Just when I thought I was out, they pull me back in. My blogging plan was to take a break from my series of naturopathy versus science posts, where I’ve been contrasting the advice from naturopaths against the scientific evidence. From a blogging perspective, naturopathy is a fascinating subject to scrutinize, as there is seemingly no end of conditions for which naturopaths offer advice that is at odds with the scientific evidence. From a health care perspective, however, reading the advice of naturopaths is troubling. Naturopaths promote themselves as health professionals capable of providing primary care, just like medical doctors. And they’re increasingly seeking (and obtaining) physician-like privileges from governments. Naturopathy seems to be getting a easy ride from regulators, despite a lack of evidence that shows naturopathy offers anything distinctly useful or incrementally superior to science-based medicine.
Defining the scope of “naturopathic” treatment is difficult. Naturopaths offer an array of disparate health practices like homeopathy, acupuncture and herbalism that are only linked by the (now discarded) belief in vitalism- the idea we have a “life force”. Within this philosophy can sometimes emerge reasonable health advice, but that has little to do with the science or the evidence. As long as it’s congruent with the naturopathic belief system, it’s acceptably “naturopathic”. In past posts I’ve looked at naturopathy perspectives on fake diseases, infertility, prenatal vitamins, vaccinations, allergies and even scientific facts themselves. An advertisement passed to me this week promoted a naturopath who claims to treat pediatric conditions like ADHD and learning disabilities:
The Learning Disabilities Association is pleased to present this Workshop for Parents and Professionals:
ADHD and LD Naturally
Guest Speaker: Dr. Joseph Steyr
Do you want to know more about natural treatments for ADHD and Learning Disabilities? Dr. Steyr is a Naturopathic Doctor and also has been diagnosed with a Learning Disability since he was a young child. His talk will start with a short introduction to what is Naturopathic Medicine and continue to a discussion of the biology of ADHD/LD. Using that foundation of understanding we will then go over ideas of how nutrition, herbal and homeopathic medicine is used to help support and treat people living with ADHD or LD”.
Naturopaths using homeopathy is nothing new (it’s a “clinical science” within their practice), but this bulletin was distributed by the Toronto District School Board, the largest school board in Canada. As a Toronto resident [full disclosure: I have family members in TDSB schools] I’ve always understood that the TDSB was large enough to manage children with special needs and learning disabilities appropriately. It’s a big board with the capacity to offer specialized, focused care. So I was disappointed to see the school board describing homeopathy as “medicine”, and permitting a naturopath to speak. This is especially concerning given that Toronto Public Health notes that some Toronto public schools have up to 40% of students with “exemptions” from the vaccination schedule. Given naturopathy as a practice is antagonistic to vaccination, I wondered if this naturopath shared the perspective of his peers. What I found was troubling. I’ve been reading far too much this week about how how alternative medicine and its purveyors can harm children, so it’s frustrating to see poor thinking about science promoted by academic and charitable organizations that should know better. What’s even more alarming that naturopathy for ADHD and learning disabilities is the naturopathic approach to autism, a condition that naturopaths claim is caused by vaccines, and can be treated with naturopathy.
Autism is a recurrent topic at SBM largely because of the manufactroversy between vaccines and autism, a link that was never based on any credible evidence. Autism is also the unfortunate target of a cornucopia of quackery, all claiming to offer benefit in areas where science-based medicine may not offer satisfactory answers or treatments. The problems with the “naturopathic” approach to autism become clear with an understanding of the science of the disease. Autism can be described as a spectrum of neurodevelopmental cognitive disorders and delays, with variable effects on communication and socialization. There’s no known single cause, and while the disease seems to be strongly based in genetics there are a number of factors that are hypothesized to contribute, which include environmental components. While the scientific understanding of autism continues to grow, there are still maddening gaps in the evidence base. There is no cure for autism, but there are evidence-based approaches that can be effective.Autism Biomed
The lack of a “cure” for autism hasn’t stopped alternative medicine proponents from bringing forward their own (unproven) treatments. “Autism biomed” is short for biomedical, and is the umbrella term for the interventions used to “treat” autism medically. There are countless “biomedical” treatments for autism, and they’re offered by alternative (and sometimes conventional) practitioners. What proponents of “autism biomed” treatments always have in common is that they proclaim a superior understanding of autism over “conventional” medicine. And with this special insight comes the confidence that their particular biomed treatments are effective. Their entire perspective on autism as a disease may be quite different. Because they believe autism has external triggers and causes, they see autism as something “done” to a child that can therefore be “undone” with the right treatment: biomed. Consequently it’s not uncommon to see biomed practitioners claim that autism is either curable or highly treatable with their treatments. Biomed treatments can range from mild interventions (like modest dietary changes) to the truly horrific, like chemical castration or bleach enemas. Joseph Steyr, the naturopath noted above, is a proponent of autism biomed. Taking a closer look at his website, his description of biomedical treatment neatly encapsulates the biomed belief system:
The Biomedical Approach believes that environmental triggers (infectious agents, vaccines, foods, pesticides, pollutants/heavy metals) accumulate to a threshold point where Autism starts. These factors can trigger Autism on their own, or in conjunction with genetic susceptibilities. Once Autism begins, untreated triggers and nutrition deficiencies will lead to a worsening of the condition. Starting Biomedical Approach treatments, along with Behavioural therapies, as early as possible increases the chances that Autistic behaviours can be reduced or possibly eliminated. Naturopathic medicine offers many treatment options, from therapeutic diets, herbal (botanical) medicines, vitamin and mineral supplements, to homeopathic remedies, hydrotherapy (waterbased therapies such as foot baths and low‐heat infrared saunas) and (needle‐free) acupuncture.
To biomed purveyors like Steyr, autism is “triggered” by products like vaccines. Other naturopaths hold these same beliefs. Hilary Andrews, a naturopath in Portland Oregon claims:
While the measles-mumps-rubella or MMR vaccine has been strongly linked to the onset of autism, I believe that prior vaccinations also play a cumulative role in this disease. Current vaccination schedules overload very young, fragile immune systems with a huge number of viruses. The number of vaccinations administered to children has more than doubled during the last decade. Today, a child receives approximately 33 doses of 10 different vaccines before the age of six.
To naturopaths, vaccines are yet another “toxin” triggering autism spectrum as well as conditions like food allergies and “nutrient sensitivities”. To detoxify your autistic child, Steyr offers useless but probably harmless treatments like homeopathy and foot baths. He also offers treatments with greater risk for harm, like herbalism or the quackery of hyperbaric oxygen. But Steyr is no rogue naturopath. There is no shortage of naturopaths offering biomedical treatments for autism. A comprehensive list of treatments would be impossible – but here are some of the common treatments promoted by naturopaths:CEASE Therapy
Anke Zimmerman, a naturopath in Victoria, British Columbia offers Complete Elimination of Autistic Spectrum Expression (CEASE) therapy which uses homeopathy to apparently rid the autistic child of vaccine toxins. Homeopathy is an elaborate placebo system, with no medicinal effects. Here’s it’s pseudoscience that’s neatly packaged snake oil and promoted to parents of autistic children.Autonomic Response Testing
Eugene Quan, a Calgary naturopath claims he can cure autism:
We now know that autism is not a psychological disorder. It is biomedical … viruses, bacteria, candida, parasites, and heavy metals cause the behaviours that lead to an autism diagnosis. Once you remove what is causing the symptoms, you can remove the diagnosis … Dr. Quan at Western Naturopathic in Calgary can help your child become autism-free in 1-2 years. Dr. Quan uses Autonomic Response Testing for clear patient assessments, resulting in successful individualized treatment plans. Dr. Quan guides us through a myriad of options, organ-supportive protocols, the vaccine issues, healing the gut, parasites, mould sensitivity, stemming, seizures, speech issues, tonsils, soul awareness, and biofilm elimination. His approach is making a positive difference in the lives of many children and parents searching for options.
Autonomic Response Testing is a variation of applied kinesiology, where muscles are “tested” to determine “sensitivities” to different products. ART is complete pseudoscience and there’s no scientific evidence that ART or applied kinesiology is anything other than a parlour trick – or in this case, a bogus diagnostic.Food Intolerance Testing
Sharon Behrendt, a naturopath in Orleans, Ontario claims that children with autism are suffering from food allergies:
Many children with ASD have food allergies, due to abnormalities in their digestive and/or immune systems. If food is not broken down and digested, then the partly digested food can pass from the gastrointestinal tract into the bloodstream. The immune system recognizes those foods as foreign to the body, and may launch an immune response to those foods, including brain inflammation. These food allergy reactions are called IgG, or delayed, food reactions, as they can take hours or even a couple of days to occur.
Perhaps not surprisingly, Behrendt wants you to stay away from gluten and milk. She also claims:
Removing allergic foods can result in a wide range of improvements in up to 65% of ASD children, in particular improvements in behavior, focus and concentration.
Citation required. I’ve blogged extensively about how naturopaths do not diagnose or treat allergies according to scientific principles. IgG food testing offered by naturopaths is clinically useless and is not recommended by medical professionals for allergy testing. IgG testing leads to unnecessary and potentially harmful food restrictions, with no relationship between the IgG test and autism.
Behrendt also recommends juicing (delicious, but medically useless) and B12 injections (useless, unless you’re deficient).Supplements, Supplements, Supplements
Marianne Fernance, a naturopath in Brisbane, Australia, recommends detoxification, but also vitamin B12, zinc, and magnesium, as well as essential fatty acids for children with autism. The reality is that many children with autism are placed on (sometimes highly restrictive) diets, which increases the risk of nutritional deficiencies if close attention isn’t paid to nutrient intake. The evidence seems to show that special diets do not work for autism, so unless there is a clear dietary restriction or deficiency, supplementation should not be necessary.Low-Dose Naltrexone
Nicola McFadzean Ducharme, a naturopath in San Diego, California, recommends low-dose naltrexone for autism. Steven Novella has a much longer summary of the lack of evidence that supports LDN. In short, LDN is an opiate antagonist, usually used to treat narcotic overdoses by blocking the drug’s action at the cell receptor. When used at very low doses, there’s no convincing evidence it has any established role in the treatment of autism.Chelation
McFadzean Ducharme also advertises chelation, a common pseudoscientific treatment offered by naturopaths:
Heavy metal toxicity is a key component in many children suffering with autistic-spectrum disorders. Whether through exposure via environmental factors such as contaminated food or water, or vaccinations these toxins are detrimental to your child’s health. The detection of toxicity levels of heavy metals is challenging and sometimes difficult to quantify. Tests such as hair analysis (Great Plains or Doctor’s Data) are a good place to start and can give some useful information with regards to the potential of heavy metal poisoning. However, it is important to realize that hair testing is a screening tool and further diagnostics may be necessary to qualify heavy metal toxicity.
Chelation has legitimate uses when it’s part of a protocol for actual heavy metal poisoning. You don’t diagnose heavy metal poisoning with hair testing, however. The hair testing is simply used to give the provider the impetus to recommend useless treatments. When used by alternative medicine providers, chelation is quackery used to remove fictitious “toxins” in the body. There is no credible evidence tthat supports the use of chelation in autism. What’s concerning about chelation is that the intravenous infusions are not without risks, and chelating children with autism has caused deaths.Conclusion
Like other medical conditions, naturopaths do not look at autism in science-based ways. Many seem to place a strong emphasis on environmental factors as causes, sometimes calling out vaccines as contributors. Naturopaths offer an array of pseudoscientific treatments they call “biomedical”, with some practitioners claiming that autism biomed can “cure” autism. The reality of autism biomed is quite different than the vision promoted by practitioners. There are countless autism biomed interventions, but there is one universal feature: There is no convincing evidence that autism biomed treatments have any meaningful therapeutic effects on the features of autism. Autism biomed is anecdote driven experimentation and ultimately health quackery. There is no convincing evidence that naturopathy has anything meaningful to offer for the treatment of autism.
A new study published in JAMA sheds further light on a controversial question – whether or not to prescribe low-dose aspirin (81-100mg) for the primary prevention of vascular disease (strokes and heart attacks).
Primary prevention means preventing a negative medical outcome prior to the onset of disease, in this case preventing the first heart attack or stroke. Secondary prevention refers to treatments given to patients who have already had their first heart attack or stroke in order to reduce the risk of subsequent events.
The evidence strongly supports the efficacy of aspirin for the secondary prevention of both heart attacks and strokes. Aspirin has two effects which likely contribute to this protective effect. First, aspirin is an anti-platelet agent – it reduces the stickiness of platelets, which are cell fragments in the blood that clump together to stop bleeding. They can also clump together around an ulcerated cholesterol plaque on an artery, forming a thrombus, resulting in blockage or embolus (the clot traveling downstream) and causing either a heart attack or stroke.
Other anti-platelet agents, such as clopidogrel, are also effective in preventing stroke and heart attack.
Of course, platelets exist for a reason, and blocking their action increases the risk of bleeding or can make bleeding worse when it occurs. Therefore determining the optimal dose and target population are important to maximize the benefit of aspirin or other anti-platelet agent while minimizing the bleeding risk.
A second mechanism of aspirin which likely contributes to its protective effect is that it is an anti-inflammatory. Inflammation likely contributes to atherosclerotic disease. This anti-inflammatory effect may also provide protection for diseases other than vascular disease. For example, there is some evidence that aspirin may also be useful in the prevention of certain types of cancer. However, as with primary prevention, any potential benefit is small compared to the burden of the disease, and has to be carefully weighed against side effects.
So, while it is the standard of care to prescribe daily aspirin or an equally effective drug to patients who have had a vascular event, it remains somewhat controversial whether aspirin should be given for primary prevention, and if so, in which populations.
A 2009 systematic review of aspirin for primary prevention concluded:
Aspirin reduces the risk for myocardial infarction in men and strokes in women. Aspirin use increases the risk for serious bleeding events.
We have found that there is a fine balance between benefits and risks from regular aspirin use in primary prevention of CVD.
That about sums up the situation – a fine balance. This means that we are trying to find slight advantages by studying very large populations and following them for many years. Perhaps, in the right patient population (those with a certain risk), we might eke out a small outcome advantage. In the US we tend to prescribe aspirin for primary prevention in high-risk populations, those with high cholesterol, hypertension, and diabetes, for example.
On this background comes the new study from Japan. They followed 14,464 patients for up to 6 years, but with a mean follow up of 5 years. Half received aspirin and half received no aspirin. This was an open-label trial with no placebo. Study outcomes were adjudicated by a blinded multidisciplinary expert panel.
The study, which was for primary prevention but in high-risk patients, found that the incidence of non-fatal heart attacks were reduced by about 50% in the aspirin group and non-fatal strokes by about 40% in the aspirin group. However, fatal events were not reduced. Further, when all cardiovascular outcomes were combined, there was no statistically significant difference between the groups.
These results, in my opinion, keep the waters just as muddied as they were previously. Proponents of aspirin use in high-risk patients can point to the reduction in heart attacks and stroke, while critics can point to the lack of overall decrease in events, and to the lack of effect on survival.
It is also reasonable to ask if this Japanese population can be generalized to other populations. While the Japanese diet and therefore risks have been increasingly Westernized over recent decades, they continue to have lower overall risk than in the West (heart disease mortality rate is 1/3 to 1/5 that in the US). Lower risk means lower benefit from prevention.Conclusion
While this recent study failed to show an overall benefit from low dose aspirin for the prevention of vascular events, it did show a benefit for the reduction in non-fatal heart attacks and strokes. Further, it is not clear if the study population can be applied to Western populations, especially since there is such a fine line between risk and benefit with this treatment.
In terms of the stakes of this question, you can look at it in one of two ways. From the individual perspective, the balance between risk and benefit for aspirin for primary prevention is slight. Aspirin will have a small statistical effect on overall health risk and may not have any net effect on survival.
From a population-based perspective, however, given the total burden of heart attacks and strokes, even a small statistical decrease in risk may translate into a large number of prevented events.
With this new study I think we are left in the same situation as before. Aspirin (or other anti-platelet or blood thinning treatment, as appropriate) should be used for secondary prevention of vascular disease – heart attacks and stroke. It should be considered for primary prevention in patients who are at risk for vascular disease, but an individualized decision should be made based on various factors. We cannot make, however, a blanket recommendation for aspirin for primary prevention.
A new stool DNA test was recently approved by the FDA for colon cancer screening. My first reaction was “Yay! I hope it’s good enough to replace all those unpleasant, expensive screening colonoscopies.” But of course, things are never that simple. I wanted to explain the new test for our readers; but before I could start writing, some other issues in cancer screening barged in and demanded to be included. They exemplify the dilemmas we face with every screening test. We have covered these issues before, but mainly in reference to mammography and prostate (PSA) screening. My article morphed into a CLT sandwich: colon, lung, and thyroid cancer screening.
The current issue of American Family Physician has a great article on cancer screening. It uses lucid graphics to illustrate lead time bias, length time bias, and overdiagnosis bias, as well the effect of varying tumor growth rates on screening success rates, all concepts that have been covered by Dr. Gorski here. Briefly, screening may do more harm than good…
Current recommendations advise screening after age 50 by any of three methods: colonoscopy every 10 years, flexible sigmoidoscopy every 5 years, or fecal occult blood (FOBT) testing every year. Sigmoidoscopy and FOBT screening have been shown to reduce the number of deaths from colorectal cancer, but colonoscopy has not; studies are in progress. There is as yet no good evidence that any colon cancer screening test reduces overall mortality. Colonoscopy is considered the gold standard because polyps and cancers can be directly visualized and biopsied, but as yet there is no good evidence from controlled studies to confirm our reasonable assumption that it ought to be the best screening test to reduce deaths from colon cancer. It is generally considered the preferred screening option; but it is invasive, requires an unpleasant bowel prep, is unacceptable to many patients, is expensive, requires sedation, carries risks, and consumes a lot of specialist time and resources.
Colonoscopy identifies cancers directly; other tests use indirect methods. Blood in the stool can be a sign of colon cancer, and fecal occult blood testing (FOBT) uses guaiac to detect blood in the stool that isn’t obvious to the naked eye. It requires 3 stool samples and avoidance of foods that could cause a false positive test. Fecal immunochemical testing (FIT or iFOBT) requires only a single sample with no dietary restrictions, and it is less likely than guaiac testing to confuse bleeding from the upper digestive tract with bleeding from the colon.
The new DNA test (Cologuard) also requires only a single specimen and no dietary restrictions. It doesn’t look for blood; it looks for DNA markers associated with colorectal cancers. It detects more polyps and more cancers than previous fecal tests, but has more false positive results.
According to The Medical Letter, the new DNA stool test “detected 92% of cases of colorectal cancer in asymptomatic average-risk persons, but it detected less than half of advanced precancerous lesions and produced a substantial number of false-positive results.” It costs $599. The appropriate interval for screening has not been established; Medicare is considering reimbursement for testing every 3 years. A positive screening test must be followed by colonoscopy. So this test is promising; but it is no panacea, and questions remain. We’ll have to wait for controlled studies to tell us whether it can replace colonoscopy screening or reduce all-cause mortality. Until we have that data, it is a reasonable option for patients who refuse colonoscopy.
Lung cancer is responsible for 27% of all cancer deaths in the US, and 33% of deaths in smokers. We used to do annual chest x-rays, but they missed small cancers and the larger ones they detected were often untreatable. We stopped doing them once we realized they didn’t improve survival. With computed tomography (CT) there is a better chance to detect small cancers that have not yet metastasized. If we did annual CTs on everyone, we would get way too many false positives and expose people to radiation for no benefit; so screening is directed at high-risk individuals. Since 1999 several studies have evaluated low dose CT to screen smokers for lung cancer. Screening reduces all-cause mortality by 6.7%. To detect one case of cancer, 320 smokers have to be screened for 5 years.
There are some problems:
The United States Preventive Services Task Force currently recommends annual screening for lung cancer with low-dose CT in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should stop when the person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. The American Academy of Family Physicians adds that it should only be done in conjunction with smoking cessation interventions.
Korea is in the midst of an apparent thyroid cancer epidemic: between 1993 and 2011, the incidence rose by a factor of 15. More than 40,000 Koreans were diagnosed with thyroid cancer in 2011. The rate of diagnosis has skyrocketed, but the death rate has not changed; the number of deaths from thyroid cancer has remained stable, between 300 and 400 deaths a year. This isn’t a true epidemic; it’s a consequence of over-diagnosis from injudicious screening.
Korea has national health insurance. In 1999 it implemented a free national screening program for cancers of the breast, cervix, colon, stomach, and liver. Ultrasound screening for thyroid cancer was offered as an add-on for a small copayment. Many people who opted for ultrasound screening were found to have small cancers. We have long known that at least one third of adults have small thyroid cancers; most of these never produce symptoms and are only found at autopsy after people die of something else. Guidelines recommend against surgery for tumors smaller than 0.5 cm, but the guidelines are frequently disregarded. Most patients are treated: 2/3 with radical thyroidectomy, 1/3 with subtotal thyroidectomy. Most of them require lifelong thyroid replacement therapy, 11% develop hypothyroidism, and there are surgical complications including a 2% risk of vocal cord paralysis and even a small risk of death.
The incidence of thyroid cancer diagnoses has also more than doubled in the US and several other countries. Ultrasound has a role in diagnosis, but indiscriminate ultrasound screening for thyroid cancer clearly does more harm than good, and can’t be recommended.
You might think we should always screen everyone for all kinds of cancer because early detection saves lives. We shouldn’t always, because sometimes it doesn’t. This is a hard message to get across to the public and even to some doctors.
Technological advances will continue to improve screening tests; but we will always face difficult decisions about who to screen and when.
A few weeks ago, Steve Novella invited me on his podcast, The Skeptics’ Guide to the Universe, to discuss a cancer case that has been in the news for several months now. The case was about an 11 year old girl with leukemia who is a member of Canada’s largest aboriginal community. Steve wrote about this case nearly a month ago. Basically, the girl’s parents are fighting for the right to use “natural healing” on their daughter after they had stopped her chemotherapy in August because of side effects. It is a profoundly disturbing case, just as all the other cases I’ve discussed in which children’s lives are sacrificed at the altar of belief in alternative medicine, but this one has a twist that I don’t recall having dealt with before: The girl’s status as part of the First Nations. Sadly, on Friday, Ontario Court Justice Gethin Edward has ruled that the parents can let their daughter die.
The First Nations consist of various Aboriginal peoples in Canada who are neither Inuit nor Métis. There are currently more than 630 recognized First Nations governments or bands in Canada, half of which are located in Ontario and British Columbia. This girl lives in Ontario, which is basically just next door to Detroit, just across the Detroit River. Unlike previous cases of minors who refuse chemotherapy or whose parents refuse chemotherapy for them that I’ve discussed, such as Sarah Hershberger, an Amish girl whose parents were taken to court by authorities in Medina County, Ohio at the behest of Akron General Hospital, where she had been treated because they stopped her chemotherapy for lymphoblastic lymphoma in favor of “natural healing,” or Daniel Hauser, a 13-year-old boy from Minnesota with Hodgkin’s lymphoma whose parents, in particular his mother, refused chemotherapy after starting his chemotherapy and suffering side effects, there’s very little information about this girl because of Canadian privacy laws. I do not know her name. I do not know anything about her case except that she has acute lymphoblastic leukemia, that she started treatment but her parents withdrew her because of side effects.
All these cases that I’ve written about over the years here and elsewhere, a depressing number that includes children such as Katie Wernecke, Abraham Cherrix, Daniel Hauser, Jeremy Fraser, Jacob Stieler, Sarah Hershberger, or others, follow a very similar script. It’s a script that on many an occasion has led me to quote Elton John sadly, “I’ve seen that movie, too.” Here’s the basic script:
How do these stories end? Sometimes they end with the death of the child. Sometimes the child lives (I’ll explain why a little later). Ofttimes it’s very difficult to find out what happened to the child, as I’ve found out to my frustration over the years. For instance, I have not been able to find out much about Sarah Hershberger since March, when Tracy Oppenheimer of Reason.com defended her medical neglect in the name of health freedom. (What are the deaths of some children with cancer compared to health freedom, eh?)
This First Nations case adds a different spin on the subject, but the script remains more or less the same. This time around, the parents have won the right to let their daughter die a horrible death from cancer based on aboriginal rights.
Aboriginal children now have the right to refuse life-saving medical treatment in favour of traditional healing.
The Friday ruling has nothing to do with whether aboriginal medicine works.
Family court heard unequivocally in the case of a First Nations girl refusing chemotherapy that no child has survived acute lymphoblastic leukemia without treatment.
Instead, it’s about Canada’s Constitution protecting aboriginal rights.
Ontario Court Justice Gethin Edward has now expanded those rights to include traditional healing, saying “there is no question it forms an integral part.”
“This is monumental for our people all across the country,” said Six Nations Chief Ava Hill. “This is precedent-setting for us.”
No doubt this ruling is monumental and precedent-setting, but in a very bad way. So, in other words, our neighbor to the south (at least to me in southeast Michigan, which is the only place where Canada is to the south) have declared that letting children die of cancer is an “integral” part of aboriginal identity. I am not exaggerating. The court apparently didn’t even take into account whether the “natural healing” chosen by the girl’s family works. Meanwhile, Six Nations Chief Ava Hill is exulting over the ruling, apparently unconcerned that it will result in the death of an 11 year old girl. As I’ve said many times before, a competent adult should have the right to choose any form of medicine he likes or even to choose no treatment at all, but children are different. They are not capable of understanding the implications of their decision, and this girl, at 11 years old, isn’t even in the gray area of the later teen years where an argument can sometimes be made for self-determination even though the child is a minor. They need and deserve protection from such outrageously bad choices on the part of the parents.
This case is a complete failure on the part of the province of Ontario and of Canada itself to protect the lives of its most vulnerable members, children, particularly children of a minority group. Even worse, it is an indictment of Fist Nations, which, rather than seeking to protect one of the most vulnerable members of its community, a girl with a treatable, potentially curable cancer, instead glommed onto this case as a vehicle to promote its rights vis-a-vis the Canadian government. I don’t think it was cynically done; no doubt the leaders of this particular First Nations community and Six Nations Chief Ava Hill believe in their aboriginal natural healing. On the other hand, it’s hard not to think that there was some opportunism given that the parents appear not to have even chosen to use aboriginal “natural healing” techniques.
Instead, they are using the rankest quackery, which has nothing to do with aboriginal natural medicine, administered by Brian Clement in a “massage establishment” in Florida:
A Florida health resort licensed as a “massage establishment” is treating a young Ontario First Nations girl with leukemia using cold laser therapy, Vitamin C injections and a strict raw food diet, among other therapies.
The mother of the 11-year-old girl, who can not be identified because of a publication ban, says the resort’s director, Brian Clement, who goes by the title “Dr.,” told her leukemia is “not difficult to treat.”
Another First Nations girl, Makayla Sault, was also treated at Hippocrates Health Institute in West Palm Beach and is now critically ill after a relapse of her leukemia.
Somehow, I doubt that the traditional healing methods used by First Nations people have ever included cold laser therapy or vitamin C injections. Looking at Makalaya Sault, you will see the future of this First Nations girl: Relapse. But what about Brian Clement? I’ve encountered him before this case but have never actually written about him for SBM. Let me tell you about him.Who is Brian Clement, anyway?
In brief, he is, in my opinion, a quack. If you have any doubt, start by looking at what he is quoted as saying in this news story:
He’s been giving lectures in and around both girls’ communities in recent months, including one event attended by Makayla’s family this past May.
In a video obtained by CBC News, Clement says his institute teaches people to “heal themselves” from cancer by eating raw, organic vegetables and having a positive attitude.
“We’ve had more people reverse cancer than any institute in the history of health care,” he says.
“So when McGill fails or Toronto hospital fails, they come to us. Stage four (cancer), and they reverse it.”
The mother of the girl whose identity is protected says she knew as soon as her daughter was diagnosed that she wanted to seek treatment at Hippocrates, a clinic she was familiar with through a relative, but didn’t have the money to go.
After securing financial support from family, she called Clement from the hospital waiting room on the 10th day of her daughter’s chemotherapy.
The story goes on to describe how the mother called Clement while her child was receiving chemotherapy and found how “confident” he sounded. As soon as he said he could help, the mother quit the chemotherapy for her daughter.
It’s all depressingly similar to a story I encountered about a year ago. It was the story of a young mother in Ireland who had been diagnosed with stage IV breast cancer and chosen the “alternative route.” She, like the anonymous young First Nations girl and Makayla Sault, found her way to the Hippocrates Health Institute. This young woman, Stephanie O’Halloran, was only 23 years old, an age range at which breast cancer is rare, but not unheard of. Here’s how she found out about the Hippocrates Center:
Declan said: “Ann’s sister in England heard about this treatment, which centres on a diet of raw vegetable, and she met the head of the clinic, Brian Clement, in Galway about two months ago.
“He told her he could help, but not to leave it too late.
“After the meeting we did a lot of soul searching and we prayed to the Lord.
“Stephanie is a very positive person and four weeks ago, she went to Florida where she spent 21 days starting on the programme. She came home at the weekend and is still very tired after the long flight. She feels much better.”
At the time, I had never heard of the Hippocrates Health Institute (HHI) or the doctor, Dr. Brian Clement before; so, as is my wont, I went to the source, the Hippocrates Health Institute website. It didn’t take long for me to figure out that its programs were a veritable cornucopia of nearly every quackery on the planet, including at least one I hadn’t realized that people did. Let’s just start with this list described in the HHI’s “Life Transformation Program“:
Yes, indeed, there it is: enemas, “infrared saunas,” and all manner of other quack treatments. But what are “implants”? It turns out that wheatgrass “implants” are, in actuality, wheatgrass juice enemas:
When used as a rectal implant, reverses damage from inside the lower bowel. An implant is a small amount of juice held in the lower bowel for about 20 minutes. In the case of illness, wheatgrass implants stimulate a rapid cleansing of the lower bowel and draw out accumulations of debris.
It also seems that there’s nothing that wheatgrass can’t do. If the HHI is to be believed, wheatgrass can increase red blood cell count, decrease blood pressure, cleanse the blood, organs and GI tract of “debris,” stimulate the thyroid gland, “restore alkalinity” to the blood, “detoxify” the blood, fight tumors and neutralize toxins, and many other things. Basically, boiling it all down, I found that HHI advocates raw vegan diets, wheatgrass (as part of the aforementioned raw vegan diets), and various other forms of quackery plus exercises as a cure for, well, almost everything. I’ve often said that one undeniable indication that a clinic is a quack clinic is whether it offers a certain treatment modality? The HHI offers this treatment modality. Can you guess which one? Yes, it’s the infamous “detox” footbath known as Aqua Chi.
All you need to know about this particularly ridiculous form of “detox” quackery has been written about before. Suffice to say, the “toxins” that such footbaths supposedly remove through the feet don’t exist, and the water would change color regardless of whether a customer has her feet in the water or not. Of course, detox footbaths aren’t all. Other quackery abounds, such as intravenous vitamin therapy, cranial electrotherapy stimulation, combination infrared waves plus oxygen, acupuncture, colon hydrotherapy (apparently with or without wheatgrass) and lymphatic drainage. There’s so much there, that the über-quack Joe Mercola featured Dr. Clement on his website last year:
There’s some serious, serious quackery in this interview, a transcript of which can be found here, if you can’t stand to watch a full hour plus of this stuff. For example, there are a lot of parts where Dr. Clements says stuff like this:
Photons come down in the secondary stage, they hit the earth. They transmute into different frequencies. Those frequencies are what create the physical body or the energetic body we really are. When you and I are talking and thinking and people are listening, that’s the energetic body. The physical body that you’re sitting watching us here now, that’s created by the microbial effect in the soil, which are still the protons but recycled or re-cached protons. It’s great stuff.
It’s great stuff if you are entertained by extravagant quackery, as I am. In the context of knowing that an 11 year old First Nations girl is having her cancer treated by this quack, not so much. That’s why I stopped there, as I couldn’t take any more. Neither, apparently, could Katie Drummond, who wrote a scathing takedown of the “health program” offered at HHI, who reassures us that if you’re not into wheatgrass enemas, don’t worry about it. HHI offers them “in ‘Original’ and ‘Coffee’ varieties.” Imagine my relief. Unfortunately, that relief is rapidly eliminated by learning that HHI also offers quack modalities such as “live blood cell analysis.”
Anyway, let’s move on.
Perhaps the most unusual form of quackery offered at HHI is something called colorpuncture:
Based on modern biophysics and ancient Chinese medicine, color frequencies are applied to acupuncture points using a light pen and crystal rods. This promotes hormonal balance, detoxification, lymph flow and immune support while reducing headaches and sleeplessness. Working on cellular memory where the cause of disease resides, color puncture promotes healing from within. 50 minutes $120
All of this makes me sad. Very sad. It’s because I know that, however much I might laugh at the utter ridiculousness and lack of science behind Dr. Clement’s treatments and quackbabble, I know that patients like Stephanie O’Halloran, whose story depressed me to no end when I learned of it and depresses me even more now that I’ve followed up on her case and learned that she died a few months ago, fell for this. I know that Makayla Sault, who, unlike O’Halloran, had a highly treatable tumor, fell for this. I know that a little girl from First Nations, who also has a highly treatable tumor, is being subjected to this quackery. The only thing HHI can accomplish for any of these unfortunate cancer patients is to drain their parents’ bank accounts and drive them to seek many thousands of dollars to pay for Clement’s treatments, all while giving their parents false hope. Already, the First Nations girl’s family has paid Clement $18,000 and counting.
This is the “alternative healing” that the First Nations girl’s mother has chosen instead of effective chemotherapy. In essence, the parents and First Nations petitioned Ontario courts and Justice Gethin Edward acquiesced to letting First Nations parents have the right to let their children die through medical neglect. It might well be that Justice Edward’s ruling was legally correct and he had no real choice, but the end result will be the same: The death of a girl who otherwise would have a very good chance of living a long and productive life. Worse, his reasoning included this:
But Justice Gethin Edward of the Ontario Court of Justice suggested physicians essentially want to “impose our world view on First Nation culture.” The idea of a cancer treatment being judged on the basis of statistics that quantify patients’ five-year survival rate is “completely foreign” to aboriginal ways, he said.
“Even if we say there is not one child who has been cured of acute lymphoblastic leukemia by traditional methods, is that a reason to invoke child protection?” asked Justice Edward, noting that the girl’s mother believes she is doing what is best for her daughter.
“Are we to second guess her and say ‘You know what, we don’t care?’ … Maybe First Nations culture doesn’t require every child to be treated with chemotherapy and to survive for that culture to have value.”
Every parent who chooses quackery over effective medicine believes she is doing what’s best for her child. Every single one of them. The same is true of parents who thought that prayer could cure pneumonia or diabetes. That’s not a reason to deny such children protection. More disturbing, however, is Justice Edward’s last sentence, in which he seems to be shrugging his shoulders and saying, “So what if a few aboriginal children die anyway? It’s just their culture.” Or, as Steve aptly put it, using human sacrifice as a reductio ad absurdum of the judge’s argument: “Are we to second guess her and say ‘You know what, we don’t care?’ … Maybe First Nations culture doesn’t require every child to survive infancy without being sacrificed for that culture to have value.”
It’s understandable, given Canada’s history of riding roughshod over the wishes of First Nations families, such as the case of residential schools pointed out by Arthur Schafer, that the court would want to bend over backwards to respect the wishes of the parents. However, in doing so, Justice Edward utterly failed to take the best interests of the child into proper account.How does this sort of thing happen?
Steve also correctly noted that the outcome of such legal battles often hinge on the reasons given by the parents for refusing chemotherapy. If, for example, they simply use medical opinions as a justification (i.e., they disagree with their doctors), the state is usually pretty quick and decisive in taking action. This is the sort of situation that ruled Daniel Hauser’s case, and ultimately Hauser underwent effective chemotherapy and lived. If, on the other hand, religion or culture is used as justification for choosing quackery over effective treatment, courts seem to be much less willing to step in and see that the child receive effective treatment. For instance, in 2009 Catherine and Herbert Schaible in the Philadelphia area to choose prayer over antibiotics for pneumonia for their first child. The child died. The Schaibles received ten years probation and had to promise, in essence, that their other children, who were not removed from their care, would receive modern medical care. In 2013, a second child, who was 8 months old at the time, died the same way. It took the second death of a child before the state actually took their children away and put htem in jail. The same dynamic came into play in the case of Sarah Hershberger, where Medina County authorities were reluctant to be too harsh because they were Amish, and their culture valued “natural healing.” Clearly, the same dynamic has led to Justice Edward’s tragic decision with respect to this First Nations girl.
Also at play is an attitude that ascribes absolute rights to parents over their children. It’s a toxic attitude that is often mixed with a general distrust of government and medical authority that fails to acknowledge that children are separate beings with their own rights aside from the rights of the parents. Those rights include the right to not to suffer from medical neglect. As has been pointed out, parents don’t have the right to kill their children; they shouldn’t have the right to let them die through medical neglect, as the parents of this First Nations child are doing.
For all my railing against the medical system, what’s really critical here is understanding why parents make these choices. Having a child with cancer is a horrible, terrifying thing to go through. Having to watch a child suffer the complications of chemotherapy with the child not understanding why it’s necessary is even harder. It’s very understandable that parents with a tendency toward believing in natural medicine or with just a distrust of medical authorities in general would be tempted by the siren song of quacks claiming that they can cure the child without all the toxic side effects of chemotherapy. In particular, it’s often hard for parents to understand why, after tumors frequently shrink away to nothing after the first couple of courses of chemotherapy, more chemotherapy is needed.
Unfortunately, for most pediatric tumors it takes a lot more than just a round or two of chemotherapy, a lesson painfully learned by pioneering pediatric oncologists back in the 1960s and 1970s. For the type of tumor that, for example, Sarah Hershberger has, lymphoblastic lymphoma, the duration of one standard treatment is two years. For chemotherapy for lymphoma, there are at least three phases. The induction phase is designed to put the patient into remission. Consolidation chemotherapy is given to patients who have gone into remission and is designed to kill off any residual cancer cells that might be present, thus increasing the chance of complete cure. Maintenance chemotherapy is the ongoing, longer term use of chemotherapy to lower the risk of recurrence after a cancer has gone into remission. It’s basically lower-dose chemotherapy given for two to three years to help keep the cancer from returning. In Sarah Hershberger’s case, her oncologist recommended chemotherapy consisting of five phases: induction (5 weeks), consolidation (seven weeks), interim maintenance (eight weeks), delayed intensification (six weeks), and maintenance (90 weeks), for a total duration of two years, three months. In this First Nations girl, who has lymphoblastic leukemia, the treatment will involve at least three phases: remission induction, consolidation/intensification, and maintenance lasting a similar amount of time.
It’s thus understandable how parents, after seeing the tumor melt away during induction chemotherapy, wonder why all this additional chemotherapy is needed. It’s quite possible that after induction chemotherapy the First Nations girl had no detectable cancer. If that’s the case, it’s the chemotherapy that she’s received thus far that almost certainly caused that result, not any quackery to which Clement has been subjecting her. If the girl is apparently tumor-free, it also means that failing to consolidation and maintenance chemotherapy greatly increases the chance that her leukemia will relapse. Worse, relapsed cancer is always harder to treat. The first shot at treating cancer is always the best shot, with the best odds of eradicating the cancer. Letting cancer relapse through incomplete treatment breeds resistant tumor cells the same way that not finishing a complete course of antibiotics contributes to the development of resistant bacteria. It’s evolution in action.
Some children will be fortunate enough to have had their cancer eliminated completely after induction and will survive to become testimonials used in support of such parents’ actions, but they are the minority. Depending on when the chemotherapy is stopped relative to the complete recommended course, most will not be so lucky. Parents also often have a view that it is the chemotherapy that is the cause of the child’s suffering, believing that if they stopped the chemotherapy the suffering would stop and, even if the child dies it would not be as bad for her as the chemotherapy. Unfortunately, death from cancer is not pretty. It’s worse than chemotherapy. Stopping chemotherapy early might relieve suffering for a while, but only at the price of an ugly death later.
Somehow, there has to be a way to get such parents to see this, to teach them the very basics of cancer biology, why chemotherapy regimens for pediatric malignancies are as long as they are, and what the consequences of not finishing chemotherapy are. Remember, the parents are almost always only interested in what they believe to be best for their child, and they are suffering in a different way as they watch their child suffer the side effects of chemotherapy. When their child is crying that she can’t take it any more, when she’s vomiting and feeling very sick due to the chemotherapy, it’s very hard for parents to see that it’s worth this pain if the tumor is already gone. They need support systems to help them deal with this. Most pediatric cancer centers provide such support, but it isn’t always enough. Again, although my memory is by no means comprehensive, since I started paying attention to these cases ten years ago, I can’t recall a single case of parents who refused chemotherapy for their child until after the child had undergone at least a couple of cycles and suffered the expected side effects. I’m sure such parents probably exist, but they must be rare, because I’ve paid a lot of attention to these sorts of cases over the years, and I can’t recall one.
Finally, when faced with parents wanting to stop chemotherapy, oncologists have to be very careful not to come across as bullying, something I suspect that they sometimes do without realizing it when hearing a parent tell them she is going to stop chemotherapy. It’s understandable that physicians and nurses would react that way. Pediatric oncologists become pediatric oncologists because they want to save the lives of children with cancer, and nurses working on pediatric oncology wards work their for the same reason. It’s understandable that they react with alarm to such pronouncements by parents and might become angry or strident. After all, the child is their patient, not the parents, and the parents have just become an obstacle to saving the child’s life. When parents threaten to stop chemotherapy, it is often a cry for help; they’re telling doctors that they can’t handle seeing their child undergo chemotherapy any more. Sensitivity is required in working with them.
None of this, however, means that, if push comes to shove and the parents can’t be moved with all the understanding and empathy in the world, the interests of the child shouldn’t come first. The interests of the child must come first, and if parents can’t be persuaded to continue treatment of a highly curable tumor, then the state has a duty to step in. It’s a duty at which Ontario and Canada have failed in the case of this First Nations girl. It’s also a duty that First Nations authorities who supported the parents in filing suit have utterly failed to uphold.
Be less curious about people and more curious about ideas. – Marie Curie’s advice to journalists
Harvard psychologist Ellen Langer was on CBS This Morning News explaining plans for a psychosocial intervention study with women with Stage IV metastatic breast cancer. The project would attempt to shrink women’s tumors by shifting their mental perspective back to before they were diagnosed.
Seeing her on TV unsettled me because I had just supplied a journalist with quotes for his article in the New York Times about Langer. I hadn’t been following her recently. Instead I focused on her now famous study of the 70s. Langer had claimed giving nursing home residents a plant for which they were responsible cut their mortality by half (the nursing home residents, not the plant), compared to residents whose plants were attended by staff. The paper continues to get uncritical coverage in the media and in psychology introductory texts.
I looked up the Times article after seeing CBS This Morning News, and it accurately quoted me:
The study that arguably made Langer’s name — the plant study with nursing-home patients — wouldn’t have “much credibility today, nor would it meet the tightened standards of rigor,” says James Coyne, professor emeritus of psychology at the University of Pennsylvania medical school and a widely published bird dog of pseudoscience. (Though, as Coyne also acknowledges, “that is true of much of the work of the ’70s, including my own concerning depressed persons depressing others.”) Langer’s long-term contributions, Coyne says, “will be seen in terms of the thinking and experimenting they encouraged.”
However, the quote from me was the single discordant note in a longread article singing praise of Langer’s medical studies in which
Results were almost too good. They beggared belief. “It sounded like Lourdes,” Langer said.
The study providing plants to nursing home residents have a key role in shaping her thinking:
To Langer, this was evidence that the biomedical model of the day — that the mind and the body are on separate tracks — was wrongheaded.
In the CBS news interview, Langer explained further:
CBS Anchor Gayle King: What is your theory? How does it work?
Langer: The mind-body unity theory. Right now this problem around forever is “how do you get from this fuzzy thing called a thought to the body?” Although everybody knows there is an effect. Walking down the street, the wind blows in your face, you get startled, your blood pressure increases, your house, and so on, till you see that it is only been a leaf. And so I said, well, let’s forget about how you get from one to the other… And see those as just words, mind and body. You put the mind and body back together and anything you putting into the mind you necessarily putting into the body.
I had been familiar with only one side of Ellen Langer’s career. She had done a number of famous psychology experiments, sometimes loosely controlled and extravagantly interpreted, but nonetheless respectable. But in the article TV interview she comes across as a New Age quack. I learned elsewhere in the Times article that Deepak Chopra
credits Langer with a profound influence on his thinking as a young doctor, and later as an author and lecturer on spirituality and mind-body medicine.
And Langer has been labeled as the mother of positive psychology:
Tal Ben-Shahar, who taught a popular undergraduate course at Harvard on the subject until 2008, calls Langer “the mother of positive psychology,” by virtue of her early work that anticipated the field.
I dug out Langer’s 1978 nursing home study, confirmed my skepticism, and blogged about it. Any mortality effect in this small study was likely spurious and disappeared anyway in an obscure erratum that has received none of the attention of the original report.
But let’s get back to the medical claims for which she claims support from 40 years of personal research.
Langer described a study in which she manipulating the sense of time of patients with type II diabetes using a special clock that could be set to display accurate time or run at half or double speed. Details presented in the Times article are sparse, but Langer hypothesized that their blood glucose levels would fall according to the time presented by the special clock, rather than actual time –
In other words, they would spike and dip when the subjects expected them to. And that’s what her data revealed. When a student emailed her with the results this fall, she could barely contain her excitement. “This is the beginning of a psychological cure for diabetes!” she told me
The Times article described the study as “yet to be published” (In press, submitted, or not yet written?). In the CBS Program, she described it as “hot off the press” but still in need of replicating. Langer does not have a record of ever replicating her studies before announcing their results. And if the study is not ready for peer review or even a presentation before a professional audience capable of expressing skepticism, how is it ready for national TV and the New York Times?
The nursing home study may be the one mentioned in textbooks, but it is the so-called Counterclockwise study that garners the most media attention, in part because of Langer has written the book about it with that title and having relentlessly promoted it.
The Times article opens with
One day in the fall of 1981, eight men in their 70s stepped out of a van in front of a converted monastery in New Hampshire. They shuffled forward, a few of them arthritically stooped, a couple with canes. Then they passed through the door and entered a time warp. Perry Como crooned on a vintage radio. Ed Sullivan welcomed guests on a black-and-white TV. Everything inside — including the books on the shelves and the magazines lying around — were designed to conjure 1959. This was to be the men’s home for five days as they participated in a radical experiment, cooked up by a young psychologist named Ellen Langer.
The methods and procedures of this study have never been described in a peer-reviewed article, only a chapter in a book that Langer herself edited. I tracked it down and found there no tables or basic statistics. With only 9 men in the experimental condition and 8 in the control condition, any significant results were unlikely for the battery of measures. This is glossed over in the chapter:
Joint flexibility (finger length) increased significantly more for the experimental group them for the control group. Finger length increased for 37.5% of the experimental group and remain the same for the rest of the group, whereas 33% of the comparison group actually got worse on this measure. Only one person in the latter group improved. There was also an increase in sitting height for the experimental group when compared with sitting height of the control group. Those in the experimental group were able to sit taller, and they also had gained more weight, as measured in body weight, triceps skinfold, and bideltoid breadth.
“Replications” consist entirely of made-for-TV re-enactments, one with aging celebrities.
The shrinking-tumor study will involve three groups of 24 women undergoing therapy for Stage IV breast cancer. One group is a no treatment control. Two of the groups will be sent to a resort in Mexico supervised by Langer and her staff. One group going there will simply receive social support from the other women patients. The other, intervention group will live for a week in environment saturated with cues invoking 2003, a time prior to their diagnosis with breast cancer.
They will be told to try to inhabit their former selves. Few clues of the present day will be visible inside the resorts or, for that matter, outside them. In the living areas, turn-of-the-millennium magazines will be lying around, as will DVDs of films like “Titanic” and “The Big Lebowski.”
These women will have a week of classes in art, cooking, and writing intended to distract them from their condition and reengage them in the health that they experience back in 2003. They will also bring personal reminders of 2003 with them, like photographs. They will be encouraged by Langer’s staff to
purge any negative messages they have absorbed during their passage through in the medical system. This is crucial, Langer says, because just as the mind can make things better, it can also make things worse.
The study raises obvious IRB concerns. The Times article suggests that the Harvard Department of Psychology institutional review board has approved the protocol, but the psychology department does not have an IRB, only the College of Arts and Sciences. I emailed their IRB and asked for the protocol. I immediately got a response.
Dear Professor Coyne
The IRB clarified with Dr. Langer after the NYT article was published whether human subjects activity had occurred since the protocol had not yet been approved. Indeed, we are waiting on the collaborating hospital to complete review; and, it was confirmed that no human subjects activity has occurred
Please direct requests for documents on the study to the Principal Investigator
The protocol is currently under review at M.D. Anderson Cancer Center, where Debu Tripathy, Langer’s oncologist collaborator has now relocated from University of Southern California. At USC, the protocol ran into trouble, some of which involved the language of the consent needing to include acknowledgment that there were no known benefits –
[Langer:] They want me to add a consent form for the people to sign saying there’s no known benefit to them. But that just introduces a nocebo effect!
Aside from the need for disclosure to the patients considering enrollment in the study, what assurance does Langer and her oncologist colleague have of the likelihood of any benefit? The Times article is vague on that. It cites somebody else’s study of baldness and risk for subsequent prostate cancer. Langer’s interpretation:
“Baldness is a cue for old age…Therefore, men who go bald early in life may perceive themselves as older and may consequently be expected to age more quickly.”
The article also cites Langer’s unpublished study that reportedly found breast cancer survivors’ self-description as being in remission was associated with lower functioning and physical health than that of survivors who describe themselves as cured.
Langer apparently has an ongoing study has to whether mindfulness can slow progression of prostate cancer at her Mindfulness* Institute in Bangalore, India. It is unclear what IRB committee approved its protocol or what its consent form states.
There is an additional human subjects issue that is not easily resolved. Part of the justification for involving humans in research, beyond any benefit they individually receive, is the promise of their contributing to scientific knowledge and human welfare. But there is little reason to believe that a study involving a week at a spa for 24 women with metastatic breast cancer will produce statistically significant results publishable in a peer-reviewed journal. I would be quite curious to find any study, even of a biomedical intervention, that has ever yielded statistically significant changes in tumor size in 2 dozen stage IV breast cancer patients with only a week of treatment.
Arguments can be made that even attempting to conduct such an underpowered study is unethical because it denies human subjects the promised opportunity to make a contribution to science. Most cancer centers require review of studies by some sort of Clinical Trials Scientific Review and Monitoring Committee, in addition to IRB clearance. Statisticians pour over the evidence for likely benefit, including formal power analyses based on relevant data. I cannot imagine that this study would pass muster.
My concern is that this spa retreat will not produce credible scientific data, but will get these breast cancer patients involved in providing anecdotes and even videos for use in Langer’s self-promotion. That is not an unreasonable concern. Past studies of support groups with metastatic breast cancer patients have yielded videos used on television and in well-paid talks to lay audiences, despite the lack of evidence that support groups extend survival. Similarly, an underpowered fMRI study conducted by James Coan and Susan Johnson has yielded a video used in promoting Johnson’s workshops, even though results were not significant.
Conflict of interest
Journalist Bruce Grierson has inordinate interest in Langer’s involvement in multiple resort projects around the world. These details might inspire awe among some readers, but they also indicate a potential conflict of interest between doing science and collecting real estate and franchise deals.
Langer told me that she chose San Miguel for her new counterclockwise study primarily because the town had made “an offer I couldn’t refuse.” A group of local businesspeople, convinced of the value of having Langer’s name attached to San Miguel, arranged for lodging to be made available free to Langer. They also encouraged her to build a Langer Mindfulness* Institute, which will take part in research and run retreats. (A local developer donated a beautiful casa, next to his Nick Faldo-designed golf course, to serve as staff quarters for the institute.) Starting sometime next year, adults will be able to sign up for a paid, weeklong counterclockwise experience, presumably with a chance at some of the same rejuvenative benefits the New Hampshire test subjects enjoyed. Langer says she is in conversation with health and business organizations in Australia about establishing another research facility that would also accept paying customers, who will learn to become more mindful through a variety of cognitive-behavioral techniques and exercises…
To my question of whether such a nakedly commercial venture will undermine her academic credibility, Langer rolled her eyes a bit. “Look, I’m not 40 years old. I’ve paid my dues, and there’s nothing wrong with making this more widely available to people, since I deeply believe it.”
And what about the women being recruited for the shrinking tumor study? Will they pay for their spa experience? If not, is being sent to an expensive Mexican spa an inappropriate inducement for consent to participate in the study? And if they survive their stay at the spa and wish to continue, will it be for free or at reduced rates, or will the study participation become an introductory offer for which they will have to continue to pay?
Such enterprises are based on the assumption there is some medical value in the spa experience. This adds to the pressure on Langer to demonstrate such a benefit. Her active involvement in the “experiment” gives her ample opportunities to attempt to influence the results.
Scientist as New Age guru – Once a guru, does the scientist remain?
Ellen Langer’s identification as an eminent, well-published Harvard psychologist is an important part of her branding and the promotion of herself and her products. The promotion is infused with references to her 40 years of research. Yet, she assumes none of the responsibility that goes with being a scientist. She does not consistently submit her work to peer review. She makes references to unpublished studies, even those that have remained so for many years. Some of her studies are described only in an ostensibly peer reviewed journal, Perspectives on Psychological Science, but with insufficient details to allow any independent evaluation of her claims. There is evidence of deliberate, selective publication from her direct quotes in the New York Times article. She talks about ongoing studies in ways that suggest biases being introduced by her monitoring incoming data. She is flippant in presenting her theoretical model and the sources of her hypotheses. There are discrepancies between claims that she makes to the media and what is available in published accounts of her research. And finally, she is dismissive of the basic responsibilities of a scientist conducting biomedical research to justify the work with reference to plausible mechanism and to provide patients with an accurate sense of the evidence base supporting or not supporting treatments.
Langer has published in scientific journals, but she is not otherwise acting like a scientist. One of her studies involved telling hotel chambermaids that their work involved lots of exercise, with the result that the women lost weight without increasing their actual exercise. These implausible results are reported in the peer-reviewed journal Psychological Science, with Langer explaining results with the same sort of mental frame explanation. If I am skeptical, do I owe it to her to carefully examine this article before dismissing it? I don’t think so. Her other activities establish sufficient prior probabilities it will not be worth the effort.
An embedded journalist and gullible CBS anchor people
Bruce Grierson went to Langer’s kitchen in Cambridge while she was preparing lasagna for her lab staff. He attended lab meetings where over 30 ongoing studies are discussed. He even went to her second home in Puerto Vallarta. He seems quite in awe of her, generally accepts everything that she says, even justifying the expensive resort experiences by suggesting the added expense will increase the placebo effect. I am the only skeptic in his article mentioned by name. Grierson sets up a narrative in which
Medical colleagues have asked Langer if she is setting herself up to fail with the cancer study — and perhaps underappreciating the potential setbacks to her work.
But the crucial issue is not between Langer and skeptical colleagues whom she is challenged to prove wrong. And not the possibility of a setback to her work. It’s a matter of her proceeding with medical experimentation on women who are chosen because they likely have a short time to live. It’s a matter of proceeding without any encouragement from available evidence and lots of evidence to the contrary.
When I googled Bruce Grierson, I was taken to a webpage where he was described as a social science writer. Among his books is What Makes Olga Run?, which is described as “the mystery of the 90-something track star and what she can teach us about living longer, happier lives”. An earlier book, U-Turn asks the question “what if you woke up one morning and realize you are living the wrong life?” Does U-Turn parallel Langer’s Counterclockwise? is he an Ellen Langer wannabe? Certainly he lacked the distance to challenge some outrageous claims.
Someone from the New York Times called me to check carefully whether direct quotes from me were exact and whether my position was accurately portrayed. Why did so much else in the article survive fact checking?
The anchor crew on the CBS This Morning News was certainly not in CBS 60 Minutes investigative reporting mode. Can you imagine a muckraking 60 Minutes account announced with “Harvard Professor operates foreign resort franchise giving incurable cancer patients false hope.” The 60 minutes cameras would be brought down to Mexico and the deals with local businesses would be exposed. Experts in white coats would challenge any evidence that such experiences could be beneficial for survival. Harvard officials would decline comment.
Gayle King and Norah O’Donnell seemed totally charmed by Langer and competed for her attention. Only Charlie Rose evinced skepticism and ended with a wry, mumbled comment at the end, seemingly “we hope that everything you say proves to be right”.
This seemed to be genre confusion going on. Certainly Ellen Langer was entertaining, almost like a standup comic at times. But this was not a sitcom in which we don’t have to worry about the protagonists. This is an utterly uncritical publicizing of a biomedical study with no evidence of background research having been done. Essentially Langer is offering a quack treatment similar to Simonton’s visualization technique. Indeed, Langer’s approach is warmed over and re-served Simonton, and her theory cannot explain why visualization would not work. Her shrinking tumors experiment is being undertaken with no more support from evidence than the Greshon organic coffee enemas, also offered at a Mexican resort. The main difference between what Langer is serving up and Gershon is that a stay at her resort would be less messy and more pleasant than a coffee enema.
The readership of the New York Times and the viewing audience of CBS This Morning News expect properly vetted and carefully researched coverage of biomedical topics especially any involving life-and-death issues like cancer. Desperately vulnerable patients and their families are seeking hope, even a false hope, but will be led astray by sources they thought they could trust.
*“Mindfulness” as in mindfulness meditation? Hardly. An article in the Harvard Magazine clarifies
Mindfulness” might evoke the teachings of Buddhism, or meditative states, and indeed, the name and some of these concepts do overlap. But Langer’s version is strictly nonmeditative (“The people I know won’t sit still for five minutes, let alone 40,” she quips). Hers is a simple prescription to keep your mind open to possibility.
There are many conspiracy theories about vaccines, and they circulate almost continuously. Some are relatively new, but most are at least a few years old. They all tend to fall into several defined types, such as the “CDC whistleblower” story, which posits that the “CDC knew” all these years that vaccines cause autism but covered it up, even going so far as to commit scientific fraud to do so. Of the many other myths about vaccines that stubbornly persist despite all evidence showing them not only to be untrue but to be risibly, pseudoscientifically untrue, among whose number are myths that vaccines cause autism, sudden infant death syndrome, and a syndrome that so resembles shaken baby syndrome (more correctly called abusive head trauma) that shaken baby syndrome is a misdiagnosis for vaccine injury, the antivaccine conspiracy theory that vaccines are being used for population control is one of the most persistent. In this myth, vaccines are not designed to protect populations of impoverished nations against diseases like the measles, which still kills hundreds of thousands of people a year outside of developed countries. Oh, no. Rather, according to this myth, vaccines are in fact a surreptitious instrument of population control designed to render people sterile, for whatever nefarious reasons the powers that be have to want to control the population.
You might recall how a few years ago antivaccinationists leaped on a statement by Bill Gates that “if we do a really great job on new vaccines, health care, reproductive health services, we could lower that [population] by perhaps 10 or 15 percent.” They used it to accuse Gates of being a eugenicist and that vaccines were in actuality an instrument of global depopulation. It was a ridiculous charge of course. In context, it was clear that Gates was referring to how the expected population increase from 6.8 billion to 9 billion could be blunted by providing good health care, including reproductive care and vaccines, to impoverished people in regions where the population increases are expected to be greatest. He was clearly referring to decreasing the expected population increase by 10% or 15%, meaning that instead of going up to 9 billion the population would only increase to between 7.65 and 8.1 billion. In other words, he was referring to how good health care could decrease the expected rate of population growth, not how vaccines could be used to depopulate the world. However, because of the prevalence of the myth that vaccines are sterilizing agents intended for global depopulation, the charge that Gates is a eugenicist, as obviously off base as it is to reasonable people, resonated in the anti-science world of antivaccinationists. Similar claims, namely that there is “something” in vaccines that results in infertility and sterilization, have been unfortunately very effective in frightening people in Third World countries and have played a major role in antivaccine campaigns that have delayed the eradication of polio.
Of late, there’s been a new variant of this particularly pernicious bit of misinformation going around the usual social media sources. Naturally, the first place I saw this story was on the site of über-quack and conspiracy theorist Mike Adams, who proclaimed in his usual hyperbole-filled way, “Tetanus vaccines found spiked with sterilization chemical to carry out race-based genocide against Africans“:
Tetanus vaccines given to millions of young women in Kenya have been confirmed by laboratories to contain a sterilization chemical that causes miscarriages, reports the Kenya Catholic Doctors Association, a pro-vaccine organization.
A whopping 2.3 million young girls and women are in the process of being given the vaccine, pushed by UNICEF and the World Health Organization.
“We sent six samples from around Kenya to laboratories in South Africa. They tested positive for the HCG antigen,” Dr. Muhame Ngare of the Mercy Medical Centre in Nairobi told LifeSiteNews. “They were all laced with HCG.”
Another such story, by Celeste McGovern (who, if you look at her articles, is obviously very antivaccine) at the ever-quacky GreenMedInfo site entitled “Vaccine Conspiracy or Racist Population Control Campaign: The Kenyan Tetanus Shot“:
When Catholic bishops in Kenya issued a press release last month questioning their government’s internationally-funded tetanus vaccine campaign directed at women and girls and warned that it might be laced with an experimental contraceptive that makes them miscarry their babies, it was barely mentioned by the mainstream media outside of Kenya. The BBC carried a brief story that dismissed the allegations as “unfounded” and suggested that even raising such questions was dangerous as it could frighten people from a “safe and certified” lifesaving vaccine.
Elsewhere, the John Rappaport has also flogged this nonsense in a story called “Depopulation vaccine in Kenya and beyond“:
“Dr. Ngare, spokesman for the Kenya Catholic Doctors Association, stated in a bulletin released November 4, “This proved right our worst fears; that this WHO campaign is not about eradicating neonatal tetanus but a well-coordinated forceful population control mass sterilization exercise using a proven fertility regulating vaccine. This evidence was presented to the Ministry of Health before the third round of immunization but was ignored.”
(“Mass Sterilization: Kenyan Doctors Find Anti-Fertility Agent in UN Tetanus Vaccine,” November 8, 2014, by Steve Weatherbe, earth-heal.com)
You have to understand that every promoted so-called “pandemic” is an extended sales pitch for vaccines.
And not just a vaccine against the “killer germ” of the moment. We’re talking about a psyop to condition the population to vaccines in general.
There is much available literature on vaccines used for depopulation experiments. The research is ongoing. Undoubtedly, we only know a fraction of what is happening behind closed laboratory doors.
This story has been popping up all over the usual antivaccine social media sites. From here in the comfortable confines of our First World nations, it’s mainly a curiosity, something that gets the antivaccine contingent here riled up, but in Kenya and other Third World countries, where neonatal tetanus is a real concern, this myth has been popping up since the 1990s, causing great harm to vaccine programs.
So here is the basic outline of the myth that is going around this time. A group known as the Kenya Catholic Doctors Association (KCDA) has claimed to have tested several vials of tetanus vaccine. Why did the KCDA test these vaccines? Who knows? Actually, for some reason, due to the persistence of the common myth that vaccines are being used for sterilization and depopulation, this group of doctors apparently felt obligated to test this vaccine. In actuality, the KCDA is an arm of the Kenyan Catholic Church, created less than a year ago by John Cardinal Njue, Chairman of the Kenya Conference of Catholic Bishops, for this purpose outlined in a speech by Cardinal Njue dated Christmas Eve, 2013:
The Sanctity of Life and its fundamental principle, .[sic]Life begins at the Conception and ends with natural death‚ are under threat from worldly forces devoid of faith.
The Catholic Church calls upon her faithful and all people of good will to appreciate the gift of life and safeguard it from the moment of conception to natural death. The Catholic Church will therefore continue to urge its Professionals especially in the medical and health care areas to be vigilant and to stand up for the moral principles and standards, as willed by God and promoted by the One, Holy, Catholic and Apostolic Church, The perfect teacher in matters of Faith and morals[sic]
Which leads Njue to proclaim:
It is therefore a good reason to celebrate as we Launch such an Association, the Kenya Catholic Doctors Association, bringing together Catholic Doctors to enable them walk the journey of faith in their profession and in Communion with each other and the Church. The Church in the Spirit of Christ invites all the Catholic Doctors to find in this Association, an opportunity to live the invitation of Christ.
Dear Catholic Doctors, allow yourselves to be enlightened by the Gospel so that your eyes of faith may penetrate the misleading attraction of the World that proclaims anti-life principles and courageously stand and be counted.
In other words, the Kenya Catholic Doctors Association is a recently formed, wholly owned subsidiary of the Catholic Church in Kenya, to which doctors have been recruited to uphold Catholic teachings in medicine, particularly with respect to reproductive health. No wonder the Kenyan Catholic bishops and the KCDA are working so closely together on this!
Before you can understand the why the claim that hCG is in the tetanus vaccine would produce fear that the vaccine is in reality a sterilization agent, you need to know about a previous experimental vaccine. hCG is what is commonly referred to as the “pregnancy hormone.” Pregnancy tests are based on detecting hCG, which can first be detected about 11 days after conception and whose levels rise rapidly thereafter, peaking in the first 8-11 weeks of pregnancy. In the past, attempts have been made to produce a vaccine that targets hCG and thus results in the inability to conceive a child. It is a technique that falls under the category of immunocontraception. It takes little more than a quick trip to Wikipedia (among other sources) to learn that as far back as the 1970s, hCG was conjugated to tetanus toxoid in order to make a vaccine against hCG, because hCG itself did not provoke enough of an immune response. It’s not necessary to know all the details and history. From the 1970s on, there have been clinical trials of such vaccine contraceptives using hCG, and it is possible to prevent pregnancy by this approach, although antibody response against hCG declines with time.
This brings us back to the claims being made, described in an editorial by Dr. Wahome Ngare for the KCDA that appeared in Kenya Today. According to this article, the WHO had embarked on a vaccination program against tetanus that somehow had aroused the ire and suspicion of the Catholic Church because it was aimed at girls and women. The reason, of course, is because in Kenya there is a high risk of acquiring tetanus during childbirth, but the Catholic Church saw more nefarious motives:
Our concern and the subject of this discussion is the WHO/UNICEF sponsored tetanus immunization campaign launched last year in October ostensibly to eradicate neonatal tetanus. It is targeted at girls and women between the ages of 14 – 49 (child bearing age) and in 60 specific districts spread all around the country. The tetanus vaccine being used in this campaign has been imported into the country specifically for this purpose and bears a different batch number from the regular TT. So far, 3 doses have been given – the first in October 2013, the second in March 2014 and the third in October 2014. It is highly possible that there are two more doses to go.
Unlike other mass vaccination exercise, [sic] this particular WHO/UNICEF organized and sponsored tetanus vaccination campaign was launched at the New Stanley Hotel in Nairobi which is extremely unusual for a public campaign. For this reason, many people, including health professional [sic] did not know about the campaign until the matter was addressed by the Catholic Bishops.
Of course, the reason the vaccination campaign is targeted at women of reproductive age is because its primary purpose is to prevent neonatal tetanus. Targeting women of reproductive age leads to immunity in these women and the prevention of tetanus in their newborn babies. As the WHO stated in its response, these campaigns are very much targeted to districts where the highest incidence of neonatal tetanus has been observed. None of this stopped the KCDA:
With the help of Catholic faithful’s [sic] who put their own lives at risk, the Kenya Catholic Doctors Association managed to access the tetanus vaccine used during the WHO/UNICEF immunization campaign in March 2014 and subjected them to testing. The unfortunate truth is that the vaccine was laced with HCG just like the one used in the South American cases! Further, none of the girls and women given the vaccination were informed of its contraceptive effect.
This proved right our worst fears; that this WHO/UNICEF campaign is not about eradicating neonatal tetanus but is a well-coordinated, forceful, population control, mass sterilization exercise using a proven fertility regulating vaccine.
None of these charges are new. This is a conspiracy theory that’s been around at least since the 1990s and appeared in nations such as Mexico, Tanzania, Nicaragua, and the Philippines. No evidence of mass-sterilization was ever found, but these rumors did adversely impact vaccination programs in those countries.
It also sounds like an awful lot of cloak and dagger on the part of the KCDA just to get their hands on some tetanus vaccine. Much is made of the reluctance of WHO/UNICEF to provide the Catholic Church with vials of vaccine to test, but given the unreliability and dissembling demonstrated by the KCDA, it’s hard to imagine why the WHO would not want to provide vials of vaccine for them to test. Moreover, every vial wasted in this process would be one less potentially-lifesaving vial that could be administered to a Kenyan woman to prevent neonatal tetanus in her baby. In any case, somehow the KCDA obtained vials to test. It’s not clear how they got them or even whether they actually did get them, but they claim to have obtained six vials. The test they subjected them to appears to be the same test used to measure hCG in blood samples for pregnancy tests. If one takes Dr. Ngare’s story at face value, it sure sounds damning. The Kenyan government is even launching an investigation.
There’s just one problem.
The WHO has investigated already and found nothing wrong. Ngare’s claims are, to put it bluntly, completely without merit. As it pointed out:
There is a situation where ant- β-HCG antibodies can be produced by the body and that can act as a contraceptive, however, this requires the administration of at-least 100 to 500 micrograms of HCG bound to tetanus vaccine (about 11,904,000 to 59,520,000 mIU/ml of the same hormone where currently less than 1 mIU-ml has been reported from the lab results.
As UNICEF also points out, there is no laboratory in Kenya capable of accurately making these sorts of measurements on non-human samples (such as vaccines):
The tests were done in hospital laboratories in Kenya. The staff in these laboratories could not however tell whether the samples were vaccines or not, as this was not declared to the testing laboratories by the Catholic Doctors Association. The laboratories tested the samples for hCG using analyzers used for testing human samples like blood and urine for pregnancy. There is no laboratory in Kenya with the capacity to test non-human samples like vaccine for hCG.
It’s also been noted that these values might have been the results of a reaction between the preservatives in a standard tetanus toxoid vaccine and a serum/urine HCG test kit. Also, the vaccine in which hCG was linked to the tetanus toxoid is 20 years out of date. Indeed, in an e-mail interview, the original scientist who developed the hCG-tetanus toxoid vaccine even said that a different carrier, LTB, has been used, to avoid the very misinformation that has been associated with the valuable tetanus vaccination. Also, as the WHO and others responding to this rumor have noted, contraceptive vaccines based on hCG don’t last very long. Antibody titers against hCG decline rapidly after around three months.
In other words, there’s no evidence to support the claims of the KCDA, and they aren’t even plausible, given what is known about the history of vaccines using hCG coupled to tetanus toxoid. Quite simply, such vaccine linking hCG to tetanus toxin are basically history, long abandoned. They didn’t even work very well as long term contraceptive, with their effect fading after three months, much less as permanent inducers of sterility. The Catholic Church and the Kenya Catholic Doctors Association are thus engaging in fear mongering. They might believe they are doing good, but they are engaging in activity that could very well lead to the preventable deaths of Kenyan babies, as young women are frightened away from receiving the tetanus vaccine by their rhetoric and highly dubious laboratory results.
None of this, of course, has stopped Mike Adams from proclaiming this “vaccination genocide” and “medical crimes against humanity”:
What is happening in Kenya is a crime against humanity, and it is a crime committed with deliberate racial discrimination. Normally, the liberal media in the United States would be all over a story involving racial discrimination and genocide — or even a single police shooting of a black teenager — but because this genocide is being committed with vaccines, the entire mainstream media excuses it. Apparently, medical crimes against black people are perfectly acceptable to the liberal media as long as vaccines are used as the weapon.
As this story clearly demonstrates, “vaccine violence” is very real in our world.
No, what this story clearly demonstrates is how utterly out of touch with reality many of the people making these claims in the US are. If you doubt me, just take a look at some of Adams’ other claims, namely that there are five vectors for what he calls the “science-based genocidal assault on humanity”:
Chemtrails? Yes, chemtrails. If you want any further evidence of just how far gone the cranks who argue that the tetanus vaccination program in Kenya is a racist depopulation program are, look no further.
Lest you think that this obsession over vaccination as a cause of infertility is limited to Kenya and other Third World countries, consider this. The very same theme frequently appears in antivaccine rants against Gardasil, which has been blamed without evidence for premature ovarian failure. Another favorite antivaccine trope is that polysorbate-80, which is used in some vaccines, causes infertility. Yes, we in the “advanced” First World nations are nearly as prone to falling for this sort of misinformation as Kenyans. Never forget that.
Also, never forget just how far antivaccine activists like Mike Adams and John Rappaport will go to demonize the object of their hatred: Vaccines.
Parent “I want #Ebola vaccine for my child”
Doc “There isn’t one, but we have #flushot“
Parent “We don’t believe in that”
So much of what we are for at Science-Based Medicine is reflected in what we oppose: all the pseudo-medical interventions and SCAMs. It is not always a positive message, forever noting why you should not be participating in a given bit of fantasy-based medicine. We are often the nay-saying curmudgeons of the medical world. Even for medical topics about for which I am in strongly in favor, vaccines, much of my prose is devoted to countering myths and lies about influenza vaccines, from why the Cochrane review is messed up to why health care workers are dumb asses for not being vaccinated.
Well no Debbie Downer or Crotchety Crislip today. Nope. We are going to ride our Rainbow Unicorn to the land of Happiness and Immunity and discuss some of the reasons why you and yours should get the influenza vaccine.
There are many fine points about the flu vaccine that makes conclusions from the literature problematic: what are the circulating strains, what strains are in the vaccine, who is getting vaccinated and the quality of the studies. Influenza is a complex and complicated disease. If you are a preponderance-of-literature kind of person, as I am, you may find that the 23,600 plus articles on influenza vaccination mostly point to widespread moderate benefit of influenza vaccination, although, as always in medicine, for every study you can find an equal and opposite study and the quality of the studies are variable. At the conclusion you will find links to the other influenza related posts I have written.
The flu vaccine decreases your chance of getting the flu. Note decreases chances, not prevents. That remains the worst aspect of the flu vaccine: it is not as effective as other vaccines. But it does prevent the influenza. Even the biased, cherry picking, awful Cochrane review has to admit efficacy:
Parenterally administered influenza vaccines appear significantly better than their comparators and can reduce the risk of developing influenza symptoms by around 4%, if the WHO recommendations are adhered to and the match is right. However, whilst the vaccines do prevent influenza symptoms, this is only one part of the spectrum of “clinical effectiveness” as they reduce the risk of total “clinical” seasonal influenza (i.e. influenza-like illness) symptoms by around 1%.
While the parenteral vaccine efficacy against seasonal (i.e. non- pandemic) influenza is around 75% for the WHO recommended and matched strain, its impact on the global incidence of clinical cases of influenza (i.e. ILI) is limited (around 16% in best case scenario).
despite their disingenuous attempts to sabotage their results with anti-vaccine editorializing.
Sorry. Kinder and gentler. But when I re-read their meta-analysis, my Rainbow Unicorn began to sob.
The CDC estimates vaccine efficacy at around 60%, although it varies from year to year and from population to population.
Vaccination was significantly effective against laboratory confirmed influenza during sporadic activity (odds ratio [OR] 0•69, 95% CI 0•48—0•99) only when the vaccine matched. Additionally, vaccination was significantly effective during regional (match: OR 0•42, 95% CI 0•30—0•60; mismatch: OR 0•57, 95% CI 0•41—0•79) and widespread (match: 0•54, 0•46—0•62; mismatch: OR 0•72, 95% CI 0•60—0•85) outbreaks.
In the elderly the high-dose influenza vaccine drops the risk of influenza although the standard vaccination has efficacy as well. The vaccine has variable efficacy in other populations as well: dialysis patients, diabetics, and immunosuppressed adults with cancer to name a few. I could not find a population where influenza vaccination did not have some benefit, although it does not provide perfect protection.
In a highly-vaccinated, closed population (a Navy ship), there was an outbreak of influenza when almost 100% of the seamen were vaccinated. 24% came down with flu. Horrible efficacy, right? But in nonimmune populations the attack rate can be has high as 80%, so it is better to have a quarter of you population ill than four-fifths.
I know there is a strong ‘screw you’ attitude in the US. I got mine, I don’t care about you. It used to be a rising tide lifted all boats, now it sometimes seems that many are not interested participating in activities that, while it may not be of personal benefit, it might benefit those around you. With infectious diseases, having the herd maximally immune is as important as having the individual immune. It protects those who cannot protect themselves.
One of my favorite examples of the population effects of flu vaccination was in Canada where one province, Ontario, had a much higher influenza vaccination rate than other provinces and the results were impressive: a decrease in influenza-associated mortality and health care use.
As they suggest:
The results of this large-scale natural experiment suggest that universal vaccination may be an effective public health measure for reducing the annual burden of influenza.
Even with only modest efficacy, when applied to large populations vaccination leads to significant decreases in morbidity and mortality:
We estimated that during our 6-year study period, the number of influenza illnesses averted by vaccination ranged from a low of approximately 1.1 million (95% confidence interval (CI) 0.6-1.7 million) during the 2006-2007 season to a high of 5 million (CI 2.9-8.6 million) during the 2010-2011 season while the number of averted hospitalizations ranged from a low of 7,700 (CI 3,700-14,100) in 2009-2010 to a high of 40,400 (CI 20,800-73,000) in 2010-2011.
As healthy adults have a low risk of complications due to respiratory disease, the use of the vaccine may be only advised as an individual protection measure against symptoms in specific cases.
It is important to remember that with infectious diseases you are vaccinating not only individuals but populations. When you get a vaccine you may also be protecting others from disease, and the effects of herd immunity are evident when you look at the effects of vaccination on the health of populations.
While the Cochrane review mentions that vaccination did not prevent influenza transmission, that was only because they did not include the studies that demonstrate vaccination leads to decreased influenza transmission. Vaccination of children decreases disease in adults. The preponderance of data shows vaccinating against influenza prevents spread to those who are not vaccinated.
The Japanese schoolchildren program provided proof of concept of indirect effectiveness of influenza vaccine. The Central Texas field trial has demonstrated significant herd protection of adults utilizing the live, attenuated influenza vaccine (LAIV) to children. Immunization of <20% of children at the intervention site resulted in an 8-18% reduction of medically attended acute respiratory illness in adults compared to rates in the comparison sites.
for every 15 healthcare providers who get vaccinated, 1 fewer person in the community will contract an influenza-like illness.
Not bad for protecting yourself and others. I think of the flu vaccine like seat belts. No guarantee that you will not die or get injured in an accident, but just as I would prefer to use seat belts in a head-on collision, I prefer to enter the flu season with a vaccination.
And if you are pregnant?
Vaccination decreases influenza in pregnancy women and their newborns:
Influenza vaccine was immunogenic in HIV-uninfected and HIV-infected pregnant women and provided partial protection against confirmed influenza in both groups of women and in infants who were not exposed to HIV
Decreases the risk of small babies and decreases the spontaneous abortion rates:
Pandemic influenza virus infection in pregnancy was associated with an increased risk of fetal death. Vaccination during pregnancy reduced the risk of an influenza diagnosis. Vaccination itself was not associated with increased fetal mortality and may have reduced the risk of influenza-related fetal death during the pandemic.
Also, by getting the vaccine you can avoid some of the complications of influenza. Death of course, but as those who listen to my ID podcasts know I like to harp on the concept that infections lead to inflammation, inflammation is prothrombotic, and prothrombosis can lead to vascular events, strokes, heart attacks or pulmonary emboli.
Almost every infection that has been evaluated has been found to be associated with a vascular event of one type or another. The difference is that with influenza the vaccine may be protective:
Recent influenza infection was an unrecognised comorbidity in almost 10% of hospital patients. Influenza did not predict AMI, but vaccination was significantly protective but underused.
Evidence from cohort studies and a randomized clinical trial indicates that annual vaccination against seasonal influenza prevents cardiovascular morbidity and all-cause mortality in patients with cardiovascular conditions.
As well as protect against stroke, although the data is variable.
Besides vascular events, influenza vaccination may prevent pneumonia as well.
So as vaccines go, the flu vaccine isn’t perfect but has many benefits at both the individual and population levels. Is it cost effective? Got me. The literature suggests so, and I will take their word for it. Cost effectiveness analyses make my head hurt.
If you like a number needed to treat:
…in well-matched years, if we divide 100 people who got the flu shot by the three people who benefitted, we get a Number Needed to Treat of 33. In well-matched years, for every 33 people who get immunized, one will benefit by not getting a bout of influenza she otherwise would have suffered.
A NNT of 33 is, by the way, a fantastically good therapy. This is far better than the NNT to benefit of many, many other common therapies, like, for example, anti-depressants, anti-hypertensive drugs and prostate cancer screening.
Even in not well-matched years, the flu vaccine is still effective, albeit not quite as well. In not well-matched years, the overall risk of getting the flu drops to 2 people out of 100. The flu vaccine cuts that number in half, for a 50% risk reduction. If you do the math, one person out of 100 benefits from the flu shot, making the NNT in not well-matched years 100.
So those are some of the reasons why you and yours should get the flu vaccine: less chance of flu, less chance of spreading flu, less chance of severe disease, less chance of complications from flu, less chance of death and it makes my Rainbow Unicorn happy.Prior flu ramblings
New York may soon join a handful of other states who reject science-based guidelines for the treatment of Lyme disease in favor of ideological guidelines based on the vociferous lobbying of patients and “Lyme literate” health care providers. Ignoring science is an unfortunate but well-known legislative phenomenon. I’ve discussed it a number of times on SBM, in the form of Legislative Alchemy, the process by which credulous state legislators turn practitioners of pseudoscience into state-licensed health care professionals, such as naturopaths, chiropractors, homeopaths and acupuncturists.
Lyme disease is an infectious disease transmitted by a tick bite. Its symptoms are a rash, fever, headache and fatigue, although not all symptoms may appear. According to the Infectious Diseases Society of America (IDSA):
Lyme disease is diagnosed by medical history, physical exam, and sometimes a blood test. It may take four to six weeks for the human immune system to make antibodies against Borrelia burgdorferi and therefore show up in a positive blood test. That is why patients with the Lyme rash usually have a negative blood test and diagnosis is based on the characteristic appearance of the rash. Patients with other clinical manifestations such as Lyme arthritis will usually have a blood test. Anyone who has symptoms for longer than six weeks and who has never been treated with antibiotics is unlikely to have Lyme disease if the blood test is negative.
Treatment with antibiotics usually eliminates the symptoms, but delayed treatment can result in more serious problems.
“Chronic” Lyme disease (CLD) is not recognized as a disease in the medical community. Its symptoms are, well, pretty much anything. One description from a post by Harriet Hall:
Lyme is a multi-systemic illness, and may affect every part of the body causing fatigue, stiff neck, headaches, light and sound sensitivity, tinnitus (ringing in the ears), anemia, dizziness, joint and muscle pain, brain fog, tingling, numbness and burning sensations of the extremities, memory and concentration problems, difficulties with sleep (both falling asleep and frequent awakening), chest pain and palpitations and/or psychiatric symptoms like depression and anxiety.
A new term, Post-treatment Lyme disease syndrome, has been coined for those who had Lyme disease but whose symptoms remain, although there is no good evidence that these symptoms can be attributed to persistent Lyme infection. There is no scientific controversy, however, that “chronic Lyme disease,” as applied to patients with nonspecific symptoms who show no objective evidence that they have been infected with Lyme disease, is a fabricated disease. It is these patients who have been victimized by “Lyme literate” doctors and alternative medicine providers. The main treatment for CLD is long-term antibiotics, for which there is no evidence of effectiveness but serious risks. (Also here.) As you would expect in cases where a collection of vague symptoms have been bootstrapped into a disease (e.g., chronic candidiasis, adrenal fatigue) there are also a number of bogus diagnostic techniques and worthless quack treatments available. (And here too.)
The whole idea that the scientific community is somehow ignoring the evidence is nonsensical when you think about it. What possible incentive would the IDSA and others have to deny the existence of CLD or reject long-term antibiotic therapy? Infectious disease doctors could make a bundle from treating patients with oral, IM and IV antibiotics, especially if it is fee for service. Of course, doctors who promote these treatments, and provide them, likely make a tidy profit doing so (again, especially if they are fee for service). What do you imagine their incentives are?State legislatures fall for the manufactroversy
But never let the lack of controversy among scientists get in the way of a good manufactroversy, as we’ve seen again and again over in the anti-vaccination department of the nation’s wildly successful anti-science movement. After the manufactroversy has poisoned the well, a variation on the “teach the controversy” strategy can be deployed, whereby credulous legislators, convinced that a controversy among scientists actually exists, proceed to legislate the manufactorversy into existence. That turns the manufactroversy into a real controversy, you see, because the law now says the controversy exists. (Just like the law says chiropractic subluxations and acupuncture meridians exist.)
Lobbying by CLD advocacy groups has resulted in several states passing laws blocking state medical boards from taking action against a physician because he prescribes long-term antibiotic therapy. Currently, Connecticut, Rhode Island, Massachusetts and California all have these laws on their books. In addition, Maine passed a law requiring state health authorities to provide information to the public about Lyme disease from both the Infectious Diseases Society of America and the International Lyme and Associated Diseases Society, the latter of which promotes the validity of CLD diagnosis and the use of long-term antibiotics. Minnesota, Connecticut and Rhode Island require insurers to cover CLD treatment.
Rhode Island’s law bears a closer look, as it demonstrates how lobbyists can successfully insert unsupported assumptions into a law. In its preamble, the bill which eventually became law states that:
Physicians whose practices are devoted to treating chronic Lyme disease patients, and who continue to provide treatment if they feel such treatment is medically necessary, have noted significant improvement in the condition of their patients.
As Steve Novella explained, this perceived improvement could well be due to the placebo effect. Or, it is possible that the antibiotics are having an anti-inflammatory or other pharmacological effect that offers symptomatic relief, in which case we should explore treatments that offer these benefits without the risks of long-term antibiotics. Yet the Rhode Island legislature saw the reported benefits (which could also be due to a number of other reasons, such as confirmation bias) as reason to exonerate these physicians, while at the same time ignoring the evidence against the existence of CLD and the use of antibiotics to treat it.
The preamble also says that “consensus guidelines for diagnosis and treatment of chronic Lyme disease have not been developed.” I don’t know if that was true in 2002, when the law passed, but it certainly isn’t true now. And just because consensus guidelines haven’t been developed, it doesn’t mean “anything goes.” The law goes on to define “Lyme disease” as an infection consistent with the CDC surveillance criteria,
but also includes other acute and chronic manifestations of such an infection as determined by the physician.
In other words, it gave physicians carte blanche to ignore the substantial evidence disconfirming CLD and warning against long-term antibiotic use.
New York appears poised to join those states protecting “Lyme literate” doctors from prosecution, a position supported by at least one credulous newspaper editorial board. Both the Senate and the Assembly passed just such a bill, which awaits the Governor Cuomo’s signature. He’s indicated he will sign it.
In the hearings leading up to passage of the bill, one legislator said he’d been asked by his constituents “suffering from chronic Lyme disease” to pass legislation like this for a long time because:
This will offer a great amount of relief to families that are truly suffering, that are going bankrupt, they’re mortgaging their homes, trying to find a way to deal with this devastating disease.
Sadly, that indicates to me that a lot of people are being ripped off by “Lyme literate” doctors.
This bill is unlike the others in that it begins with this startling introductory sentence:
Neither the board for professional medical conduct nor the office of professional medical conduct shall identify, charge, or cause a report made to the director of such office to be investigated based solely upon the recommendation or provision of a treatment modality by a licensee that is not universally accepted by the medical profession, including but not limited to, varying modalities used in the treatment of lyme disease and other tick-borne diseases.
This seems to cover not only treatment with long-term antibiotics but pretty much anything any physician wants to dream up in the way of a “treatment modality” for any disease or condition as long as there is not “universal acceptance” that this is not a good idea. Of course, anytime a small group of dissenters wants to take exception to the medical profession, they can argue that there is not “universal acceptance,” no matter how kooky their ideas are.
This interpretation appears to be confirmed by the next sentence in the bill, which says a physician can employ these “varying modalities” as long as the treatment is in accord with this “health freedom” provision of the NY physician practice act that permits the use of:
whatever medical care, conventional or non-conventional, which effectively treats human disease, pain, injury, deformity or physical condition.
I suppose there two outs here for the science-minded. One is that the bill covers only treatments, not diagnoses, perhaps providing some leeway for disciplinary action based on a diagnosis of CLD. The other is the provision in the existing law, which says the treatment must be effective.
All I can say is good luck to the state medical board and the courts in interpreting this one.
The legislature also passed a resolution asking the CDC, the NIH, and other federal agencies for additional Lyme disease prevention efforts and research. One does wonder, however, if they will pay attention to the research produced. If the legislature is ignoring the medical consensus at this point, what exactly is it that would convince them of their folly? And will they go back and repeal the new law (if it becomes law) if this new research somehow persuades them that the IDSA and other responsible experts are, in fact, correct?Blumenthal: still promoting CLD after all these years
As I explained in an earlier post, former Connecticut Attorney General, and now U.S. Senator, Richard Blumenthal:
sued the Infectious Diseases Society of America (IDSA) and the American Academy of Neurology (AAN) for antitrust violations because both groups reached the same conclusion regarding the non-existence of Chronic Lyme disease.
According to Blumenthal, both groups’ reasoning in reaching the same conclusion “at times used strikingly similar language.” He smelled a conspiracy. In his view, the guidelines “improperly ignored or minimized consideration of alternative medical opinion and evidence regarding Chronic Lyme disease.” Apparently, Blumenthal knew so little about science he didn’t realize that when the same evidence is reviewed by two different groups it is perfectly reasonable for them to come to the same conclusion. Nor did he realize that, in reviewing evidence, it is not appropriate to consider any quack theory that comes along, no matter how ludicrous. The irony is obvious: Blumenthal was willing to accept Chronic Lyme disease despite the lack of evidence that it exists. He then turned around and sued the doctors’ groups for relying on good evidence to support their conclusion that it didn’t.
The suit was settled when the IDSA agreed to review its position. That review has now been completed with the IDSA reconfirming its earlier position after another look at the evidence.
Sen. Blumenthal remains unrepentant and as far as I know has never acknowledge the IDSA’s confirmation of its earlier position in 2010. At a forum last year hosted by, among others, Sen. Blumenthal, he continued to maintain that there is a legitimate controversy in the medical community and that insurers should cover treatments doctors think is best, noting Connecticut’s insurance mandate. The latter sentiment, if applied to quacks and charlatans and all diseases, real or imagined, could drive us all to bankruptcy with increased premiums.
A similar hostility to the current evidence was displayed by U.S. Rep. Chris Gibson (R-NY), who also spoke at the forum. He is the sponsor of legislation recently passed by the House of Representatives, the “Tick-borne Disease Research Transparency and Accountability Act,” now pending in the Senate. Rep. Gibson accused the CDC of “Lyme illiteracy” and spoke of a “bifurcation in the medical community” concerning Lyme disease.
The House bill may not be a bad idea. It forms a “Lyme and Tick-Borne Disease Working Group” to look into the evidence and make recommendations, although it provides no money for the Group to perform its duties. It requires the inclusion of advocacy groups. The bill also requires that a “diversity” of scientific opinion be represented.
As with NY’s effort, however, one wonders exactly what level of evidence would be acceptable to those convinced that their symptoms are due to chronic Lyme disease and that long-term antibiotic therapy is the proper course of treatment. Or to Lyme literate doctors who treat them, whose income is jeopardized by further evidence of the lack of safety and effectiveness. There is clearly a scientific consensus among responsible parties that CLD is not a valid disease and that long-term antibiotic treatment is not only not beneficial, it can be dangerous. What else is necessary to sway the dissenters?
I don’t think anyone doubts there are people who experience fatigue, joint stiffness, neck pain and the like, but for whom no clear diagnosis exists. Nor does anyone doubt that some medical professionals brusquely dismissed their symptoms. And no one doubts that real Lyme disease exists or that improvements in diagnosis and treatment, as well as research into other tick-borne diseases and prevention, is warranted. But none of that is an excuse to take advantage patients with a fake diagnosis of “chronic Lyme disease” or treat them with long-term antibiotics and other dubious remedies. Nor is it a valid reason for advocacy groups to browbeat legislators into enshrining CLD into law or for legislators to equate popularity with scientific evidence.
Case reports are perhaps the weakest form of medical evidence. They are essentially well-documented anecdotes. They do serve a useful purpose, however. They can illuminate possible correlations, the natural course of illness and treatment, and serve as cautionary tales regarding possible mistakes, risks and complications. I say “possible” because they are useful mainly for generating hypotheses and not testing or confirming hypotheses.
Dramatic case reports, however, with objective outcomes, like death, can be very useful by themselves in pointing out a potential risk that should be avoided. For example, case reports of objective and severe adverse outcomes are often used as sufficient evidence for pulling approved drugs off the market, or at least adding black box warnings.
The chiropractic community, it seems, does not respond in a similar way to dramatic adverse events that suggest possible risk from chiropractic manipulation. A recent and unfortunate case raises once again the specter of stroke following chiropractic neck manipulation. Jeremy Youngblood was 30 years old, completely healthy, and saw his chiropractic for some neck pain. According to news reports, Jeremy suffered a stroke in his chiropractor’s office while being treated with neck manipulation for the neck pain. According to reports the chiropractor did not call 911, but instead called Jeremy’s father who had to come and pick him up and then bring him to the ER. Jeremy suffered from a major stroke and later died.
According to his death certificate, which includes the findings of his autopsy:
I. Hemorrhagic infarction of cerebellum, mainly inferior surface, right, with obstructive hydrocephalus at the level of the 4th ventricle
A. Status post right posterior/inferior cerbellar artery embolism with distal right vertebral right artery dissection at the skull base in C-1
B. Status post being coiled with a 6 mm x 20 mm Azure coil (x2), (status post coil embolisation of right vertebral artery)
C. Diffuse cerebral edema (weight 1600 gm)
D. Status post chiropractic manipulation of neck
A dissection is a tear in the artery. This tear can then result in the formation of a blood clot which can block flow through the artery or dislodge and plug a more distal artery, either way causing a stroke. In this case Jeremy had a stroke in the cerebellum, which is in the back of the brain just above the brainstem. The stroke also bled. This is a very dangerous situation, as swelling can damage the brainstem, and in Jeremy’s case also blocked the flow of cerebrospinal fluid out of the brain, leading to a further increase in pressure. This situation is often, and in this case was, fatal.
This is not an isolated case. There are other reports of patients having strokes right in their chiropractor’s office. There are now also several studies showing an association between chiropractic neck manipulation and vertebral dissection. The evidence is sufficiently concerning that the American Heart Association and the American Stroke Association recently came out with a statement which concluded:
Clinical reports suggest that mechanical forces play a role in a considerable number of CDs [cervical dissection], and population controlled studies have found an association of unclear etiology between CMT [cervical manipulative therapy] and VAD [vertebral artery dissection] stroke in young patients. Although the incidence of CD in CMT patients is probably low, and causality difficult to prove, practitioners should both strongly consider the possibility of CD and inform patients of the statistical association between CD and CMT, prior to performing manipulation of the cervical spine.
What they are saying is that there is sufficient evidence to be concerned that CMT can cause a dissection in a young patient resulting in a catastrophic stroke, even death. While the overall risk of this occurring is probably low, at the very least practitioners should obtain informed consent and disclose this risk before performing CMT. We have not had the kind of definitive controlled trials to prove that the neck manipulation is causing the dissection because it is possible that the neck pain itself was caused by the dissection which occurred before the CMT. It seems unlikely, however, that this explains every case, as with this one, in which the stroke occurs in the chiropractors office. Even if the dissection was pre-existing, that would be a contraindication to manipulation, which can turn a dissection into a stroke by making it worse or dislodging a clot.
I would go much farther than the AHA/ASA statement. In medicine we must consider the risk vs benefit of every decision and intervention. In this case there is no evidence the CMT is of any therapeutic value for neck pain, headache, or any indication. A systematic review of the evidence concludes:
Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior.
There are gentler alternatives, such as exercise, using moist heat, or gentle massage. No matter how you look at it, there is no justification for chiropractic manipulation of the neck. Any risk is not justified when there is insufficient evidence to support efficacy and when there are safer options available. In this case the risk may be rare, but the adverse events are catastrophic – stroke or death in otherwise-young, healthy people.
If CMT were a drug, it would have been pulled off the market. If it were a common medical procedure, there would be more studies exploring the risk and more definitively answering the question of safety and efficacy. The response of the chiropractic community to the issue of neck manipulation and stroke, however, is denial and diversion. According to a KFOR article reporting Youngblood’s death:
Chris Waddell is the President of the Oklahoma Board of Chiropractic Examiners. He says their work speaks for itself.
“I think if the benefits weren’t there, people wouldn’t utilize our services. They know what works and what doesn’t,” Waddell said.
Wadell says data doesn’t back up the idea that visits to the chiropractor can kill.
The data he’s referring to is the Cassidy Study, which was done in Canada years ago.
“We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care,” the report states. “For those 45 years of age and older there was no association.”
The notion that patients know what works is a common defense of alternative practitioners, or anyone using a treatment that is scientifically dubious. The claim is that patients would not seek out a treatment unless it actually works. This is demonstrably untrue, however. History is full of examples of worthless and even harmful interventions that were popular. Placebo effects are sufficient to explain the popularity of a worthless treatment.
Waddell also refers to the Cassidy study, which was a scientifically terrible study (as Mark Crislip explains here). This is a good example of cherry picking low grade evidence in favor of better or more comprehensive evidence. As the quote above indicates, the Cassidy study found no association with those 45 years and older. The study, however, looked at all strokes, not just those associated with arterial dissection. Also, by looking at the older population, any signal of association with chiropractic manipulation would be statistically drowned out by the far more common causes of stroke in the older population. The Cassidy study is essentially useless, but chiropractors love it because it gives them the cover they seek.
In another study, only vertebrobasilar strokes were examined, in those <45 years old. They found that patients with such strokes were 5 times more likely to have visited a chiropractor in the last week than a control population.
The Oklahoma Chiropractic Association also put out this statement:
The Oklahoma Chiropractors Association wishes to express its deepest condolences to the family of Jeremy Youngblood. The loss or harm of any patient is a very disturbing circumstance that medical professionals have struggled with throughout history. Unfortunately, there is no single form of medical care without risks.
Oklahoma Chiropractors are proud to provide thousands of Oklahoman’s drug free medical care daily. The safety of chiropractic care is evident by the lowest medical malpractice insurance rates of any licensed medical profession.
This is another piece of masterful denial and diversion. First they depersonalize this case – harm happens, no intervention is without risk. Then they tout the safety of chiropractic overall. Of course it is easy to claim safety when you ignore or deny risk. The issue here is relative risk vs benefit. There is a serious claim being made by healthcare professionals and organizations, based on existing evidence, that chiropractic neck manipulation carries risk that is not justified by the benefit.Conclusion
The chiropractic profession has a responsibility to deal with this issue in a way that is best for their patients, not their profession. In my opinion the current evidence supports the following measures:
That’s it, actually. I don’t see how any other reaction would be appropriate. However, short of simply abandoning this procedure, other measures would at least be helpful:
One of my early forays into the world of pseudoscience was an investigation of “Vitamin O” (the O stands for oxygen). The story is hilarious; please click and read; I guarantee you won’t be able to read it without at least a chuckle. Vitamin O is still for sale; it’s even available on Amazon.com. You can read the manufacturer’s ridiculous rationalizations about the FTC’s and FDA’s regulatory actions against them and their bogus “research” here. In my article, I mentioned oxygen bars, which were popular at the time. I was under the impression that they had gone out of fashion since then. Alas, no.
Dr. Stephen Barrett of Quackwatch e-mailed me to suggest that I might want to write about the O2 Planet website. It calls itself “the largest oxygen bar and oxygen spa source on the planet.” I can’t decide whether to thank Dr. Barrett for steering me to a source of entertainment and making me laugh or curse him for making me suffer through a disgusting collection of pseudoscientific rubbish. Some of the company’s claims are listed on the graphic above.
Their website says,
Oxygen is a miracle, an anti aging miracle! Oxygen therapy can help to jump start the body’s antioxidant defenses and ability to fight free radicals, boost metabolism, and counteract the hypoxia (low oxygen level) that leads to slower cell activity and oxidative stress. Research has shown that oxygen therapy can help to improve the efficiency of hemoglobin in transporting oxygen around the body, improve blood flow by helping to keep cell membranes flexible, and detoxify and fight infection by destroying bacteria, viruses, parasites and fungi that thrive in low-oxygen environments and don’t have the antioxidant resources to fight back. Hyperbaric oxygen can treat carbon monoxide poisoning-by displacing the lethal gas with oxygen, it may also be beneficial to people who have sustained burns, crush injuries and radiation damage as it stimulates the regrowth of damaged tissues. There is some evidence to mean that hyperbaric oxygen may also help to kill cancer cells and reduce toxic symptoms associated with chemotherapy, relieve fatigue and numbness associated with AIDS, increase resistance to opportunistic infections in people with AIDS, reduce post-ischemic stroke damage, and relieve the symptoms of multiple sclerosis. However, none of these benefits of hyperbaric oxygen therapy has been clinically proven.
One wonders why they even mention hyperbaric oxygen, since it has nothing whatsoever to do with their normobaric products.
Some of their other questionable claims:
They sell oxygen bars and kiosks, aromatherapy headsets, oxygen vending machines operated by tokens (perfect for gyms, vap shops, bars), air purifiers, an oxygen water maker, an oxygenated mineral water maker, an oxygen laser wand for facial rejuvenation therapy, infrared spas with O3 (an extra oxygen molecule [sic] to zap pollutants), and multiuser units. There is even a versatile steam spa that can be used for aromatherapy with essential oils, herbal treatment, full spectrum light therapy, and acupoint massage (I’m surprised they didn’t mention homeopathy). And then there is my favorite: an oxygen footbath that uses “negative and positive ions to pull the toxins out through the feet and into the basin.” It removes waste products such as diacetic, lactic, pyruvic, uric, carbonic, acetic, butyric, and hepatic acids. It infuses your body with oxygen. It evacuates heavy metals and blood clotting cellular debris. Only $1,400 for a course of 14 treatments!
Interestingly, their obligatory FDA disclaimer includes the statement that their products are for recreational use only. You can become a distributor and get free marketing material for your customers.
Of course they don’t supply any scientific evidence; there isn’t any. Time for a reality check. Normal oxygen saturation is 97-99%. Adverse effects of low oxygen levels are usually not seen until the saturation drops below 80%. We know that inhaling 100% oxygen is harmful. The flow rate of O2 Planet’s devices is 3 ½ liters per minute; a simple oxygen facemask used in hospitals supplies 5-8 liters per minute with an oxygen concentration of between 28 and 40%. It’s highly unlikely that inhaling oxygen from O2 Planet’s devices would measurably raise the amount of oxygen in the blood, and it’s even less likely that a small increment in oxygen would have any significant effect on health.
So no evidence, and no plausible rationale, but lots of testimonials. Some of those testimonials are quite amusing:
While looking for information on that company, I ran across a couple of other oxygen websites that are equally reprehensible.
Oxygen Elements Max
This website tells us that “our bodies were also intended to get oxygen from water.” (True only of our ancestors during the fish stage of our evolutionary history. We no longer have gills, unless you count the vestigial remnants that appear transiently during embryological development.) They admit that their product actually contains very little oxygen. But that doesn’t matter, because it:
creates oxygen at the cellular level in your body by using the oxygen components that are already there. To put it simply, Oxygen Elements Max (formerly Hydroxygen Plus) actually splits the water molecule (H2O – two parts Hydrogen and one part Oxygen) and starts a chain reaction that releases the Oxygen as the body demands it. This reaction continues for up to 72 hours, but peaks in your body at about 6-12 hours. Thus, your body has a ready supply of oxygen stored up in its water and is released as needed.
The product also contains:
Since the dosage is in drops, and a single bottle lasts a month, for all these components to be packed in, they can only be present in homeopathic quantities.
Ed McCabe, “best selling oxygen author and pioneer” brags about being raided by the FDA for selling his oxygen supplement. He claims that an increase in someone’s oxygen saturation can be measured 30 minutes after taking the drops. I find that hard to believe. I also find it hard to believe some of his other astounding claims:
Testimonials for Oxygen Elements Max abound, for a long list of practically every human ailment. Order options include a bottle with a 30 day supply for $31.95, membership to save money, and a Business Membership option which is a typical multilevel marketing (MLM) opportunity. There is a money back guarantee, of course, providing you return the unused portion.Richardson’s Miracle Cure
Kevin Richardson offers a downloadable book The Miracle Cure: in which he “Reveals The Simple And Natural Nutrient Known To Relieve Virtually All Ailments, Diseases, And Illnesses With No Side Effects.” Among other things, his book promises to reveal a particular golden honey that is rich in oxygen water and will even provide recipes for an oxygen diet.
He claims that oxygen is the cure for 95% of all the diseases that you are otherwise doomed to suffer or die from. He lists some of them here.
It’s hardly surprising that his list includes the ever-popular autism and Lyme disease, but it did surprise me that it included insect bites and “Food Allergies Warts,” whatever that is. He says Dr. Robert Atkins was jailed for curing cancer with oxygen. He says there are no side effects other than “the rare ‘healing crisis’ when your body expels harmful, toxic and even deadly poisons from your body.”
He cites Otto Warburg; his simplistic misinterpretation of the Warburg hypothesis is that Warburg “proved” that lack of oxygen was the cause of cancer and that supplying your cells with it not only kills cancer cells and tumors, but blocks future cancer cells from forming. Warburg did have an intriguing hypothesis about cancer metabolism, but he “proved” no such thing.Conclusion
There are a lot of myths about the health benefits of supplemental oxygen, and they keep popping up like whack-a-moles no matter how often science beats them down. I found all of this profoundly depressing. Apparently the American public is so ignorant of science that unscrupulous entrepreneurs can easily make money by snowing the gullible with the most egregious pseudoscientific nonsense. There are legitimate uses for supplemental oxygen and hyperbaric oxygen within scientific medicine. The kinds of oxygen therapies I have covered here are not scientific and are not medicine; they are simply disreputable moneymaking enterprises.
Retcon (shortened form of RETroactive CONtinuity; first made popular in the comic book world):
For many years, I was a comic book geek. At the height of my geekdom, I generally purchased anywhere from eight to twenty titles a month and read them all voraciously. This went on from around the time I was 12 or so until around six or seven years ago, when, for reasons that I still don’t quite understand, my interest waned. I bought fewer and fewer titles. These days there remain only one or two to which I subscribe, and all that remains of those three decades are around 10 long boxes full of comics dating back to the mid-1970s and even earlier.
If there’s one thing any long-time comics geek knows, it’s the concept of retconning, and retconning is what this post is about. To understand how, please indulge me a moment while I discuss something unrelated to medicine, namely comic books. “Retcon” is short for “RETroactive CONtinuity.” It’s something that happens in virtually all comics at one time or another in which something about the back story of character is changed, sometimes in major ways, to serve the current story (or, not infrequently, because some editor thinks it would be cool). There are several general forms of retconning. Sometimes retcon changes add to the back story and lead the reader to see the fictional character or world in a new and interesting way (retcon definition #1, above); more commonly, they obliterate or significantly alter previous events in ways that have the potential to ruin current enjoyment of the story (retcon definition #2, above). Sometimes they’re just “meh” and do neither (this can happen in retcons following either definition #1 or #2).
In comics, TV, and literature, retconning is not inherently good or bad. It’s to be expected when any serial story lasts decades—ofttimes even necessary. (After all, if my favorite superhero team of all time, the Fantastic Four, hadn’t been retconned, they’d all have to be around 90 or older, given that Reed Richards and Ben Grimm both fought in World War II.) Admittedly, retconning does have a bad reputation because most of the time retcons tend to range from bad to insulting. For example, if you want to see examples of how ridiculous retconning can get, there are articles like “The 15 Dumbest Superhero Retcons Of All Time“, which require no knowledge of the comics discussed to appreciate the sheer stupidity of the retcons mocked, such as the one that changed Spider-Man’s origin so that he was new the avatar of a spider god or the one where Iron Man/Tony Stark was revealed to be a sleeper agent for the villain Kang The Conqueror. The latter was a storyline so bad that it had to be immediately retconned again back to the Iron Man we all know and love. Come to think of it, one of those retcons, the “One More Day/Brand New Day” retcon of The Amazing Spider-Man, was probably the bit of sheer stupidity that finally made me give up Marvel comics, much the way arguably the most infamously lazy retcon of all time, in which Bobby Ewing’s death and everything that happened after it was revealed to be just a dream, led some Dallas fans to drop the show.
Finally, some retcons are useful and necessary. For instance, the retconning of how Susan Storm (a.k.a. the Invisible Woman of the Fantastic Four) first met and fell in love with her future husband Reed Richards (a.k.a. Mister Fantastic) when he was a college freshman rooming at her aunt’s boarding house to change her from being a 12-year-old girl at the time, who then waited to be old enough for Reed to notice her romantically, isn’t a bad thing. That version, which itself was a retcon of Stan Lee and Jack Kirby’s original origin story in which Susan was the “girl next door” that Reed left behind when he went to serve in the OSS during World War II, comes across as profoundly creepy to 2014 sensibilities and was therefore best retconned away.Brand New Day, part 1: The story of TCM and why Oceania has always been at war with Eastasia
Now that you (hopefully) understand the basic concept of retconning, you’ll soon see what I’m getting at. It’s not just fictional stories that can be subject to retconning. The narrative of history can also be retconned. Of course, the difference between retconning fiction and historical narrative is that historical narrative has facts and evidence to support it. Still, as all historians know, history is often incomplete, and there are often errors that need to be corrected, and that doesn’t even take into account different interpretations of the past. This is often referred to as historical revisionism, but you can see the similarity to the concept of retconning. Similar to retconning, revisionism is not in and of itself inherently good or bad. It is, in fact, an accepted part of historical scholarship, given that new documents about various historical events often need to be put into context with the old, altering the historical narrative. However, like retconning, revisionism also has a very dark side. One dark version of revisionism, the study of which served as my “gateway drug,” so to speak, into skepticism, is Holocaust revisionism, which is in reality Holocaust denial, whose main purposes are to minimize the suffering Jews endured, to deny or minimize the genocide of the Holocaust, and to rehabilitate fascist beliefs that led to the Holocaust.
To be fair, the revision of history to serve a current political narrative is not a new idea. What was the Ministry of Truth in the fictional nation of Oceania, for which the proponent Winston Smith worked in George Orwell’s Nineteen Eighty-Four, but an entire ministry devoted to revising historical narratives? In that famous novel, Smith’s ministry was responsible for continuously updating—dare I say, retconning?—news and history to be in agreement with Oceania’s ever-changing official version of the past. The original documents were thrown down the “memory hole,” where they were destroyed, and people became “unpersons,” not just killed but every memory of them erased, every document and photo indicating that they had ever existed eliminated. This very concept of erasing “inconvenient” history led to one of the most famous lines from the novel. When the fictional totalitarian nation of Oceania in which Smith lives suddenly shifts alliances in its never-ending war, making peace with Eurasia and going to war with Eastasia, its people are informed that “Oceania has always been at war with Eastasia” and expected to believe it.
Unfortunately, false historical revisionism is a very common practice. Perhaps the key difference between retconning fiction and retconning history (i.e., historical revisionism) is that for fiction the reasons for changing or ignoring past narratives are often convenience, lazy plotting, and/or a genuine desire to flesh out a character. For history, the motivation tends to be ideological. Such is the case with TCM, beginning with one of the greatest retconners/revisionists of all, Chairman Mao Zedong. After all, totalitarian regimes, as Orwell so astutely noticed, rely on controlling history in order to control present-day narratives. Given that TCM is, by and large, prescientific, pseudoscientific, and religion-based quackery grounded in vitalistic beliefs, to make it palatable to doctors who are ostensibly advocates of evidence-based medicine requires the retconning of its history on a massive scale. Of course, retconning/revisionism can only work if the original narrative that is replaced is not well known.
Particularly galling about the ascendency of TCM in the US is the myth that is swallowed whole by its advocates and promoted as truth. That myth is the very history of TCM, whose true origins are unknown by all but a very few. Contrary to popular belief (particularly about acupuncture), TCM does not go back thousands of years into antiquity, when the ancient healing wisdom of the Chinese was supposedly first discovered and codified and acupuncture discovered. In actuality, very few people are aware that the single person most responsible for the current popularity of TCM was not an ancient Chinese healer but rather Chairman Mao Zedong, as described in an excellent summary by Alan Levinovitz in Slate.com last year, “Chairman Mao Invented Traditional Chinese Medicine“:
…Mao was under no illusion that Chinese medicine—a key component of naturopathic education—actually worked. In The Private Life of Chairman Mao, Li Zhisui, one of Mao’s personal physicians, recounts a conversation they had on the subject. Trained as an M.D. in Western medicine, Li admitted to being baffled by ancient Chinese medical books, especially their theories relating to the five elements. It turns out his employer also found them implausible.
“Even though I believe we should promote Chinese medicine,” Mao told him, “I personally do not believe in it. I don’t take Chinese medicine.”
Much of the reason for the popularity of TCM in China and its spread to the US and beyond was actually because Chairman Mao promoted it. The reason, as has been explained by our very own Kimball Atwood, Steve Novella, Harriet Hall, and Ben Kavoussi, is because there simply weren’t enough doctors in China trained in scientific medicine, as admitted by Mao (quoted by Levinovitz):
Our nation’s health work teams are large. They have to concern themselves with over 500 million people [including the] young, old, and ill. … At present, doctors of Western medicine are few, and thus the broad masses of the people, and in particular the peasants, rely on Chinese medicine to treat illness. Therefore, we must strive for the complete unification of Chinese medicine. (Translations from Kim Taylor’s Chinese Medicine in Early Communist China, 1945-1963: A Medicine of Revolution.)
Who knew? (Well, I did.) I also knew, as Levinovitz relates, that this was the very first “integrative” medicine, “integrating quackery with science-based medicine more than five decades before the term “integrative medicine” caught on in the US. A particularly pertinent quote sums this idea up:
“This One Medicine,” exulted the president of the Chinese Medical Association in 1952, “will possess a basis in modern natural sciences, will have absorbed the ancient and the new, the Chinese and the foreign, all medical achievements—and will be China’s New Medicine!”
Indeed, what’s interesting about Levinovitz’s article is his description of how the exportation of TCM to the world was quite deliberate, as part of a strategy to popularize it among the Chinese. There was a problem, however. As Levinovitz noted, there was no such thing as “traditional Chinese medicine.” Rather, there were traditional Chinese medicines. For many centuries, healing practices in China had been highly variable. Attempts at institutionalizing medical education were mostly unsuccessful and “most practitioners drew at will on a mixture of demonology, astrology, yin-yang five phases theory, classic texts, folk wisdom, and personal experience.” Mao realized that TCM would be unappealing to foreigners, as even many Chinese, particularly those with an education, understood that TCM was mostly quackery. For instance, in 1923, Lu Xun realized that “Chinese doctors are no more than a type of swindler, either intentional or unintentional, and I sympathize with deceived sick people and their families.” Such sentiments were common among the upper classes and the educated. Indeed, as we have seen, Mao himself didn’t use TCM practitioners. He wanted scientific “Western” medicine. The same was true of educated Chinese. It still is.
Mao’s strategy to deal with these criticisms was quite deliberate—and clever. It consisted of two strategies, both designed to mythologize TCM as being a scientifically sound and harmonious “whole medical system” and to provide “evidence” in the form of testimonials that it worked, as Levinovitz relates:
His solution was a two-pronged approach. First, inconsistent texts and idiosyncratic practices had to be standardized. Textbooks were written that portrayed Chinese medicine as a theoretical and practical whole, and they were taught in newly founded academies of so-called “traditional Chinese medicine,” a term that first appeared in English, not Chinese. Needless to say, the academies were anything but traditional, striving valiantly to “scientify” the teachings of classics that often contradicted one another and themselves. Terms such as “holism” (zhengtiguan) and “preventative care” (yufangxing) were used to provide the new system with appealing foundational principles, principles that are now standard fare in arguments about the benefits of alternative medicine.
This effort to “scientify” TCM, or, as I like to call it now, to retcon the science, is very much a part of the promotion of TCM and continues this very day, as you will see in the concluding section of this post.
The second part of Mao’s strategy was the dissemination of spectacular anecdotes to “prove” the efficacy of TCM. The most famous of these was the case of James Reston, a New York Times editor who underwent an emergency appendectomy while visiting China in 1971. Even though the surgeons there used a fairly standard anesthesia technique, described by our SBM colleague Kimball Atwood as sounding like a “standard regional technique, most likely an epidural,” acupuncture was used to treat cramping on second evening after the surgery, which I interpreted as being the evening of postoperative day one. The story is familiar to any general surgeon; about a day and a half after surgery Reston had some cramping, likely due to postoperative ileus that kept the gas from moving through his bowels the way it normally does. It passed after an hour or so. Around that time, the staff at the hospital used acupuncture to treat his discomfort, and the logical fallacy known as post hoc ergo propter hoc fallacy (and a bunch of credulous Westerners, eager to believe that some magical mystical “Eastern” wisdom” could do what “Western medicine” could not) did the rest. Most likely what happened is that Reston finally passed gas spontaneously (which is how postoperative ileus nearly always resolves), letting the built-up gas move through and relieving the cramps and bloating. About a day or two after an uncomplicated appendectomy is about right for that.
Over time, reports of “acupuncture anesthesia” trickled out of China to a welcoming, credulous “Western” press. When examined closely by doctors who know about anesthesia (such as an anesthesiologist), these stories universally have big holes in them. Just a few examples were catalogued by our very own anesthesiologist, again Kimball Atwood. In fact, you can view Levinovitz’s article as the CliffsNotes version of the campaign by Mao to convince the West that acupuncture (and, by extension, TCM) worked as well or better than any “Western medicine.” Read Kimball Atwood’s epic “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part I, Part II, Part III, Part IV, and Part V) for the detailed version. Of particular interest to students of “integrative medicine” is Part III, in which Dr. Atwood has an entire section entitled “From ‘Co-operation’ to ‘Integration,’” in which he lists the five main party slogans about TCM:
Mao’s idea was nothing less than the complete unification of TCM and “Western” medicine, as quoted by Kimball Atwood further from The Private Life of Chairman Mao:
Mao laughed. ‘The theory of yin and yang and the five elements really is very difficult,’ he said. ‘The theory is used by doctors of Chinese medicine to explain the physiological and pathological conditions of the human body. What I believe is that Chinese and Western medicine should be integrated. Well-trained doctors of Western medicine should learn Chinese medicine; senior doctors of Chinese medicine should learn anatomy, physiology, bacteriology, pathology, and so on. They should learn how to use modern science to explain the principles of Chinese medicine. They should translate some classical Chinese medicine books into modern language, with proper annotations and explanations. Then a new medical science, based on the integration of Chinese and Western medicine, can emerge. That would be a great contribution to the world.’
Moreover, acupuncture is probably not nearly as ancient as its advocates portray it. Common portrayals of acupuncture paint it as being 3,000 years old, as implausible as that is. Why implausible? For one thing, the technology to make such incredibly thin needles didn’t exist 3,000 years ago. For another thing, as Harriet Hall points out, the earliest Chinese medical texts from the 3rd century BC don’t mention acupuncture, and the earliest reference to “needling” is from 90 BC referring to bloodletting and lancing abscesses. Indeed, even by the 13th century the earliest accounts of Chinese medicine reaching the West didn’t mention acupuncture, and the first account of acupuncture by a Westerner in the 1600s described large golden needles inserted into the skull and left in place for 30 respirations. It has also been argued that acupuncture evolved from bloodletting based on astrology. In any case, as Harriet Hall described, as recently as less than 100 years ago, acupuncture involved the insertion of needles that were frequently red-hot and sometimes left in the body for days, as described by Scottish surgeon Dugald Christie, who served as a missionary doctor in northeastern China from 1883 to 1913:
Chinese doctors own that they know nothing at all of surgery. They cannot tie an artery, amputate a finger or perform the simplest operation. The only mode of treatment in vogue which might be called surgical is acupuncture, practised for all kinds of ailments. The needles are of nine forms, and are frequently used red-hot, and occasionally left in the body for days. Having no practical knowledge of anatomy, the practitioners often pass needles into large blood vessels and important organs, and immediate death has sometimes resulted. A little child was carried to the dispensary presenting a pitiable spectacle. The doctor had told the parents that there was an excess of fire in its body, to let out which he must use cold needles, so he had pierced the abdomen deeply in several places. The poor little sufferer died shortly afterwards. For cholera the needling is in the arms. For some children’s diseases, especially convulsions, the needles are inserted under the nails. For eye diseases they are often driven into the back between the shoulders to a depth of several inches. Patients have come to us with large surfaces on their backs sloughing by reason of excessive treatment of this kind with instruments none too clean.
Compare this to the prevailing narrative today of the history of acupuncture and TCM as “ancient wisdom” that has existed for millennia. Retconning, revisionism, or whatever you want to call it, the history that we are told does not match the real history, which has largely disappeared down the memory hole.Brand New Day, Part 2: Retconning the science of TCM
Over the last 30 years or so, what was once quackery, rightly dismissed in a famous 1983 editorial in the New England Journal of Medicine as a “pabulum of common sense and nonsense offered by cranks and quacks and failed pedants who share an attachment to magic and an animosity toward reason” has become mainstream, evolving from quackery to “alternative medicine” to “complementary and alternative medicine” (CAM) and finally to “integrative medicine.” For no form of quackery has this been more true than for traditional Chinese medicine, which is now considered downright respectable in many places, practiced and studied, as it is, in some of the most prestigious medical schools and academic medical centers in the US. Mao, I suspect, is laughing in his grave.
At each stage of this “evolution,” the idea was to retcon the history and science of TCM in order to represent various ancient folk medicines from China based on pseudoscientific, mystical, and/or prescientific beliefs as somehow being co-equal with “Western” or “scientific” medicine through the clever use of language. If you want to see just how successful TCM has been at not only infiltrating itself into what should be bastions of science-based medicine but at changing the very terms and language under which it is evaluated, just look at this article by Shirley S. Wang that appeared in The Wall Street Journal last Monday entitled “A Push to Back Traditional Chinese Medicine With More Data: Researchers Marry Modern Analytical Techniques to Centuries-Old Theories on What Makes People Sick“:
Traditional Chinese medicine teaches that some people have hot constitutions, making them prone to fever and inflammation in parts of the body, while others tend to have cold body parts and get chills.
Such Eastern-rooted ideas have been developed over thousands of years of experience with patients. But they aren’t backed up by much scientific data.
Now researchers in some the most highly respected universities in China, and increasingly in Europe and the U.S., are wedding Western techniques for analyzing complex biological systems to the Chinese notion of seeing the body as a networked whole. The idea is to study how genes or proteins interact throughout the body as a disease develops, rather than to examine single genes or molecules.
“Traditional Chinese medicine views disease as complete a pattern as possible,” says Jennifer Wan, a professor in the school of biological sciences at the University of Hong Kong who studies traditional Chinese medicine, or TCM. “Western medicine tends to view events or individuals as discrete particles.” But one gene or biological marker alone typically doesn’t yield comprehensive understanding of disease, she says.
At least she acknowledges that TCM isn’t “backed up by much scientific data.” Of course, that acknowledgment is the justification for studying TCM, the assumption being that, because it is ancient, there must be something to it. As if to drive home the “integrative medicine” narrative that TCM is equivalent to “Western” medicine, the article even includes a truly infuriating illustration of a stylized human body, half of which is filled with TCM-related illustrations such as herbs and words like “fire” and “metal,” and half is filled with illustrations covering “Western medicine” like the DNA double helix and a gel electrophoresis:
In the illustration, “Western medicine” ascribes the cause of the disease example used, rheumatoid arthritis, to autoimmune disease and lists treatments such as nonsteroidal antiinflammatory drugs, steroids, and disease-modifying antirheumatic drugs to slow disease progression. On the other side, TCM postulates as the cause of rheumatoid arthritis “blockage in flow of qi and blood in the energy pathways of the body; wind, cold, and damp penetrate the body and get into muscles, joints; there are different forms of arthritis depending on if wind, cold, damp, or heat predominate.” Truly, I kid you not. And the TCM treatment? Acupuncture, tai chi, and herb thunder god vine. This is such a great example that I’m saving this poster for use in future talks, so emblematic is it of the false equivalence “integrative medicine” lends to prescientific, unscientific, and pseudoscientific ideas. The overall idea communicated by the illustration? Clearly, the illustration is intended to imply strongly that TCM’s magic-based description of the pathophysiology and treatment of rheumatoid arthritis is worthy of being considered as an equal to science-based knowledge about the disease, gathered over decades, of what causes rheumatoid arthritis and how to treat it.
This narrative has become so depressingly common that it ought to have a name. “They thought it was quackery but now it’s science”? Too long, but that’s the false message of every one of these stories, which is that they thought us mad, mad, I tell you! But now we’re showing those nasty, close-minded, reductionistic “Western” doctors! Except that they aren’t, and this story inadvertently shows why they aren’t. Still, a punchier name for the trope would be useful. “They thought us quacks,” maybe? The “we’re really, really science, maaaan” trope, perhaps? Perhaps you can help me out. I’ll leave thinking of a pithy, punchy name for this trope as an exercise for the reader in the comments.
In the meantime, let’s take a closer look at the article. It’s based entirely on the very hubris behind “integrative medicine,” namely that medicine based on prescientific and religious beliefs, like traditional Chinese medicine, is at least nearly co-equal with medicine based on science and rigorous clinical trials. Or, at least, it would be equal to scientific medicine if there were actually some evidence for it, which these brave maverick doctors and scientists are furiously searching for, no matter how much they have to torture modern systems biology and molecular biology techniques to shoehorn TCM’s fantasy-based “networks” into the networks of gene activity being increasingly understood by modern molecular biology.
Here’s where the retconning comes in. Look at the passage above. Wan claims that TCM views disease as “complete a pattern as possible.” This is a narrative that we hear time and time and time again about TCM, that it considers the “whole patient,” that it is “wholistic,” that it considers the patient as a “system.” Of course, if that “system” isn’t based on science and evidence, then who cares? After all, what about ancient “Western” medicine, which stated that imbalances in the four humors (phlegm, blood, yellow bile, and black bile) caused disease? It’s pretty similar in many ways to TCM postulates, which ascribes illness to six pernicious influences. These include wind, cold, heat, dampness, dryness and summer heat, which are, like totally not like the four humors. (There are, after all, six pernicious influences. Can’t you count?) TCM also has the “five elements” (fire, wood, earth, water, and metal), which are associated with different organs. So maybe TCM is on to something because its prescientific belief is a bit more complicated than the prescientific belief system that undergirded “Western medicine” for many centuries before scientific medicine arose. That means TCM must be better, right? After all, there must be a reason why there’s all this scientific interest in studying diagnoses based on the five elements and six pernicious influences, but no love left over for studying diagnoses based on imbalances between the four humors, right?
At this point, I feel obligated to acknowledge that regular readers are probably wondering why I’m using the term “Western” medicine given that I find the whole “East-West” dichotomy favored by advocates of TCM and “integrative medicine” to be borderline, if not outright, racist. After all, the unspoken assumption behind this dichotomy, whether those using it realize it or not, is that the “West” is cold, reductionistic, and scientific while the “East” is “wholistic” and connected to the human. It’s all pernicious nonsense, of course, insulting to Chinese and other Asian scientists. Science is science, and those in the “East” can do science as well as we “Western” scientists can. What counts are evidence, experiments, and reason, none of which knows “East,” “West,” “North,” or “South”. However, it is the language assumed in Wong’s article; so I use it as I see fit in order to deconstruct it.
Another trope is plain in the passage above. “Western” medicine is disparagingly presented as “reductionistic.” Note the bit about viewing events or individuals as “discrete particles” and how “one gene or biological marker alone typically doesn’t yield comprehensive understanding of disease. We hear this time and time and time again, but it’s a straw man. Yes, “Western” science tends to break down processes to their smallest component parts but it also recognizes (and always has recognized) the complexity of the networks made up by those component parts. Oddly enough, no one seems able to tell me how viewing organs as related to “five elements” (which are not actually elements) and disease as being caused by “six pernicious influences” is in any way “wholistic” or more “wholistic” than viewing disease as being due to imbalances in four humors. Moreover, although in metabolism science has always looked at whole networks (e.g., glycolysis, the Krebs cycle, oxidative phosporylation, and all the metabolic networks that feed into these pathways), part of the reason why science focused on single genes for so long is because it was limited by the technology. It wasn’t until about 15 years ago that the tools were developed to start looking at, yes, “wholistic” changes in gene expression using whole genome expression profiling, which allows the detection of changes in the expression of every known gene in the genome. Since then, we’ve only become better at this. Using next generation sequencing techniques, it’s possible to examine changes in expression of every transcript in the genome, coding and noncoding, simultaneously, and the technology has gotten to the point where it is now becoming possible to examine the changes in gene expression of the whole genome of single cells.
Much of the second half of the article deals with what TCM refers to as “hot” or “cold” syndrome. What’s happening with this system of diagnoses is that credulous scientists are retconning the science, in essence shoehorning diagnoses based on prescientific vitalism into modern, systems biology and pretending that they were always harmonious and that systems biology supports TCM. Oceania has always been at war with Eastasia, and ancient TCM practitioners, in their wisdom, figured out things that science is only now coming to understand.
I swear, when I saw this next passage I couldn’t believe an otherwise intelligent journalist could write something so ridiculous with a straight face:
One promising area of TCM research several independent groups of scientists are investigating is the notion of hot and cold syndromes. The work is still in its early stages. But it could result in a new direction for TCM research by using the systems biology approach and integrating it with experience gleaned from TCM patient care, says Yale’s Dr. Cheng, who also serves as chairman of the Consortium for the Globalization of Chinese Medicine.
In a series of studies, Tsinghua’s Dr. Li and his colleagues examined people with hot and cold syndromes and whether they exhibited different signs of illness, including gastritis, a common digestive disorder in which the lining of the stomach becomes inflamed or irritated.
To gauge whether gastritis patients had cold or hot syndromes, researchers asked questions like whether individuals had chilly body parts or exhibited a preference for hot beverages or a susceptibility to catching colds. Doctors dug into their subjects’ emotional states, asking whether they experienced so-called cold feelings like apathy. The scientists also measured proteins linked to gastritis and took measurements of the bacteria in the gut and imaged the bacteria in the tongue’s coating.
They found some variations depending on whether patients were identified as hot or cold. They also found differences in the bacteria of patients’ tongues that corresponded with tongue coating color and whether patients had been diagnosed with hot or cold syndrome.
One might as well run systems biology experiments on patients subjected to magical incantations, because that’s basically what is happening here! As I’ve said before, if the treatments and diagnostic modalities being tested are prescientific or pseudoscientific, using all the flashy new science in the world won’t make the experiment science. If there’s one thing I see in common with experiments examining whether “hot” or “cold” diagnoses correlate with changes in biomarkers and other laboratory values is that they tend to be small studies, prone to false positives, and to be massive fishing expeditions, with large numbers of comparisons. In this they remind me of some homeopathy studies.
Consider what it is that TCM means by “hot” and “cold” diagnoses. The root of the “hot-cold” dichotomy is not based on any science. Rather, it’s based in Taoist religion, the “Yin Yang theory” of disease. As described here, TCM states:
The root of many of the ideas within Chinese medicine lies in the concept of Yin and Yang. Yin and Yang are emblems of the fundamental duality in the universe, a duality that is ultimately unified. Yin and Yang are complementary, and not contradictory. Nor is one regarded as ‘good’ and the other ‘bad’. People will often state that, “I am Yin”, or “I am Yang”, but this would be inaccurate; they may have a Yin-Yang imbalance or tendancies [sic], but everyone has both qualities.
Harmony is sought between these Yin and Yang qualities and any imbalance avoided when approaching the body as a holistic union. Yin is matter like Blood, fluids and tissue in the body. Yang is the action potential, Qi, and heat in the body. Chinese medicine balances Yin and Yang and can also build these qualities in the body when they are deficient. No one person is completely Yin or Yang; rather, one would look for tendencies and patterns, and weigh them out; one organ system may have Yang excess while another organ system in the same body can have Yang Deficiency.
From the same source, we learn that “yang excess” or “yin deficient” signs include things like constipation, thirst, dark yellow urine, red tongue, dryness, heavy loud respiration, burning bowel movement, and strong body odor. (I suppose the last two probably go together.) We also learn that signs of “true heat” include blood in the nose, stool, or urine; yellow green mucus; fever; and sticky, thick excretions. These are the sorts of things that TCM practitioners look for and ask about. I suppose it’s possible that certain biomarkers might be different in people with true heat or yang excess or yin deficiency, but whether those have anything to do with a disease like rheumatoid arthritis due to anything other than coincidence is unlikely.
Oceania has always been at war with Eastasia
This whole endeavor is, of course, as perfect example of what Harriet Hall likes to refer to as Tooth Fairy science as I’ve ever seen. Basically, Tooth Fairy science involves applying the scientific method to phenomena that don’t exist. As Harriet’s pointed out many times (and I’ve echoed), we can study the amount of money left by the Tooth Fairy in different settings, but since we haven’t determined that there really is a Tooth Fairy, any conclusions we reach will be falsely attributed to a magical being, rather than to the real cause. The prescientific beliefs behind TCM are a lot like the Tooth Fairy. It’s not for nothing that a Chinese physician has issued a TCM challenge, not unlike James Randi’s million dollar challenge to TCM practitioners to prove their methods.
Lots and lots of research money is being wasted studying prescientific superstition such as qi, yin and yang, and “hot” and “cold” applied to human disease, and universities are embracing such twaddle with both arms. Just this year, for instance, the Cleveland Clinic opened an herbal medicine clinic run by a naturopath practicing largely TCM (mentioned in the article). Dozens of academic medical centers offer this sort of quackery to their patients, in the name of supposedly wanting to study it, but if they don’t know it works how can they offer it as anything other than experimental therapy? Instead, they offer it as though it were validated medicine. Meanwhile, TCM advocates try to sell this prescientific form of medicine as though it were somewhere on the same planet, evidence-wise, as scientific medicine when it is not. Let’s just put it this way. You can make up all the complex “networks” and “systems” that claim to describe human physiology and disease as you want, but if they aren’t grounded in reality and evidence they’re nothing more than fantasy. Indeed, fantasy is what is being “integrated” with scientific medicine, fantasy like TCM. To make it fit, the very history of TCM has been retconned beyond recognition, and believers are furiously retconning the narrative about the science of TCM. This retcon has been a smashing success for TCM.
Sadly, the reaction of the vast majority of physicians to the popularization of quackademic medicine is a shrug. It is more than a little depressing to think there are more than a few Very Serious Academic Doctors out there who have bought into this myth and have even widened Mao’s vision of “integration” beyond “integrating” SBM with TCM to include virtually every form of magical quackery in existence.
Gayle DeLong has been diagnosed with what she refers to as “autism-induced breast cancer”. She’s even given it an abbreviation, AIBC. Unfortunately, as you might be able to tell by the name she’s given her breast cancer, she is also showing signs of falling into the same errors in thinking with respect to her breast cancer as she clearly has with respect to autism. As a breast cancer surgeon, regardless of my personal opinion of DeLong’s anti-vaccine beliefs, I can only hope that she comes to her senses and undergoes science-based treatment, but I fear she will not, as you will see. Her brief post announcing her diagnosis and blaming it on autism, however, does provide what I like to call a “teachable moment” about cancer.
We’ve met DeLong before on this blog. For instance, she published an execrably bad study that—of course!—tried to link vaccine to autism and failed miserably, despite doing some amazing contortions of analysis, combining diagnoses willy-nilly, all in the service of the discredited vaccine-autism hypothesis. As I said at the time, it just goes to show that someone who is an associate professor of economics and finance shouldn’t be doing epidemiological research. As I also described at the time, if the sorts of analytical techniques she used in her study are acceptable in the world of economics and finance, no wonder our economy has been so screwed up for so long. Another time, DeLong wrote a broadside against the regulatory machinery that oversees vaccine development and safety that was full of the usual antivaccine misinformation, tropes, and pseudoscience and hugely exaggerated perceived “conflicts of interest” among the various parties.
So it’s not surprising that DeLong latches on to dealing with her autistic children as the cause of her cancer:
I have autism-induced breast cancer (AIBC). While I am not absolutely certain that the 1.9 centimeter lump that grew in my left breast is the result of the stress of raising two autistic children, all indications point in that direction. There is virtually no cancer in my family, I eat organically, I exercise, I’m a good weight. OK, so I live in the toxic dump known as New Jersey, but that is the only other major risk factor. No, the drop in cortisol levels whenever one kid’s school calls or the other kid has a public “flare up” is enough for the cancer to take root.
First of all, it’s very telling to me that she blames her breast cancer diagnosis on having to take care of her autistic children as the root cause of her breast cancer. The implication, of course, is that her decision to vaccinate her children is what led to their autism and her breast cancer. Be that as it may, notice how DeLong is very emphatic in proclaiming her healthy lifestyle bona fides and that there’s “no cancer in my family.” It’s a very common misconception about breast cancer (indeed, nearly all cancer) that it must be familial. In the case of breast cancer, while it’s true that there is a familial component and that there are genes, such as BRCA1 or BRCA2, that, when mutated, result in an enormously elevated lifetime risk of breast cancer compared to women without them, the simple fact is that only around 10-15% of breast cancer cases have a familial or genetic component. That means around 85% of breast cancer cases are what we in the biz call “sporadic.” That basically means “we can’t identify a specific cause.” True, there are well-characterized risk factors for breast cancer, such as age, early menarche, late menopause, nulliparity, and others, but the magnitude of the risk increase due to these factors is way less than, say, a strong family history (i.e., a first degree relative with breast cancer) or an identified cancer-predisposing mutation in BRCA1.
Of course, people don’t like the concept of “sporadic” cancer, mainly because humans crave explanation. The default assumption is that everything must happen for a reason and there must be a cause for every disease or cancer. Perhaps the most emphatic statement of this that I’ve encountered thus far comes from (who else?) über-quack Mike Adams when he heaped contempt on the idea of sporadic disease as “spontaneous disease.” He did this in the context of a story four years ago when America’s quack, Dr. Mehmet Oz, followed recommended care and underwent screening colonoscopy to look for polyps and was shocked that he actually had some:
Dr Oz even seems to think he has a perfect health record, saying, “I have done everything right. I don’t have any family history, and yet I’m high risk now.” His personal physician, meanwhile, is implying that even though Dr Oz’s “healthy” diet was perfect, it wasn’t enough to prevent colon polyps, and therefore you might get them too. (And therefore everybody should get screened…)
This led Adams to bloviate:
Colon polyps, in other words, appear without any cause! Mainstream medicine, you see, believes in the theory of “spontaneous disease” that “strikes” people at random.
Sort of like disease voodoo.
No matter what you do, they say, you can’t be totally sure that you’re disease free. Therefore, you need all their disease screening protocols, mammograms, and CT scans (which irradiate your body and can actually cause cancer, by the way).
What a bunch of nonsense. As any real scientist knows, everything that happens in our universe has a cause. It’s a cause-effect universe, and unless you’re God or can magically change the laws of the universe, you can’t alter the laws of cause and effect.
So if you develop colon polyps, there is a cause for it, and that cause is without question related to the foods you’re consuming, because that’s what is in contact with your small intestine, large intestine and colon. (It’s not the only factor, but it’s the primary factor.)
This is exactly the sort of thinking DeLong is exhibiting. It’s understandable, particularly when you’ve been diagnosed with a potentially life-threatening disease. Indeed, it’s quintessentially human. We all want to know why, and our default is to assume that there must be a cause. It’s also wrong. At least, it’s wrong in the sense that while, yes, there are causes of breast cancer (or colon polyps or whatever), they are often highly multifactorial and can’t be placed into a simple “box” of diet, lifestyle, or failing to do the “right” thing. This whole idea feeds into magical thinking (which I’ve seen voiced before many times) that every disease can be prevented, if only you would do the right thing. The dark side of such thinking, of course, is the opposite assumption, which goes something like this: If every disease has a definite non-inherent (i.e., non-genetic) cause, such as crappy diet, then it’s the victim’s fault, in part or in whole, for getting sick. We’ve seen this same thinking from Bill Maher before as well when a few years ago he attacked the flu vaccine and proclaimed that the “soil” matters much more than the seed; i.e., if you live a healthy lifestyle and eat a healthy diet, your “soil” won’t be conducive to the flu virus and you won’t get the flu. This reached a ridiculous extreme when Maher proclaimed that he was so healthy that he wouldn’t get flu even if exposed in a closed-in space like an airplane, leading Bob Costas to snort, “Oh, come on, Superman!” Sometimes this thinking goes beyond even Maher’s, in that cancer or other diseases are blamed on “psychic trauma” or some other psychological factor. This idea is at the very heart of the quackery known as German New Medicine or its variant Biologie Totale. The attraction of such ideas is obvious: They give the illusion of control, that you as a cancer patient can cure yourself if only you will it enough and act on that will. The dark side of this idea is an even worse version of what I just described. Now, it’s not only your fault for being sick because you didn’t live a “good” lifestyle, but you’re sick because you either lack the will not to be sick or you secretly want to be sick.
As for the idea that stress can cause cancer, even the National Cancer Institute proclaims the evidence that stress can cause cancer to be “weak,” further pointing out that there is “no strong evidence that stress directly affects cancer outcomes.” Indeed, the evidence with respect to stress and cancer is at worst conflicting, at best quite negative, with the occasional study hyped in dubious outlets like the <cite.Daily Mail being proclaimed as evidence that stress causes cancer, but a recent meta-analysis of 116,000 people, found no significant correlation between stress and bowel, lung, breast or prostate cancers. So, despite it being a very common and intuitively seemingly-reasonable idea that stress and cancer are linked, they almost certainly are not, at least not as far as causation. That’s not to say that chronic, unrelenting life stress is a good thing for your health, but evidence strongly suggests that it doesn’t increase the risk of cancer. So, while it’s understandable that DeLong might think the stress of her raising two autistic children is the cause of her breast cancer diagnosis, she’s wrong about that. What’s more disturbing to me is how she views her children’s autism as the cause of her cancer to the point of even calling it “autism-induced breast cancer” and giving it an abbreviation AIBC.
Even worse is how she views autism itself as being as bad as cancer. Actually, I get the distinct feeling she views it as worse than cancer, given the title of her post “The Lesser of Two Evils: Breast Cancer and Autism“. Look at her comparison between how cancer is viewed and her perception of how autism is viewed:
So, I speak from experience when I say Stage 1 breast cancer has nothing on autism. The differences are vast and significant. Unlike autism, no one is telling me to “celebrate” my cancer. No one is telling me that cancer is “just a different way for cells to grow.” People have told me that we’ve always had cancer, but no one is using that is an excuse for not doing anything about it. No one is blaming me (or my mother) for my cancer. Unlike a person with autism, society does not say my cancer is my fault. Another difference is that in three years, I’ll either be dead or cured. Autism is not tangible, so it neither exists concretely nor definitely leaves the body. Although cancer could do to me what autism did to Avonte Oquendo, the chances of dying from a tumor that I treat properly are small and growing smaller.
First off, unless DeLong’s cancer is a certain subtype called triple negative (and even then not entirely), it’s not true that in three years she’ll be cured or dead. Such a binary outlook! Estrogen receptor-positive [ER(+)] tumors can recur 5, 10, 15, and even 20+ years later, and the treatment for ER(+) tumors involves Tamoxifen or an aromatase inhibitor for at least five years. Indeed, trends based on clinical research showing better results are moving towards the recommendation of ten years of anti-estrogen therapy to reduce recurrence risk. Triple negative tumors, while more aggressive at the outset, tend not to recur after five years, usually recurring within three years, but they certainly can recur later. More offensive is her explicit likening of autism to cancer, in which she proclaims that “no one is telling me that cancer is ‘just a different way for cells to grow.’” This suggests to me that she views her autistic children as cancers or at least their autism as bad as any cancer, hence her resentment at the neurodiversity movement that seeks to destigmatize autism.
Avonte Oquendo, by the way, was a teenage boy with autism who walked out of his school to go missing and whose remains were found months later. In other words, DeLong makes the connection between her view of cancer and her view of autism even more explicit: Both to her are killer diseases, but there is a difference. Her cancer is potentially curable.
Finally, if there’s one similarity we see between antivaccine thinking and other quackery, it’s made explicit by DeLong:
However, one major similarity exists between breast cancer and autism: the “wisdom” of the experts. The standard of care for cancer includes popping this sucker out of my breast, and I’m fine with that. However, I’m more than a bit uneasy about the radiation treatment that the surgeon has recommended post-op. Taking a sledge hammer to my breast may indeed kill the cancer, but what about the organ that lies directly under my breast, my heart? If 10 or 20 years from now I develop a heart condition – which is also unheard of in my family – would it be the result of the radiation or just bad stuff happening to good people? The cancer experts don’t care; after all, the cancer didn’t return! Except that sometimes (often?) cancer does return, perhaps because radiation can cause cancer? And don’t get me started about chemo! I didn’t question the established wisdom concerning vaccines, and my kids have autism. I won’t repeat that mistake. I’ll look for alternatives, weigh the options, and determine the best path for me. Amazing how a little pain in the breast can turn one into a huge pain in the derrière.
So her magical thinking with respect to vaccines is leading to magical thinking with respect to her cancer. I find it rather odd many times how patients often have no problem with surgery for their cancer but have so much trouble with other options. Of course, “cutting out” the tumor makes intuitive sense, so much so that I’ve not infrequently had patients show up in my clinic expecting that I would be doing just that that very day. In the old days, surgery alone was it, too; it’s the oldest and most reliable treatment for early stage breast cancer.
I’m assuming that the surgeon recommended a lumpectomy/partial mastectomy because DeLong has a stage I cancer (clinically, at least) and he’s recommending radiation. What DeLong doesn’t understand is that there’s a reason for the radiation. If she undergoes lumpectomy and doesn’t follow it up with radiation, the local recurrence rate (the chance of her tumor recurring in her breast near the surgery site) is 30-40%. With radiation, it’s in the range of 5-8%. That’s a huge difference. Of course, as I’ve described in many of my analyses of breast cancer testimonials going right back to the very beginning of this blog and beyond, in which women undergo surgery but refuse chemotherapy and radiation, it’s still more likely than not that the tumor won’t recur, but a roughly one in three chance of recurrence are not odds that I would be willing to take, particularly when the risk of serious heart impairment due to “collateral damage” from the radiation is so low when modern techniques are used. She’s also quite incorrect that radiation oncologists “don’t care” if she gets radiation-induced cardiac disease because “the cancer is gone.” They care very, very much. An enormous amount of research over the last three decades has gone into developing techniques that minimize the risk of heart damage.
The other question is chemotherapy. If DeLong has a stage I tumor, then it’s quite possible she might not even need chemotherapy! If her tumor is not HER2(+) but is ER(+), and she doesn’t have any positive lymph nodes, what will be recommended is Tamoxifen if she’s premenopausal or an aromatase inhibitor if she is postmenopausal. If she’s triple negative (negative for ER, progesterone receptor, and HER2), chemotherapy will be recommended, as it will if she’s node positive regardless of markers. If she’s HER2(+), chemotherapy with Herceptin or one of the newer anti-HER2 agents will be recommended. In any case, the benefit of chemotherapy in early stage breast cancer tends to be relatively low as an absolute percentage; so it’s quite possible to refuse chemotherapy and do fine. The veritable plethora of “I refused chemotherapy and I’m fine” breast cancer testimonials that I’ve analyzed over the years attests to that. It’s just that DeLong should understand that if she refuses recommended chemotherapy she is increasing her risk of recurrence and death due to cancer. In early stage breast cancer, that increased risk might only be a few percent, but she needs to understand now that if she refuses chemotherapy and does well, it will be because of the surgery that removed her tumor and (if she accepts it) the radiation that reduced the risk of local recurrence, not due to any “alternative” treatments she ends up choosing to use after surgery.
What I fear we’re seeing right here is the beginning of yet another alternative breast cancer cure testimonial. DeLong will likely have surgery and then refuse radiation and chemotherapy. Assuming she doesn’t have any positive lymph nodes (which might or might not turn out to be true), the odds are more likely than not that she’ll probably be OK, but her survival and failure to recur, assuming that’s what happens, will be due to surgery and a lot of luck to have dodged the 30-40% chance of local recurrence. Her odds could be so much better if she just accepted everything modern oncology has to offer for treating breast cancer, and her survival and lack of recurrence. Our locations on opposite sides of the divide over vaccines notwithstanding, I sincerely hope she does just that, because I hope that she does not become this kind of breast cancer testimonial.
During my first clinical rotation in medical school, I found myself at the pediatric nurse station one afternoon waiting for a patient to arrive from the emergency department. An adorable older infant was there sitting in a bouncy chair, smiling and drooling as babies tend to do, and looking rather well for an inpatient. The nurse watching her explained that she had come a long way since first being transported to the facility by ambulance after being admittedly shaken (and almost certainly also beaten) by her mother’s new boyfriend one evening when she wouldn’t stop crying.
Now, cortically blind and facing a lifetime of disability, the child was awaiting placement by social services. I had experienced my first exposure to child abuse, a scourge of pediatric medicine that I hadn’t thought of at that point despite having decided on a career in pediatrics well before being accepted into medical school. I’ve since had many more opportunities to care for abused children, some of which involved considerably more visually disturbing findings and a couple that resulted in a child’s death. But I will never forget her and the feeling of utter revulsion I felt that day.
Child abuse is common and it comes in many forms that can involve physical abuse as well as neglect. Children under the age of 4 years are the most frequently affected, but children under a year tend to suffer the most severe manifestations. Head injuries make up the bulk of physical abuse in this age group, and they are often fatal. Roughly 40% of child abuse-related deaths occur in the first year of life and there is frequently both a history of abuse prior to the fatal event as well as missed opportunities for medical professionals to have intervened.
The head injuries that children suffer at the hands of abusive caregivers, if not fatal, are frequently still devastating. It is not uncommon for these children to suffer permanent neurologic injury which can include persistently altered mental status, cognitive impairment, cerebral palsy, blindness and recurring seizures. In addition to the child’s injuries, the psychosocial impact on the family can also be quite severe. I’ve seen families torn apart because of guilt and anger.
Now if you’ve read more than two of my posts on Science-Based Medicine, then you are probably well aware of my feelings on the shady marketing tactics of the overwhelming majority of practicing chiropractors. According to thousands of websites, commercials and print ads, the average chiropractor has the ability to prevent SIDS, resuscitate distressed newborns and treat a variety of common (and not so common) ailments usually managed by actual medical professionals. They make these claims despite a lack of appropriate education and training, and a blatant disregard for even our most successful medical interventions.
Until very recently, if asked what I thought was the most vile example of the chiropractic community taking advantage of parental fear in order to put more patients on the adjusting table I would have gone with their claims to prevent sudden infant death syndrome. I still would probably choose that but I may at least have discovered a close runner-up. It has come to my attention, thanks to yet another self-inflicted descent, with nose pinched and breath held of course, into the miasmic internet sewers of subluxation-based make-believe, that many chiropractors are using the terms and imagery of severe child abuse, specifically the infamous shaken baby syndrome, to encourage parents to have their infants and toddlers evaluated for injuries to the spine.
Child abuse, especially involving injury to the head and the precious contents within, deserves to be taken seriously by our society. And if the chiropractic community joined legitimate pediatric healthcare professionals in providing science-based education on ways to recognize and modify risk factors in order to potentially prevent abuse, or discussed ways of recognizing abuse after it has occurred and how to access appropriate resources, I would give them the credit they would deserve. Instead, and to be honest this didn’t surprise me in the slightest, they have decided seemingly en masse to provide blatant misinformation. But before I delve more into this inexcusable chiropractic practice-building technique, first a brief primer on shaken baby syndrome.What is shaken baby syndrome, and what it isn’t?
First described by pediatric radiologist John Caffey in a 1972 paper, “On the theory and practice of shaking infants”, what is popularly called shaken baby syndrome is actually a somewhat outdated term that continues to be used publicly because of its utility in parental education and awareness campaigns. But it is too narrow in scope for clinical utility. The more accurate and preferred diagnosis is abusive head trauma (AHT). Children suffer injury to the skull, brain and spine via a variety of mechanisms, one of which might involve the extreme translational and rotational acceleration-deceleration forces seen during a shaking event.
The other major component of abusive head trauma in children is the force applied to the head via blunt impact. Historically, there has been controversy regarding the roles of shaking and impact forces, and the literature is a bit unclear. There are biomechanical models that have led some to question shaking alone as a cause of the physical manifestations of AHT. Or perhaps severe shaking causes injuries to the spinal cord that are difficult to discover on autopsy, without injuring the brain directly.
There are clear cases of blunt trauma causing severe injury, where the physical findings can be agreed upon by all and seen from across the room. But there are also many cases where there are minimal or no obvious findings consistent with an impact to the head and a caregiver who readily admits to shaking the child aggressively and with significant force. Of course it is entirely possible that they were lying or that they didn’t realize that one or more impacts occurred while the child was being shaken. The likely reality is that shaking plays some role, although perhaps a much smaller role than initially theorized, and only in some cases of AHT.What are the effects of abusive head trauma?
It appears that infants are more likely than older children and adults to develop “shaken baby syndrome”, whether from actual shaking or from blunt impacts, because of their unique anatomy and physiology. The infant brain not only has a bit more room to move around within the skull, thus increasing the opportunity for injury as it sloshes around during acceleration and deceleration, it is encased in a thin and less-rigid skull that does not provide the same degree of protection as in older kids and adults. The large head of a baby is also poorly stabilized by their weak neck muscles, leaving them less able to counteract forces occurring during vigorous shaking. Their brains are also generally less dense and their nerves largely lacking a protective myelin sheath.
The pathophysiology of AHT involves both primary and secondary sources of neurologic injury. Primary injury occurs when the child’s head is rotated or moves in a straight line (translational) quickly and forcibly followed by sudden deceleration. This can occur either during shaking back and forth and side to side or when the head is impacted by a blunt object like a table or caregiver’s hand. Although again there is some controversy over the exact mechanism of primary injury, the most widely accepted belief is that these forces injure nerve fibers and lead to bleeding within the retina and between the brain and the thick membrane that covers it.
As if this wasn’t enough, the related secondary injury can play an even larger role in the development of acute and chronic neurologic manifestations of AHT. This occurs when the brain is starved of oxygen for a long enough period of time for cell injury and ultimately death to occur. Acute primary injury can result in periods of breathing cessation and prolonged seizure activity, to name just two of the possible mechanisms of secondary injury.
There are more injuries seen in the setting of AHT than simply the classic triad of subdural hemorrhages, retinal hemorrhages and diffuse injury to the brain. Bleeding is often seen in other areas such as between the skull and dura, and within the brain itself. Fractures of the skull, although common, aren’t always present, even in the setting of severe intracranial injury. Fractures involving other bones also frequently accompany AHT, with posterior rib, femur, humerus and metaphyseal fractures associated with abuse more so than accidental injury.How is abusive head trauma in children diagnosed?
AHT can be challenging to diagnose with certainty in some cases. Severe brain injury frequently occurs absent a history of trauma, although it should not come as a shock to hear that an alleged child abuse perpetrator might not be too keen on ‘fessing up to healthcare professionals or the authorities. More importantly there are also frequently no or only minimal external findings on physical examination. Adding to the complexity of AHT in children is the fact that accidental head injury, as well as a few medical conditions, can potentially result in overlapping presentations.
So if the mechanism of AHT is somewhat murky, and we can’t always count on the presence of overt findings of blunt trauma to the child’s head, how is it diagnosed? Very carefully considering the possible repercussions to the family and involved medical professionals if the wrong call is made. Children are often removed from their home and people go to jail. It keeps some of us up at night with worry, and unfortunately I have no doubt that the system doesn’t always get it right. But if the appropriate steps are taken, the likelihood that a medical condition or incidental injury would truly present in the same fashion as AHT is very low.
Diagnosis typically involves an expert combination of forensic interviewing, physical examination, radiologic imaging and laboratory analysis in order to rule out potentially confounding medical conditions that can result in a similar pattern of findings. The assistance of pediatricians specially trained in child abuse, when available, as well as experts in pediatric radiology, ophthalmology and neurosurgery, are often called for. And when there is suspicion of abuse, child protective services and/or law enforcement are notified. The role of the pediatrician in these situations isn’t to assist in a criminal investigation or to assign blame but to care for an injured child, although we are often asked to interpret medical information.AAP recommendations for pediatricians regarding abusive head trauma
The American Academy of Pediatrics has released guidelines regarding the diagnosis and discussion of AHT:
Now that I’ve provided a decent, although far from complete, review of abusive head trauma from the standpoint of science-based medicine, let’s look into how the chiropractic community tackles this complicated subject. Keep in mind their push in many states to gain primary care practitioner status. A search of the American Chiropractic Association yielded no discussion of child abuse in general, let alone AHT. The International Chiropractic Pediatric Association mentions the concept of shaken baby syndrome in an issue of their Pathways to Family Wellness magazine:
Shaken Baby Syndrome was originally referred to as a “whiplash” injury. Shaken Baby Syndrome occurs when a child is shaken violently in a to-andfro [sic] fashion. Such violence can cause hematomas (bruising) in the area between the skull and the brain, retinal hemorrhaging (bleeding in the eyes), and, less commonly, fractures to the skull.
Though most people feel that Shaken Baby Syndrome occurs only as an act of violence, it can also occur during play activities that were never meant to harm. These activities include:
Signs and/or symptoms of brain stem swelling (e.g. Shaken Baby Syndrome) include: constant crying, stiffness, inability to wake up or sleeping more than usual, and vomiting. If you see any of these symptoms in your infant or child after any play or injury, take them to their doctor immediately. Please use caution at all times in order to best protect your infant or child from such injuries.
Many individual chiropractic practice websites express even more blatant misinformation:
This damage has been known to occur after playfully throwing the child up in the air and catching him/her. The damage caused is called Shaken Baby Syndrome. Not only being shaken or thrown but being spanked can also cause spinal or neurological damage to a child. Any child who has been subjected to this rough behavior desperately needs a chiropractic checkup to prevent possible nerve damage.
An infant’s spine is very susceptible to injury. “Shaken Baby Syndrome”, which occurs when a baby is severely shaken, can cause eye and brain damage, blindness, paralysis, convulsions, and even death. It is a cause of post-natal brain damage that most medical doctors don’t even recognize. Chiropractors have been dealing with the effects of SBS for over a century.
Childhood is a very “physical” time for all of us. Although they are all part of normal childhood, running, jumping, falls, and accidents can all cause VSC [verterbral subluxation complex] and nerve damage, with serious consequences.
It only makes sense for parents to have their children’s spines checked regularly throughout the growing years.
As parents and caregivers it is important to be aware of how fragile our children and their delicate bodies can be. As chiropractors, when adjusting newborns and children, our mission is to remove all nerve interference that prevents a child from reaching their optimum potential. This happens through our adjustments of course, but educating our patients about preventing activities that cause injury and nerve interference in the first place is also a big part of our mission.
Mention of shaken baby syndrome most frequently comes up on chiropractic websites when touting their ability to cure colic. They rightfully state that babies perceived as having colic are at increased risk of being abused. Tired and stressed caregivers are more likely to both interpret their infant as being fussy and to have poor coping skills, sometimes resulting in “losing it.” But chiropractors are begging the question that they can do anything about infant crying. I’ve covered chiropractors and colic in a prior post.
It is abundantly clear, and hardly a shock, that chiropractors have an extremely limited understanding of abusive head trauma in children. And their use of “shaken baby syndrome” is a marketing ploy that preys on parental fear rather than informs caregivers how to reduce the incidence of abuse. Their claim that a child might suffer brain damage during normal activity and play is absurd and abhorrent. There may be controversy over the exact mechanism of injury in AHT, but it is well accepted that the force applied must be violent in nature. Even incidental falls involving impact to the head rarely result in the patterns and severity of injuries seen with AHT.
Abusive head trauma is a tragic event associated with high rates of mortality and severe morbidity in the most vulnerable among the pediatric population. Although imperfect, over the past several decades our understanding of the risk factors and underlying mechanism of injury has steadily improved, and pediatric medical professionals at every level of care strive to prevent abuse or at least recognize it as soon as possible. We are aware of our limitations and even our failures in this endeavor via the process of scientific endeavor, but remain steadfast in our goal of saving lives and preserving families.
The chiropractic community, a substantial percentage of which would like to serve as primary care practitioners for young children, appears to take a different approach. Taking advantage of the mental imagery attached to severe child abuse, primarily the entity known as shaken baby syndrome, they seek to increase their income by telling parents of healthy children that routine activity and play might lead to a similar outcome. And naturally they claim the ability to detect and correct injury before it results in serious problems.
To be fair, I don’t really know what is in the hearts of the chiropractors that do this. It’s entirely possible if not likely that the majority of them truly believe it. Yet no evidence exists to support the claim that neurologic injury remotely as severe as that associated with shaken baby syndrome or abusive head trauma can occur with routine activity and play. Similarly the evidence that chiropractic training, even their own version of advanced training in pediatrics, provides insight into childhood illness or injury management is also lacking. But ignorant or evil, the end result is the same.