are proposing a system that classifies organisms based upon their genetics alone. The advantage here, they argue, is that we can rapidly genetically type an organism and then assign it a highly specific classification code, without spending the time for careful morphological or phylogenetic analysis. They also argue that such a system is highly stable. The classification will not change over time, as both Linnaean and cladistic classifications can, as new knowledge comes in.
The result is a code reflecting genetic similarity. They point out that this system is not meant to replace any of the existing species classification systems, but rather is meant to classify strains/breeds/variations within a species. In the press-release they explain:
More than 1,200 strains of anthrax — or Bacillus anthracis — exist. Each one possesses an arbitrary name chosen by researchers that does nothing to illuminate genetic similarities.
With the naming scheme developed by Vinatzer, the name of every single anthrax strain would contain the information of how similar it is to other strains. Using Vinatzer’s genome sequence, the Ames strain used in the bioterrorist attack would, for example, be known as lvlw0x and the ancestor of this strain stored at the U.S. Army Medical Research Institute for Infectious Diseases would be known as lvlwlx.
Their system is hierarchical, with the codes to the left being more fundamental. Therefore, the farther to the right you have to go in the code before there is a difference reflects greater genetic similarity among strains.
Of course I have no idea if this scheme will be adopted in any capacity. It is just a proposal. It seems rigorous, however, and the authors make a persuasive case about its utility. The community, however, will have to decide if it is worthy. The tell will be whether or not other researchers start publishing papers using the classification system.
Classification systems should not be denigrated or minimized as “mere” labels. These labels reflect our understanding of the field and the relative utility of various criteria in organizing complex natural systems and technical communication among experts. It turns out that in science there is a lot in a name.
Still, it is often amusing how emotional battles over names and classification can become. I suspect this is precisely because there is often no objective answer. It comes down to which criteria to prefer with what priority, each with their own strengths and weaknesses. You end up in a “Mac vs PC” debate with passionately held opinions but no objective resolution.
In many cases, however, when the dust settles, some sort of compromise emerges. When possible there is often a combined classification system. When combination is not possible or practical, sometimes multiple systems are used side-by-side in different contexts where they are most useful. At the end of the day scientists have to communicate with each other to get on with the business of science, so they settle their differences and move on.
I suspect, however, that there are still astronomers harboring ill feelings about Pluto’s loss of planetary status. In such a case time is the ultimate answer – a new generation will come around and take the current classification system for granted. That Pluto was once a planet will become just a nerdy bit of trivia.
One of the encouraging shifts I’ve seen in health journalism over the past few years is the growing recognition that antivaccine sentiment is antiscientific at its core, and doesn’t justify false “balance” in the media. There’s no reason to give credibility to the antivaccine argument when their positions are built on a selection of discredited and debunked tropes. This move away from false balance and towards a more accurate reflection of the evidence seems to have started with the decline and disgrace of Andrew Wakefield and his MMR fraud. And there is now no question that antivaccine sentiment has a body count: Simply look at the resurgence of preventable communicable disease. Today, antivaccinationists are increasingly recognized for what they are – threats to public health. It seems less common today (versus just 5 years ago) that strident antivaccine voices are given either air time or credibility in the media.
But false balance on topics like influenza can occur without giving a voice to groups like antivaccinationists. A more subtle technique to shift perceptions is both widespread and hard to detect, unless you’re aware of it: the naturalistic fallacy, known more accurately as the appeal to nature. In short, it means “It’s natural so it’s good” with the converse being “unnatural is bad.” In general, the term “natural” has a positive perception, so calling a product (or a health intervention) “natural” is implying goodness. The appeal to nature is so common that you may not even recognize it as a logical fallacy. Unnatural can be good, and natural can be bad: Eyeglasses are unnatural. And cyanide is natural. Natural doesn’t mean safe or effective. But the appeal to nature is powerful, and it’s even persuasive to governments. If we believe that health interventions and treatments should be evaluated on their merits, rather than whether or not they’re “natural”, then decisions to regulate “natural” products differently than the “unnatural” ones (like drugs) makes little sense. Yet the Dietary Supplement Health and Education Act was a legislative appeal to nature, introducing a different regulatory and safety standard for a group of products while drawing a fallacious distinction with “unnatural” products like drugs. Canada fell for the appeal to nature too: It has the Natural Health Products Regulations which entrenched a lowered bar for efficacy and safety for anything a manufacturer can demonstrate is somehow “natural”.
The combination of false balance and the appeal to nature has a subtle but insidious effect on how we view health care. Promoters of CAM (complementary and alternative medicine) know and use this strategy very effectively. If we’re willing to mentally distinguish between “conventional” and “natural” health approaches, then we may be more willing to overlook issues with respect to evidence – the Achilles’ heel of CAM. It’s a simple strategy for advocates to wrap their products with the “natural” banner, and our own perceptions give it a mental pass. As consumers, we’re the ones with the fallacious reasoning. The promoter is just priming us to accept the fallacy.
While I take some comfort in the fact that I’m told this blog is both widely read and well-respected, its reach is still miniscule compared to those that promote CAM. (The SBM logo should be Sisyphus, because that’s how it can feel when you’re providing science-based information against a torrent of pseudoscience.) I don’t envy Dr. Oz, but I do envy his reach and his platform, and only wish he used his prominence to promote credible health strategies, instead of what is often rank quackery. As a pharmacist I can literally see the effectiveness of the mainstream media on shaping perceptions of heath, and driving consumers to act on those demands. When I used to work in a retail pharmacy, it was immediately obvious which new miracle supplement had been hyped on Oprah, as demand would explode following an episode.
No matter how effective we are as promoters of science-based medicine, we’ll be fighting a losing battle against pseudoscience and CAM unless we have health journalists as partners. The very best health journalists are not just superb communicators; they share SBM’s goals of advocating for the best health care. My hypothesis is that the decline of major media organizations (particularly print) over the past decade may be making the task of public health and science communication more difficult. Not only do the number of dedicated health and science journalists seem to be declining, but those journalists that are tasked with covering health issues may lack the experience, background and context to communicate in the most responsible and effective way. Today it’s a hunt for eyeballs and clicks.
A series of columns in The Globe and Mail summarizes the continued challenge to communicating science-based medicine. If you’re not familiar with The Globe, it’s Canada’s largest national newspaper, and while it’s no New York Times, it’s generally considered Canada’s paper of record. The Globe has some excellent health journalists like André Picard and Carly Weeks who consistently provide some of the best health content in the country. But recently The Globe launched a new online feature, the Health Advisor, which appears to be a series of contributed posts from writers that are external to the paper:
Most of the columns I’ve seen seemed to have reasonable content, and some have medically qualified authors. The series seems to be an effort to gain web traffic, as there’s no coherent theme other than the intent for posts to be clickbait, with titles such as “Former Olympian Jennifer Heil’s five tips for eating healthy on the road” or “How to tell when your memory loss is normal – and when it’s dementia.” But a recent column made me look more closely at the series: “Eight easy, natural ways to keep the flu at bay (without leaving home).” It’s written by Bryce Wylde, a homeopath who is a regular on shows like Dr. Oz. It would be a straightforward matter to look at Wylde’s recommendations and the science evidence supporting them. But the story is far more interesting than that. It starts with what Wylde suggests. He leads off with:
There are some highly effective natural solutions you can try to help prevent contracting the flu, or mitigate the symptoms once you have it. Still, recent news about the effectiveness of some supplements and home remedies has left many confused with what remedies are best to take both proactively and reactively.
Cue the appeal to nature and the false balance. His most conventional recommendation is getting more sleep. No argument there. But he goes on to suggest the following:
By any responsible health journalism standard, this has serious problems. I was not alone in noticing Wylde didn’t actually recommend strategies that do have some evidence to support them, such as vaccination, handwashing and social isolation. When I put the question to The Globe on Twitter, Wylde responded and claimed that the mention of vaccines had been removed at The Globe’s request, which I found pretty concerning. And then The Globe responded:
And then it doubled down on the column, promoting it all day:
Spot the fallacies? A lot of people did, and commented online and via Twitter. The Globe’s response was more problematic than Wylde’s – it ought to know better. To The Globe’s credit, they subsequently took the feedback seriously enough for the paper’s “public editor” to address it a few days later, in a column entitled Homeopath’s advice needs to be balanced:
Last Friday, a blog on natural ways to keep the flu at bay written by an alternative-medicine specialist garnered criticism on social media and in the story comments. The blog suggested a variety of solutions that the writer, who has a diploma in homeopathic medicine, felt could either help to prevent contracting the flu or mitigate the symptoms. The blog was criticized by medical professionals on a number of points and most said it missed the key advice that what really works is the flu vaccine.
One public health physician-in-training wrote to me to say the article “makes a number of health claims regarding ways to prevent or treat the flu, but which lack any evidence to support them. Indeed, [the] … recommendations (such as the use of probiotics) …demonstrate a basic misunderstanding of what the flu is (a virus, not a bacteria). “As a member of the medical community, it concerns me when unfounded claims from Complementary & Alternative Medicine (CAM) providers are presented as fact and given legitimacy via publication. Incomplete or incorrect health information can produce very real harm, as it often prevents people from seeking out appropriate, evidence-based care (e.g. flu vaccine, antiviral medications).”
The physician’s question was about The Globe and Mail’s obligation in presenting health information. It is an excellent question. Medicine is a science based on studies and factual observations, unlike, for example, politics, where it is important for media coverage to balance the different sides of a debate.
The Globe has published many articles on the importance of getting a flu vaccination. But if the paper chooses to run an article by a homeopath in addition to the articles by medical professionals, such as a doctor, nurse or pharmacist, the article needs to be seen in the context of who the writer is and what his credentials are.
The article properly sets Health Advisor in context, saying this is a blog where contributors share their knowledge. At the bottom in italics is an explanation of the credentials of the writer so that readers will see this person is not a medical doctor but rather an alternative-medicine expert.
However, in my view, the label Special to The Globe and Mail is not clear, as it is commonly used to indicate articles by freelance journalists. It also would have been preferable to have the related links to the story balance the homeopath’s advice with a medical professional’s advice. The top three links were about learning to dream, outdoor fun and good germs. In my view, the top link should have been this article: “As a doctor, I’ve seen why vaccination is a ‘no brainer.’ ”
I think there should be a bias toward medical professionals writing about medicine and, while there is room for some coverage on alternative or homeopathic treatments, care should be taken to always balance such coverage with a doctor’s or other medical professional’s experience and expertise.
Regrettably, this response seemed to miss the point of the criticism, suggesting that all the Globe needs to do is to “balance” columns like this with a bit more science. I see the issue of “freelance journalist” as a bit of a red herring – this is the Globe and Mail, and the paper shouldn’t be lending its credibility to contributors touting unscientific health information. The proper way to deal with pseudoscience isn’t to “balance” it with links to credible health information, it’s to present the facts accurately the first time, and not give a platform to quackery. And when it comes to CAM, the science is very clear: if a “natural” approach or remedy has medicinal effects, it’s simply medicine. (All the rest is a nice bowl of soup and some potpourri, argues Dara O’Briain). There is no need to present two different perspectives. Just describe what’s effective.Conclusion
The appeal to nature is one of the most insidious logical fallacies, and it can contribute to misguided attempts to “balance” science-based information against treatments and strategies that lack good evidence of effect. While The Globe and Mail is to be commended for publicly acknowledging and responding to online criticism, a stronger response would have acknowledged the paper’s responsibility to ensure that contributed health content is reviewed and vetted by the appropriate subject-matter experts. Logical fallacies are critical thinking “blind spots”, and it’s only when we know they exist that we can spot them.
The “just asking questions” maneuver is familiar to many skeptics. The idea is to feign neutrality, to insulate oneself from accountability or being held to answer for any specific position, but meanwhile to sow doubt about a scientific claim by raising (dubious) questions.
Sometimes the “I’m just asking questions” gambit also tries to disguise itself as sincere journalism. That’s what journalists do, right, ask the tough questions, uncover the uncomfortable truth?
I find this approach particularly deceptive. It tries to hide the fact that the journalist is working off of a particular narrative. Asking questions is, in fact, just another narrative style, one that is meant to lead the reader/viewer to a particular conclusion about the subject. The narrative determines what questions are asked and how they are answered.
A perfect example of this deceptive approach is the HIV denialist movie, House of Numbers. Here is the synopsis from the movie’s website:
What is HIV? What is AIDS? What is being done to cure it? These questions sent Canadian filmmaker Brent Leung on a worldwide journey, from the highest echelons of the medical research establishment to the slums of South Africa, where death and disease are the order of the day. In this up-to-the-minute documentary, he observes that although AIDS has been front-page news for over 29 years, it is barely understood. Despite the great effort, time, and money spent, no cure is in sight.
Hyping ignorance is one denialist strategy. Leung asks questions, pretending to be neutral, but implying that those questions are controversial or unanswered. He characterizes AIDS as “barely understood” and summarizes the current medical situation as “no cure in sight.” The summary continues:
The HIV/AIDS story is being rewritten, and this is the first film to present the uncensored POVs of virtually all the major players — in their own settings, in their own words. It rocks the foundation upon which all conventional wisdom regarding HIV/AIDS is based. If, as South African health advocate Pephsile Maseko remarks, “this is the beginning of a war…a war to reclaim our health,” then House of Numbers could well be the opening salvo in the battle to bring sanity and clarity to an epidemic clearly gone awry.
Clearly, this is a denialist movie. Rocking the foundation of conventional wisdom, bringing clarity, and being uncensored are all standard parts of the denialist rhetoric.A brief history of HIV
HIV denial was galling in the 1990s, but it is even more so today given the stunning advances in HIV medicine.
On June 5th 1981 the CDC published a report of five cases of a rare pneumonia (PCP pneumonia) in five otherwise-healthy young gay men. In 1982 it was recognized that these and other patients were suffering from an immune deficiency syndrome and opportunistic infections. In 1983 a retrovirus was discovered as the probable cause of this new syndrome (AIDS). The virus was initially called Lymphadenopathy Associated Virus but later renamed Human Immunodeficiency Virus (HIV). In 1985 the first blood test for HIV was approved. In 1987 the FDA approved the first drug for the treatment and prevention of HIV – AZT.
Over the next 20 years scientists developed what is called highly active antiretroviral therapy, or HAART, treatment. This is a cocktail of multiple drugs designed to interfere with HIV at multiple steps in its infection and replication. As these drugs continue to be developed, the life expectancy of those with HIV increases. Just last year, in 2013, data suggests that those with HIV who start HAART treatment early have essentially a normal life expectancy. In 30 years HIV went from a short term death sentence to a chronic illness with an essentially normal life expectancy.
There have been only a few “cures” of HIV, meaning that those with a documented infection are now virus free after treatment. One such cure was effected with a bone marrow transplant, and another with high dose HAART in an infant infected at birth. These approaches will likely not be applicable to most patients with HIV.
Research into an HIV vaccine is ongoing. The best we have done so far is a phase III trial showing 31% efficacy in preventing initial infection. This is a modest result, but shows we are making progress. HIV is particularly challenging for various reasons – it mutates throughout the infection, it evades the immune system, and it can hide in a dormant state.
In short, HIV is one of the stunning success stories of modern medicine. Science rapidly discovered the nature and cause of AIDS, we have had a steady increase in our understanding of this virus, it is now a manageable disease and we continue to make progress toward a vaccine and even possible cure.HIV denialism
Throughout this 30 year success story, there have been those who have denied that HIV exists and/or is the cause of AIDS. Initially they claimed that the lack of clear benefits from anti-retroviral therapy was evidence that the HIV hypothesis was wrong. If that were true, then the stunning success of HAART should be considered evidence that the HIV hypothesis is correct. In fact, the success of HAART has taken the wind out of the sails of much HIV denialism, and yet it limps on.
In House of Numbers, Leung (who is just asking questions) asks: Is there really a consensus on HIV? Is the test reliable? Why do doctors ask about risk factors? Why doesn’t everyone who is exposed get the disease? Why is the disease so variable?
And, of course, the Big Pharma gambit – isn’t HIV just an invented fiction so that pharmaceutical companies can make money from selling drugs?
Jeanne Bergman over at AIDSTruth.org does a good job of answering these questions. Yes, there is a robust consensus on HIV, based upon mountains of evidence. Yes, the test is reliable. Asking about risk factors is standard practice. Not everyone exposed to an infectious illness catches the disease. The disease is actually very consistent. The opportunistic infections may vary by region, however.
Regarding the Big Pharma gambit – I suspect that someone living a normal life with a normal life expectancy on HAART medication doesn’t think the pharmaceutical industry is ripping them off. If you search for HIV on Pubmed you get 265,637 results. That is a lot of research. In there are clinical trials and systematic reviews of HAART therapy demonstrating clear efficacy. There is no controversy over the appropriateness and effectiveness of HAART therapy in those with HIV.
The response to Bergman’s deconstruction of House of Numbers by the denialists is predictable. They simply double down on the “we’re just asking questions” gambit. On the HoN Website they include this formal response by the HIV denialist Perth group:
The “legitimate scientist” and Nobel laureate Jacques Monod: “In science, self-satisfaction is death. Personal self-satisfaction is the death of the scientist. Collective self-satisfaction is the death of the research. It is restlessness, anxiety, dissatisfaction, agony of mind that nourish science”.
Perter Abelard: The first key to wisdom is assiduous and frequent questioning…For by doubting we come to inquiry, and by inquiry we arrive at truth”.
They further state:
Howard Temin, the father of modern retrovirology: “when an experiment is challenged no matter who it is challenged by, it’s your responsibility to check. That is an ironclad rule of science, that when you publish something you are responsible for it…even the most senior professor, if challenged by the lowliest technician or graduate student, is required to treat them seriously and consider their criticisms. It is one of the most fundamental aspects of science” (emphasis in original).
HIV scientists do not respond to challenges. In fact, according to the rules at AIDSTruth, “We will not engage in any public or private debate with AIDS denialists or respond to requests from journalists who overtly support AIDS denialist causes”. Apparently these “legitimate scientists” cannot stick to their own rules.
Here we see the true agenda of “just asking questions” laid bare. Denialists are not asking sincere questions with the goal of further exploration and getting closer to the truth. They have an agenda of casting doubt on established science. They will tirelessly ask questions in order to create the false impression of controversy where none exists, all the while pretending to be skeptics who just value doubt as a scientific tool.
The quote above from Temin does not apply. Even the lowliest technician who is asking questions is assumed by Temin to be sincere in their motives. This does not apply to denialists, who abuse questioning, abuse skepticism, and abuse doubt for an a priori agenda of denial.
“Just asking questions” is a win-win for denialists. If you respond, you validate the notion that there is a controversy, a question that needs answering. If you refuse to engage, then you are hiding something and not being a true scientist.Conclusion
The medical science behind HIV/AIDS is astoundingly robust. Of course there is much more to be discovered, and we need to further develop HIV treatments. An effective vaccine and/or effective cure are greatly needed, especially if we are ever going to eradicate HIV. Eradication is possible, however, as HIV has no significant non-human reservoir.
Denialists, however, confuse consensus with being closed minded. They confuse refusal to engage with cranks with being evasive. They pretend to be just asking questions when in reality they clearly demonstrate that they are not honest brokers. Rather they are merchants of doubt and confusion with an agenda.
I don’t know if Leung came to this question a denialist, or if he is just a journalist who decided to build his career off a “man bites dog” story. A movie confirming the standard scientific view of HIV would not have been as sensational.
We also have to acknowledge the potential harm of HIV denialism. Trying to convince the public that they are not being told the true story of HIV has the potential to convince some people not to trust the system, and therefore not to get tested or take HAART medication. With serious medical issues, “just asking questions” has a body count attached to it.
Robert Todd Carroll, the author of The Skeptic’s Dictionary, has a new book out: The Critical Thinker’s Dictionary: Biases, Fallacies, and Illusion and what you can do about them. Since some of our commenters and most of the CAM advocates we critique are constantly committing logical fallacies, a survey of logical fallacies is a good idea both for us and for them, and this book fits the bill.
When I received the book in the mail, I set it aside, thinking it would be a somewhat boring listing of things I already knew. When I finally got around to reading it, I was surprised and delighted. It held my interest, reminded me of things I had forgotten, explained other things I had never heard of, and provided entertaining stories to illustrate each point. Best of all, the bulk of his examples are taken from medicine and relate directly to the topics we discuss on SBM.
Carroll is well-qualified to write about logical fallacies: he is a retired professor of philosophy who has long promoted skepticism and taught classes in critical thinking, and he writes in an entertaining, accessible style. He started The Skeptic’s Dictionary website in 1994 with 50 articles and it has now grown to several hundred articles. It attracts more than a million visitors a month, and some of its entries have been translated into more than a dozen languages. It has become a go-to reference for anyone seeking the facts on questionable claims about everything from crop circles to homeopathy. Its articles are thorough and well documented with lots of references and links.
I am partly responsible for this book, as he explains in the acknowledgements and Preface. I reviewed his e-book Unnatural Acts: Critical Thinking, Skepticism, and Science Exposed! for Skeptical Inquirer in 2012. The original version of that book included a list of 59 fallacies, biases, and illusions that readers could learn about on their own. I suggested that he add a short description of each fallacy rather than simply listing their names, and he did. This led him to expand on the descriptive paragraphs in a blog, addressing one each week for 59 weeks. The new book is a re-organized and improved version of those blog posts.
He starts with a case study of an anti-vaccine activist, Stephanie Messenger, who wrote the unfortunate Melanie’s Marvelous Measles, a book that teaches unvaccinated children to welcome childhood diseases. He tells her story with insight and understanding. She had a child who became ill after vaccination and eventually died. She was desperate to understand why and to have the power to protect her other children from a similar fate. The specialists caring for her child suspected Alexander disease, a rare genetic neurodegenerative disease, but for some reason she rejected that possibility and became convinced that vaccines were responsible. Carroll details the series of fallacies and illusions that misled her and reinforced her convictions: the post hoc ergo propter hoc fallacy, confirmation bias, community reinforcement, the reverse halo effect, the illusion of understanding, and the illusion of control. He makes it very easy to understand why she thinks as she does. Hers was a very natural human response, but with education in critical thinking, we can hope to overcome those natural tendencies and avoid the kind of errors she made.
In a discussion of the ad hominem fallacy, he says something that I wish our critics would read and take to heart before assaulting us in our comments threads:
To refute my argument, you must show that my evidence is insufficient, that it is based on false or questionable assumptions, that the evidence I present is irrelevant, that I’ve omitted important evidence, or that I’ve given improper weight to various piece of evidence.
It’s not enough to accuse us of bias, financial gain, or pimping for Big Pharma; you have to address what we wrote rather than who we are, and show that what we have written is wrong (with credible references, please!).
His description of how his article on EMDR (eye movement desensitization and reprocessing) was attacked is typical of what we have repeatedly seen here on SBM. His critic:
He uses the NCCAM (National Center for Complementary and Alternative Medicine claim that 38% of Americans use alternative medicine to illustrate the ad populum fallacy. He illustrates other fallacies with examples from medicine. He discusses fears about cellphones and vaccines, testimonials, placebo effects, the appeal to tradition (“acupuncture is thousands of years old”), the appeal to authority (“Dr. Jay Gordon says vaccines aren’t safe.”) and how “authority” is not the same as expert scientific consensus.
He illustrates the availability heuristic with an experience Dr. Jerome Groopman had. He misdiagnosed a patient suffering from aspirin toxicity because her symptoms were compatible with the many cases of viral pneumonia he had recently been swamped with, so that the viral pneumonia diagnosis was readily available to his mind while aspirin toxicity was not.
In begging the question, the conclusion of the argument is entailed in its premises: abortion is murder, murder is illegal, so abortion should be illegal.
He covers a lot of recent psychological research into phenomena like change blindness, priming, the backfire effect, and many, many others.
He discusses the illusion of skill and the illusion of understanding (We can relate to that: we’ve seen many examples of the Dunning-Kruger effect among our commenters).
The clustering illusion: several cases of cancer in a neighborhood can occur by chance and don’t necessarily mean the inhabitants are being exposed to carcinogens in the soil or water. Communal reinforcement is when a claim becomes a strong belief through repeated assertion by members of a community. Confabulation: we all do it; our memories sometimes mix fact and fiction to recall things that never happened, and on a daily basis we invent reasons to explain how we feel.
Selection bias: Edzard Ernst tells how, as a young doctor, he gave mistletoe injections to cancer patients and was impressed by the results until he realized that his hospital was known throughout Germany for its approach, and desperate patients went there because they wanted that type of treatment and had high expectations.
Under causal fallacies (correlation is not causation) he covers the problem of multiple endpoints in small randomized controlled trials, where spurious correlations are expected due to the laws of chance. He also tells how doctors were interpreting signs of disc disease on MRI scans as an indication for back surgery until someone thought to do MRIs on patients without back pain and found that 2/3 of those showed the same changes.
I already knew the word pareidolia, but apophenia was new to me. It means the spontaneous perception of connections and meaningfulness of unrelated phenomena, the tendency to find personal information in noise, seeing patterns where there are none, the kind of subjective validation that cold reading exploits.
This is only a brief taste of the profusion of riches in this book. I highly recommend it to everyone. Whether you are a novice who needs a primer to learn about detecting logical fallacies or are already a seasoned pro, you are certain to learn something from The Critical Thinker’s Dictionary, and you are sure to enjoy the experience.
Somehow, I’ve a feeling we’re not in Kansas anymore—except that we are, as you will soon see.
Because I’m the resident cancer specialist on this blog, it usually falls on me to discuss the various bits of science, pseudoscience, and quackery that come up around the vast collection of diseases known collectively as “cancer.” I don’t mind, any more than my esteemed colleague Dr. Crislip minds discussing infectious diseases and, of course, vaccines, the most effective tool there is to prevent said infectious diseases. In any case, there are certain things that can happen during a week leading up to my Monday posting slot on SBM that are the equivalent of the Bat Signal. Call them the Cancer Signal, if you will. One of these happened last week, thus displacing that post I’ve been meaning to write on a particular topic once again. At this rate, I might just have to find a way to write an extra bonus post. But not this week.
In any case, this week’s Cancer Signal consisted of a series of articles and news reports with titles like:
These stories, to varying degrees, miss the point. Unfortunately, I confess that I wasn’t able to help at least one of them. A reporter happened to leave me a message Tuesday morning, which is my operating room day, and I didn’t have time to read the paper and to get back to her before her deadline. That paper, by the way, appeared in Science Translational Medicine from Jeanne Drisko and Qi Chen from, yes, Kansas University Medical Center, and indicates to me that STM‘s standards are slipping. But then, STM did publish a rather credulous paper by our old friend Ted Kaptchuk on placebos; so maybe I expect too much. Clearly STM appears to be looking for more papers on “complementary and alternative medicine” (CAM) or “integrative medicine.”
Be that as it may, a typical story describes the recently published research thusly:
People with ovarian cancer who receive high-dose vitamin C injections are less likely to report toxic side effects from chemotherapy than people who had chemotherapy alone, according to the results of a small clinical trial.
The study, published today in Science Translational Medicine1, was too small to assess whether the combination of chemotherapy and vitamin C combats cancer better than chemotherapy alone. But accompanying work in mice suggests that the two treatments could be complementary.
The results are the latest salvo in long-running controversy over the use of vitamin C against cancer. Early studies championed by Nobel-prizewinning chemist Linus Pauling in the 1970s suggested that vitamin C could help to fight tumours2. But larger clinical trials failed to substantiate those claims3, 4.
With the spin, from another typical story, being:
One potential hurdle is that pharmaceutical companies are unlikely to fund trials of intravenous vitamin C because there is no ability to patent natural products.
“Because vitamin C has no patent potential, its development will not be supported by pharmaceutical companies,” said lead researcher Qi Chen.
“We believe that the time has arrived for research agencies to vigorously support thoughtful and meticulous clinical trials with intravenous vitamin C.”
Yes, indeed. The same old tropes are there, from the claim that vitamin C has usefulness in treating cancer to the old ascorbate warriors’ lament that there’s no patent potential in vitamin C, which means that pharmaceutical companies don’t want to invest money into doing science and clinical trials on it because there’s no profit potential. Of course, I’ve written fairly extensively about vitamin C and cancer before, using it as an example of how even a two-time Nobel Prize winner like Linus Pauling could fall prey to bad science when he wandered outside of his area of expertise. Every so often these stories come up suggesting that Linus Pauling has somehow been vindicated and how vitamin C is the greatest thing for cancer patients since surgeons first discovered that some cancers could be cured by cutting them out. Inevitably, I have to throw cold water on such claims. No, Linus Pauling has not been vindicated, and, no, vitamin C for cancer is not all that great.
Also, no, contrary to what critics say, I’m not close-minded about vitamin C and cancer. Unlike so many “alternative” cancer treatments, it’s actually a chemical and, at the doses used by alternative cancer practitioners, a drug. There’s even a (very) weakly plausible mechanism by which it might work. However, in vitro, the concentrations required to provide even a whiff of a hint of antitumor activity are ridiculously high, and the same is true in animal models. Let’s just put it this way. Imagine a pharmaceutical company had developed a compound with properties identical to that of vitamin C and could thus own the complete patent on it as a drug. Given the ridiculously high concentrations and doses required in preclinical models to demonstrate a hint of antitumor activity, that pharmaceutical company would probably retire that compound before even the animal model stage because, as I like to put it, getting any useful anticancer activity out of it would be such a long run for a short slide. A good drug for cancer is, at the very minimum, active at low or reasonable concentrations against the cancer cells being targeted, and vitamin C fails miserably on that count. Worse, there are at least indications that in some cases vitamin C might interfere with chemotherapy.Vitamin C in Kansas
So does this study change my opinion? Not really. It suggests there might be some utility for ascorbate (vitamin C) against ovarian cancer, but that ascorbate therapy for cancer still remains at best a long run for a very short slide right into the gloved ball of reality to be tagged for a third out. (OK, I’ll stop with the baseball analogies.)
The dubious reasoning begins right in the first paragraph, with the authors’ justification for “re-examining” ascorbate as a cancer therapy. Basically, they point out that the pharmacokinetics of oral ascorbate dosing is different from intravenous dosing, to the point where it is possible to obtain serum ascorbate concentrations of 10 mM (millimolar). To give those of you who aren’t chemists a rough comparison of just how high that concentration is, most cancer drugs have active concentrations in the nanomolar (nM) to micromolar (uM) range, in other words, a thousand-fold to a million-fold lower than 10 mM. For example, the IC50 (the concentration that leaves only 50% of cells alive) for paclitaxel is in the 2.5 to 7.5 nM nM range, depending upon the cell line, and 50 nM is considered a good, effective therapeutic concentration. You get the idea. You need a lot of ascorbate:
By contrast, when ascorbate is injected intravenously, tight control is bypassed and pharmacologic concentrations of ascorbate are established until excess ascorbate is excreted by kidney. Plasma concentrations greater than 10 mM are safely sustained in humans for ~4 hours (10–13). When patients have normal renal function and glucose-6-phosphate dehydrogenase (G6PD) activity, toxicity is minimal even with intravenous doses as high as 1.5 g/kg, equivalent to 105 g for a 70-kg person (2, 12). These data indicate that intravenous administration of pharmacologic ascorbate doses is safe and similar to drug administration. Therefore, the effect of ascorbate in cancer treatment is worth reexamining.
These are huge doses, consistent with previous experiments in mice with a xenograft from an ovarian cancer cell line (Ovcar5) in which 4 g/kg of ascorbate was administered twice daily for a total of 8 g/kg/day. The result was an inhibition of xenograft growth of around one-third after 30 days. Results for a pancreatic cancer cell line and a glioblastoma cell line were only marginally better.
The authors did several cell culture studies in which ovarian cancer cell lines were treated with ascorbate and various chemotherapeutic agents. The authors reported an IC50 of between 0.3 and 3.0 mM, which is still incredibly high for an anticancer drug. The authors blithely write that this is “easily achievable” with IV ascorbate. Maybe so, but given the quantities involved, if you’re going to use a drug that requires such high plasma concentrations to have activity, that activity had better be awesome. None of the activity shown in this paper can be characterized as being particularly impressive. Worse, the authors, despite testing several ovarian cancer cell lines, only tested one non-tumorigenic immortalized ovarian line, HIO-80, and, finding that the IC50 to kill HIO-80 cells was much higher than all but one of the other cell lines (SHIN3), proclaimed a high degree of specificity for cancer. Moreover, HIO-80 cells are hardly “normal.” They likely contain BRCA1 mutations. Finally, the authors only used one assay for proliferation, the MTT assay. This particular assay is very popular (I use it in my lab not infrequently) because it is faster and easier than counting viable cells and also allows for large experiments using 96-well plates. However, the MTT assay depends on the metabolism of cells to produce a dye that is detected. The amount of light absorbance due to the dye is assumed to be proportional to the number of viable cells. Usually, this assumption is reasonable accurate, but lots of things can interfere with this and render that assumption incorrect. For instance, one wonders if very high concentrations of ascorbate can interfere. I’d want to see a control demonstrating that the MTT results correspond to cell number.
In other words, if I were a reviewer for this paper, not so fast, I’d have said. I want to see the results for at least a couple of more non-tumorigenic cell lines and a control validating the MTT in the presence of so much ascorbate (even if just a reference) before I’ll let you conclude that the effects of ascorbate are highly specific for cancer over normal ovarian cells. At the very least, I wouldn’t have considered it unreasonable to ask for a couple more non-tumorigenic ovarian epithelial cell lines to be tested.
In any case, the authors also did some mechanistic studies, the results of which were consistent with the activity of ascorbate in cancer requiring the production of peroxide (H2O2), as H2O2 scavengers blocked the effect. They also did a series of experiments that indicated synergy between ascorbate and carboplatin, a common chemotherapy drug used in ovarian cancer. One area that, as a reviewer, I’d have gotten on the authors’ case was the series of xenograft experiments using ovarian cancer cell lines implanted under the skin of immunodeficient mice, specifically this part:
Two-tailed Student’s t test was performed for comparison of treated groups to control group in the cell and animal experiments, as well as for toxicity comparison between chemotherapy group and chemotherapy + ascorbate group.
No, no, no, no, no! This is some pretty basic stuff here. There are eight different experimental groups, and the authors didn’t control for multiple comparisons, as far as I am able to tell. Pair-wise two-tailed t-tests are not the correct statistical test for determining statistical significance in such a case; likely some form of ANOVA would be, given that the dataset consists of tumor weights and volumes of ascites, the latter being a common estimate of ovarian tumor burden in mouse models. Some form of ANOVA, likely factorial ANOVA, would have been the proper test, given that there are combinations of three drugs being used. Whatever the correct test is (and I’ll leave that to the statisticians out there), I know that Student’s t-test isn’t it, and that using Student’s t-test will often produce “false positives” that appear statistically significant but aren’t.
All of this, however, is the warm-up to the part of the study that got it noticed, namely the clinical trial. Without the clinical trial, this would have been yet another in vitro and animal study of high dose vitamin C that provokes a collective yawn throughout the scientific community. The clinical trial itself was a randomized prospective phase I/IIa clinical trial, which means that the trial was designed to combine an evaluation of toxicity with a pilot study to evaluate efficacy and safety. Its primary objective was to “determine the safety of high-dose intravenous ascorbate when combined with first-line chemotherapy paclitaxel and carboplatin in the treatment of advanced-stage ovarian cancer,” along with evaluation for toxicity. Consequently, the two groups were (1) standard carboplatin plus paclitaxel (Cp + Pax) and (2) carboplatin plus paclitaxel plus ascorbate (Cp + Pax + AA) according to this design:
Ascorbate dose for the Cp + Pax + AA arm was established via dose escalation initiated at 15 g per infusion titrated up to a therapeutic range of 75 or 100 g per infusion, with a target peak plasma concentration of 350 to 400 mg/dl (20 to 23 mM) (12, 13). The ascorbate infusion was given at a rate of 0.5 g/min, and 400 mg of magnesium chloride (Wellness Pharma) was supplemented into each infusion. Once the therapeutic dose was established, the Cp + Pax + AA group received ascorbate two times per week in conjunction with chemotherapy for 6 months, and injectable ascorbate was continued for another 6 months after chemotherapy completion.
In addition, the authors noted:
Two subjects voluntarily withdrew from the Cp + Pax arm before treatment commenced because they wanted intravenous vitamin C, and they were excluded from data analysis. Two subjects were removed from the Cp + Pax + AA arm because they were noncompliant with tobacco use, and one was removed from the Cp + Pax + AA arm after in vitro cytotoxic assays detected that her tumor cells were resistant to all chemotherapy. These three subjects received doses of chemotherapy and ascorbate, so their adverse events were counted, but they were excluded from the survival report (table S3). Double blinding was used at enrollment and randomization, but was not maintained during the treatment because no placebo control was used.
So what we have here is a small clinical trial with a 19% dropout rate that wasn’t even blinded. It reported zero difference in overall survival (both were, as one would expect for ovarian cancer at this stage, abysmal), and zero statistically significant difference in time to relapse/progression. In all fairness, there would have had to have been an enormous effect to produce a statistically significant effect on survival or progression in such a small study, but these are the two “hard” endpoints that would be least affected by the lack of blinding, although one notes that time to progression could be affected by lack of blinding when the definition depends on interpreting scans. It’s also hard not to note that the differences in toxicities are all in the mildest reported toxicities, grades 1 and 2 (out of a scale of 1 to 5, with a score of 1, which denotes mild toxicity that requires no intervention to 5, which is death). There were no statistically significant (or even close to statistically significant) differences in toxicities graded 3 or 4, which are the most troubling kind. Take a look at the graph:
Then, when the authors broke it down, this is what they found:
Notice the types of complaints with the biggest difference: gastrointestinal (which usually includes symptoms such as nausea, abdominal pain; dermatology, which usually includes itching and rashes of various types); pulmonary, which often includes symptoms of shortness of breath, cough, and the like, and renal/genitourinary, which is the only one that’s less objective. So, basically, what we have is a study that found no benefit in overall survival or time to progression (not unexpected for such a small study). More importantly, contrary to the way it was trumpeted to the press, the decrease in adverse events actually observed was limited to the least serious adverse events (grade 1 = minor, causing no limitation of activity, no intervention required; grade 2 = moderate, some limitation of activities, minimal intervention indicated) with the most potential to be subject to reporting bias, which in the context of a trial that is not blinded makes the difference reported probably meaningless. In other words, this was probably a negative study, a long run for a short slide, indeed. (Sorry, couldn’t resist.)There’s no woo like Kansas woo
I thought it might be interesting to provide SBM readers with a bit of context about the institution from which this rather pointless study emerged. The reason that this particular study rose to the level that I thought I had to blog about it was not because a reporter contacted me about it. Rather, one of the key investigators on the study, Jeanne Drisko, recently appeared on a web chat, Can Alternative and Conventional Medicine Get Along?
This chat featured, in addition to Dr. Drisko, Dr. Josephine Briggs, the current director of the National Center for Complementary and Alternative Medicine (NCCAM) as well as an associate editor from Science Translational Medicine, Yevgeniya Nusinovich, M.D., Ph.D., who served as moderator. Dr. Jeanne Drisko’s titles include Director, KU Integrative Medicine and the Riordan Endowed Professor of Orthomolecular Medicine, and, consistent with her involvement in this study, KUMC offers its patients high dose vitamin C for cancer. The video itself was standard fair, discussed by a certain “friend,” where the Trial to Assess Chelation Therapy was incorrectly touted as a success warranting further study for chelation therapy for heart disease. However, what tweaked me to write this was Dr. Drisko’s mention at the end of her “hot off the presses” study of high dose vitamin C.
Personally, I found it instructive to take a look at the website for Dr. Drisko’s home department, the University of Kansas Medical Center Integrative Medicine Program. The first thing I noticed when I perused its website was this:
Nourishing the whole person — body, mind and spirit — and stimulating the body’s natural healing response, is our mission at KU Integrative Medicine. We combine the best therapies from conventional medicine with our integrative medicine approach, to form a comprehensive system of biomedical care.
From a patient’s very first visit with us, we attempt to uncover the underlying story that set the patient on their journey from wellness to disease. We listen. Based on our findings, we tailor a plan for each individual patient based on their lifestyle, their needs and their preferences. We consider the patient an integral part of the treatment team, and encourage patients to take control of their medical care.
Practitioners at KU Integrative Medicine include physicians, a naturopathic doctor, nurses, certified neurofeedback technicians and registered dietitians. We hope that you want to learn more about us, our services, and how we can help you forge a new path to healing and wellness.
Because Integrative Medicine attempts to dig deeper, very specialized lab work is often ordered. This also enables us to personalize your care and cater to your biochemical individuality.
Yes, it’s the same old tropes. KU claims to combine the “best of both worlds”. Unfortunately, whenever I hears that phrase, there’s another “best of both worlds” that I can’t help but think of, and it involves assimilation. Sadly, in this case the assimilation appears to involve science-based medicine being assimilated by quackery. After all, there’s a naturopath there, and naturopathy is nothing more than a cornucopia of pretty much every quackery imaginable under the sun, be it homeopathy, traditional Chinese medicine, “energy healing” modalities, and, of course “detoxification.”
However, it isn’t the fact that there’s a naturopath based at an academic medical center promising to “listen” and provide “individualized care.” That’s pretty much par for the course. In fact, it’s probably hard to find an “integrative medicine” program that doesn’t claim to “listen” and provide “personalized” or “individualized” care. Nor was I particularly surprised to see “healing foods” or neurofeedback. Nor was I even particularly surprised to see that KU offers detoxification. No, what caught my interest was the fact that KU offers “oral and intravenous vitamin and mineral therapies,” as in IV vitamin C being offered at a major academic medical center.
Orthomolecular medicine? Yes, Orthomolecular medicine, a form of quackery that posits that if the body needs some vitamins and minerals that more, more, more would be better. Indeed, it’s the quackery espoused by Linus Pauling that features, in particular, high dose vitamin C as one of its favored modalities. And guess what? The integrative medicine program at KU offers high dose intravenous vitamin C to its patients. It even has a FAQ about vitamin infusions on its site. What’s really scary, however, is this:
How do I know if the intravenous vitamin C therapy will work for my cancer?:
Each individual responds differently, and we can’t predict how different tumor types will react. A PET scan is usually a guidepost. If the PET is positive, the tumor usually responds to the vitamin C. If the PET is negative but there is active tumor present, the vitamin C is less effective in most cases. Vitamin C works best in the early stages of cancer when used in conjunction with chemotherapy or radiation. They will only consult patients who are also following along with a traditional oncologist.
It’s even said that there are “no contraindications to giving intravenous vitamin C with any chemotherapy when proper protocol is followed” and that the only chemotherapy that intravenous vitamin C doesn’t work with is methotrexate “because of urine pH requirements.” Upon what evidence is this based? Well, before it was minimal. One study examined on intravenous vitamin C. It was an in vitro and xenograft study (i.e., preclinical), and Dr. Drisko wasn’t even the corresponding author. Another study was a case series involving two patients. The third was a review article. None were particularly impressive. After this study, the evidence still remains unimpressive.
But that’s not all.
It turns out that Dr. Drisko has a rather dubious honor (dubious, at least to me; no doubt she doesn’t consider it so). I’m referring to her title of Chair of the Alliance for Natural Health USA. Yes, ANH-USA is one of the premier “health freedom” organizations in this country, “health freedom” in reality meaning advocating for freedom from pesky government regulation that might interfere with the selling of supplements. She’s also an advisory board member for the Institute for Functional Medicine. Functional medicine, a nebulously defined “specialty,” is pure pseudoscience, as has been described before. Perhaps the most famous practitioner of “functional medicine” is Dr. Mark Hyman, who promotes it under the title of “Ultrawellness.” In fact, the sad thing is this:
Dr Drisko teaches a fourth-year medical student elective in integrative medicine along with other teaching duties to 1st and 2nd year students, nursing students, and practicing physicians. A fellowship program in integrative medicine for primary care physicians began in 2008 under Dr Drisko’s leadership. She was nominated by the University of Kansas Medical Student Assembly to receive the Rainbow Award for Excellence in Teaching the Art of Medicine.
Dr Drisko serves the School of Medicine at KU Med by sitting on multiple committees, provides guidance for the State of Kansas on topics in integrative medicine, and participates at the national level on CAM initiatives. Dr Drisko is a member of the Kansas Cancer Research Institute and an advisory board member of the General Clinical Research Center at the University.
Meanwhile, the website for KUMC helpfully tells patients:
Will my insurance cover the costs of the vitamin C infusions?
They will not cover them in most cases. Alternative medicine doctors must use billing codes that are not usually accepted by insurance companies. And because vitamin C infusions are not FDA approved, insurance companies are not inclined to cover costs. Vitamin C infusions range in price from $125.00 to $160.00.
Good to know.
Yes, you read that right. An academic medical center is trying to facilitate patients going to alternative medicine practitioners who administer high dose vitamin C.
Depressingly, Dr. Drisko is intimately involved in the education of the next generation of doctors in Kansas and has started an “integrative medicine” program for primary care physicians, the better to “integrate” woo into real medicine. This latest highly unimpressive study being touted as evidence that high dose intravenous ascorbate/vitamin C therapy is anything other than a long run for a short slide (oops, there I go again!) is merely part of the campaign to insinuate quackademic medicine even more firmly into the mainstream than it has regrettably already succeeded in doing.