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Egnor Doubles Down on Incoherent Nonsense

Neurologica Blog - 9 hours 57 min ago

Egnor continues his dualist neuroscience denial in two follow up posts, mostly responding to PZ Myers’ take down of his original post. Egnor has also been writing separately about computers, arguing that they have no memory and will never be intelligent (have agency).

In all  of these posts Egnor is following the same basic intellectual strategies – use words in a vague and confusing way to befuddle your reader, and assume your conclusion (dualism). Ironically, he writes:

The contemporary criticism of such phrases as “memory is stored in the brain” and “the brain evaluates propositions” and “the occipital cortex perceives images” — criticism made by neuroscientists and philosophers like Maxwell Bennett and Peter Hacker among others — is in keeping with the salient critiques by ordinary language philosophers who insist that we need to be honest and careful with the meanings of words in our scientific discourse. Ordinary language philosophy in neuroscience is an appeal to conceptual hygiene.

The projection is truly amazing. Science denial truly is pseudoskepticism – all of the form with none of the actual substance.

As far as I can tell, Egnor has two actual points to make. The first is that memories (or representations of memories – whatever that means) cannot be stored in the brain, because then the brain would need to know the location of each memory, and the location of the location, with infinite regression. Therefore the notion of physically storing memories collapses under its own logical impossibility.

This point, at least the extent to which one can derive a point from his incoherent nonsense, is demonstrably wrong. Egnor even contradicts himself on this point:

No one doubts that the brain can store representations or at least things that seem like representations — proteins and dendritic arrays and electrochemical gradients and the like. Much of modern neuroscience is the study of these things.

If he acknowledges that the brain stores some useful information that neuroscience can study, wouldn’t any such information for prey to his alleged infinite regression problem? If there is a solution to this problem for some brain functions he does not find ideologically objectionable, then why not for memory itself?

Also, as many commenters have pointed out, if Egnor were correct then computers could not function. Computers store information that must be retrieved as needed and don’t seem to have any difficulty reliably doing so, without running into any infinite regression problems.

Also, in all Egnor’s various follow ups and side posts, he has not addressed the key factual objection to his position – that the brain stores information in multiple overlapping patterns of neurons. A prominent feature of brain function is that it learns largely by association, so you can get to a memory through the many other associated memories, without the need for the brain knowing the physical location of the memory. Memories are not isolated discrete things, but integrated, overlapping, analog things in the brain.

The alleged infinite regression problem is Egnor’s only new point in his recent spasm of blog posts. It is demonstrably wrong on multiple levels. If Egnor had any intellectual integrity he would acknowledge that he made a mistake and this point is not valid. He has largely ignored it in his follow ups, however.

Egnor’s second point is the tired old dualist claim that mental phenomena are not physical, therefore dualism. I have already pointed out that this amounts to little more than assuming one’s conclusion. It is pure circular reasoning. He writes:

Often, unintelligible assertions in neuroscience are simply the careless use of metaphors. We say metaphorically that we store our memories in our photo albums or on our hard drives or in our brains. But memories are psychological things. They have neither mass nor volume nor location, and the assertion that they can actually be stored in anything is unintelligible — no less unintelligible than the assertion that the square root of a number can be a color or that mumbles can be stuffed in pockets.

Egnor does not explain in any scientific or operational way what he means by a “psychological thing” other than that it is not physical. But that is, of course, the very question of the philosophy of mind. It cannot be assumed as a given in order to prove the dualist position of the philosophy of mind.

As an aside, it is true that our everyday language does not contain terms that precisely deal with the concepts necessary to have a meaningful discussion of the philosophy of mind. That is why scientists and philosophers have to invent precise technical terminology, and use metaphors when explaining their concepts to an audience not familiar with the technical jargon. Egnor dismisses all of this, in a manner that amount to anti-intellectualism, in my opinion. Speaking of the ordinary language philosophers he writes:

They seek to clear up the morass of conceptual confusion in science and philosophy caused by use of language that did so much violence to the ordinary meanings of words that it had become nonsensical. In their view — a view to which I hold as well — the idiosyncratic use of words, divorced from logic and common sense, reduces to an attempt at private language, which Wittgenstein proposed was incoherent.

What is interesting is that it is Egnor who is using language as a weapon of confusion in order to make it seem as if neuroscience is incoherent. He dismisses the technical language necessary for precision, then dismisses the metaphors necessary to translate the technical language into ordinary language, and then argues that the whole thing is a mess – but it’s a mess of his making.

The key to his argument is that memories are not physical and therefore cannot be stored, and that representations of memories cannot be stored because of the infinite regression problem (which I have already demolished).

Egnor does not address the actual position of philosophers of mind, like Daniel Dennett, who have already dealt with this issue (if he disagrees, he should address their arguments, not just ignore them). As I have pointed out numerous times myself – mental phenomena are functional active things. They are based in the physical substance of the brain, but they are not just the physical substance – they are what results from the function of the physical substance. The mind is what the brain does.

To use another metaphor, the mind is like fire and the brain its fuel. The fire is not the fuel, it is a chemical process happening to the fuel. Take the fuel away and no fire. Stop the fire and you still have the fuel, but it is not burning.

The brain is a biological organ that is comprised of 87 billion neurons with trillions of connections to each other, capable of making electrical discharges that affect each other. Neurons fire in synchrony, organized in functional networks and pathways. The brain is also plastic – it can dynamically change the strength, number, pattern, and modulation of these connections, functionally changing the firing of neurons.

After more than a century of neuroscience, which is progressing at an accelerating rate, we have every reason to believe, and no reason to doubt, that all mental phenomena (including memory) do not simply correlate with the firing of neurons in the brain – they are the firing of neurons in the brain. The mind is the fire of the brain.

Egnor has provided no reason at all to doubt this elegant conclusion of neuroscience. He certainly has not demonstrated this conclusion to be incoherent or false.

What Egnor has demonstrated only is his overwhelming hubris – that in a rhetorical flicker he can disprove the work of thousands of scientists carefully building a scientific discipline over decades of careful thought and research.

As always, he does provide a useful demonstration of the power of motivated reasoning. If you desire a specific ideological conclusion strong enough, even someone with an advanced education (perhaps especially) can use their cognitive skills to produce sophisticated nonsense.

Categories: Medicine

No, the HPV vaccine does not cause promiscuity

Science Based Medicine - 11 hours 43 min ago

Today’s post isn’t about the flu vaccine, but that vaccine played a part in bringing you today’s topic. It seems that this year’s vaccine is a mediocre match for the circulating strains of influenza, and I was one of the unlucky ones in whom it didn’t appear to provide much protection. After spending several days effectively bedridden, I still feel like I’m emerging from a cognitive fog. So today’s post will be short. In the midst of my own infection, the results of a new study were announced that examined the effects of HPV vaccination on indicators of sexual behaviour in adolescent girls. I admit to being a bit dumbfounded by the topic when I heard it, and I initially thought I had heard the research question incorrectly. After all, the answer seemed (to me) so clearly self-evident, I questioned if this was an ineffective use of research dollars. This question seemed as pertinent as continuing to study the relationship between vaccines and autism: there is little reason to think there would be any causal relationship. But surveys of parents show this is a real concern for some. And now we have an answer grounded in real-world evidence.

The HPV vaccine is an effective means of preventing cancer. Let’s pause to reflect on the sentence I just wrote. We can prevent cancer, before it starts, with a vaccine. The human papillomavirus (HPV) is the most prevalent sexually-transmitted infection in North America, and almost all cervical cancer is caused by HPV. HPV causes a substantial number of cancer cases every year (26,000 per year in the US). As an anti-cancer strategy, vaccination is a pretty sensible one. HPV is not the only sexually-transmitted infection that can be prevented by vaccine. Hepatitis A and B are also sexually transmitted, and can be prevented with vaccines. However, immunization rates for HPV have lagged those of HBV and HAV, and anecdotally I haven’t seen a parental backlash against the hepatitis vaccines like I’ve seen against Gardasil and Cervarix, the two brands of HPV vaccine. Here are some uptake statistics for the Province of Ontario, where you can see the difference between hepatitis B and HPV:

I’m not going to spend time in this post reviewing the efficacy of the vaccine – that’s been blogged about before, and the CDC has excellent resources. And the safety of the vaccine has also been well established, in girls as well as boys. Despite what you may read on Natural News, Mercola or see in your Facebook feed, the HPV vaccine is effective and it lacks serious side effects. It is well tolerated and it works. Gardasil provides protection against four strains of the virus and Cervarix protects against the two strains that cause the most cases of cervical cancer.

The first vaccine, Gardasil was launched in 2006 and since that time has come to be offered by many public health agencies worldwide. In Ontario, where I happen to live, the program to vaccinate all girls started with the 2007 grade 8 cohort. The vaccine is offered in schools. Regrettably, the appropriateness of the vaccine was initially an issue with the publicly-funded Ontario Catholic School system but it’s now my understanding that the vaccine is being made routinely available to all grade 8 girls in Ontario. There are still substantial opt-out numbers, as you can see.

So why are HPV vaccination rates lagging? There’s been considerable study into the factors that influence vaccination decisions, and which can potentially be modified. You might expect that decisions are based on knowledge about the vaccine, but there doesn’t seem to be a relationship between the two. That is, some with low vaccination knowledge accept the vaccine, and some with a sophisticated knowledge base do not accept it. Studies of behaviours suggest that this factual knowledge about the vaccine may not make any material difference in decision-making. Instead, decision-making could be more related to beliefs, some of which may not be easily modified by facts.

And what are those beliefs? Some parents believe that HPV vaccination will increase sexual promiscuity, possibly by encouraging more sexual risk-taking owing to protection from the vaccine. And given the HPV vaccine provides no protection against viruses like HIV, there is the risk of more illness, in addition to the potential for more pregnancies. While there is no persuasive evidence that sexual education or other health interventions have this effect, the fear among parents persists, and has been reported as a contributor to HPV vaccine refusal.

This brings us to the study published last week:”Effect of human papillomavirus (HPV) vaccination on clinical indicators of sexual behaviour among adolescent girls: the Ontario Grade 8 HPV Vaccine Cohort Study.” The full-text article is available from the Canadian Medical Association Journal. This study used administrative databases to look at two groups of grade 8 girls: pre-vaccine (2005-7) and post-vaccine (2007-9). The vaccine receipt status on each girl was obtained, and then indicators of sexual behaviour (pregnancy, non-HPV sexually-transmitted diseases) were tracked through grade 12.

This was a large study. The initial cohort was over 260,000 girls and they were followed for an average of 4.5 years. While only 51% received all three doses of the vaccine, less than 1% in the earlier cohort received the three doses. The results were reassuring. Across 10,000 pregnancies and over 6,000 sexually-transmitted illnesses, there was no statistically-significant increase in indicators of sexual behaviour related to receipt of the HIV vaccine. This was the case both for those that received the vaccine, and even those in the cohort eligible for the vaccine. (I won’t bother showing the graphs, as they’re essentially superimposable.)

Conclusion

Some parents fear that vaccinating girls against HPV will increase promiscuity. New research studying actual behaviours shows this worry to be unfounded. The HPV vaccine is safe, effective, and has the potential to dramatically reduce the prevalence of cervical cancer in the population. There are no substantive downsides to HPV vaccination. Despite this, vaccination rates remain suboptimal. This study may play a small part in addressing parental concerns and hopefully increasing the acceptance of this vaccine.

Reference

Smith L.M., E. C. Strumpf & L. E. Levesque (2014). Effect of human papillomavirus (HPV) vaccination on clinical indicators of sexual behaviour among adolescent girls: the Ontario Grade 8 HPV Vaccine Cohort Study, Canadian Medical Association Journal DOI: http://dx.doi.org/10.1503/cmaj.140900

Photo from flickr user Patricia H. used under a CC licence.

 

 

Categories: Medicine, Skepticism

Communicating Health Science News

Science Based Medicine - Wed, 12/17/2014 - 08:17

A recent study addresses the problem of sensationalism in the communication of science news, an issue we deal with on a regular basis. The study looked at: The association between exaggeration in health related science news and academic press releases: retrospective observational study. The results show two interesting things – that university press releases frequently overhype the results of studies, and that this has a dramatic effect on overall reporting about the research.

The authors reviewed “Press releases (n=462) on biomedical and health related science issued by 20 leading UK universities in 2011, alongside their associated peer reviewed research papers and news stories (n=668).” They found that 40% of the press releases contained exaggerated health advice, 33% overemphasized the causal connection, and 36% exaggerated the ability to extrapolate animal and cell data to humans.”

Further:

“When press releases contained such exaggeration, 58%, 81%, and 86% of news stories, respectively, contained similar exaggeration, compared with exaggeration rates of 17%, 18%, and 10% in news when the press releases were not exaggerated.”

This study points a finger directly at academic press offices as a significant source of bad science news reporting. This does not let other links in the news chain off the hook, however.

The problem is worsened by changes over the last decade in the new infrastructure. The internet and changing business models make it difficult for large news outlets to maintain specialist journalists and editors. Therefore science and health news is more frequently being reported by generalist reporters, and not filtered through a dedicated science editor.

As a result, some outlets simply reprint science press releases without doing any independent investigation, talking to experts who did not author the study, and without any ability to put the new research into a proper context. This is evident simply by searching on a science news item and finding dozens of websites publishing the exact same copy, word for word, which ultimately leads back to the press release.

Bad science news reporting that I have covered over the years have demonstrated problems at every level of reporting, sometimes even starting with the scientists themselves. In some cases the conclusion or discussion of a published study will contain speculation that goes well beyond the data. The discussion is a legitimate place to explore the implications of a study, but authors need to be clear about what conclusions flow from the study and what questions are prompted by the study but not addressed by its data.

Authors also should avoid the temptation to draw causal conclusions from correlations and associations. In fact, they need to do more than avoid making spurious conclusions themselves. The discussion is a great place to anticipate and discuss what the study cannot be used to conclude. It is expected that authors will discuss the limitations of a study, but often they can be more explicit and anticipate common abuses.

The BMJ study above discusses two very common ways in which studies are overhyped. The first is drawing causal conclusion from correlations. Correlations alone do not prove causation, but a pattern of correlation can suggest some causal relationships over others. This can often be a complex and nuanced evaluation, and study authors should do their best to put correlations into a proper context.

Another potential source of hype is extrapolating from one type of data to conclusions that the data does not directly address. In healthcare reporting the most common form of this problem is extrapolating from preclinical data to clinical conclusions. Preclinical data includes in-vitro studies looking at cell cultures, or animal data. Such evidence should only be used as a means of determining whether or not human clinical trials are likely to be safe and useful.

Also, there are different types of clinical studies, and often they are misrepresented. For example, pragmatic studies are used to compare the use of treatments which have already been established as effective in real-world clinical settings. They are not designed to test efficacy, because they are typically not blinded placebo comparisons. Yet it is not uncommon to use unblinded pragmatic studies to make efficacy claims.

The biggest problem, however, is reporting preliminary or exploratory data as if it is confirmatory. I have argued previously that preliminary data should not even be reported to the press, in most cases. Such data simply does not rise to the level of newsworthiness, as it is far more likely to be wrong than to pan out in later research. If  preliminary data is communicated, it should come with a bold disclaimer about the preliminary nature of the study.

Sometimes the scientists themselves are innocent, but their university press office tries to find an angle that will promote the study by making it seem relevant to some headline grabbing issue. Their job is to get press attention, and dry pre-clinical studies are unlikely to do the job. Therefore they turn to a number of common ploys to make any research seem relevant to a topic that is likely to grab media attention.

In the health arena, this means any study involving viruses might cure the common cold, any study involving cell metabolism might lead to a cure for cancer or obesity, and any study of brain cells might cure Alzheimer’s disease.

Sometimes a tiny footnote in the discussion is latched onto and presented as if it were the main focus of the study, even when the study actually has nothing to do with the topic.

Scientists are usually given the opportunity to review the university press release before it is released. This means that scientists have an opportunity to be more active in making sure that their research is presented properly.

Of course, journalists and news outlets have responsibility for the news they report, and should not simply be reprinting press releases word-for-word. Science journalists need to at least read the original study and see if the results match what is being sold in the press release. Ideally they will also talk to independent experts to put the study into context.

Conclusion

The BMJ study is not surprising and fits in with my experience reporting science and health news over the last decade. I was a bit surprised at how much an effect the press releases were having on later reporting. This is actually good news, because it means that if scientists and university press offices were more responsible, then a significant amount of bad science news reporting can be avoided.

Scientists are press offices should follow some basic rules for good science news reporting:

- Put a study into an overall scientific context.

- Do not emphasize minor aspects of the research simply because they are more exciting

- Do not search for any health implication of pre-clinical data just for the headline, and certainly don’t make it seem like the focus of the study.

- Anticipate and explicitly address common misinterpretations of the research.

- Consider not reporting preliminary data at all, or at least clearly label preliminary data as such early in the press release and make is absolutely clear what this means.

- Do not report correlations as if they prove a specific causation.

- Be up front about all the limitations of a study and alternate interpretations.

- Make it clear when a study is an outlier, if there are multiple schools of thought, or where the study lies in relation to the current preponderance of expert opinion. In other words, do not present one small study as if it overturns a well-established consensus.

In short, a good press release not only summarizes the results and conclusions of a study, but educates anyone reading it (journalists and the public) about the kind of research being done and how it fits into the overall scientific enterprise.

In my opinion, this falls into the broader mission of universities, which is education. They should not only be concerned about the education of their students, but also the public at large. A great deal of the education of the public about scientific matters (or other academic matters) is handled out of the university press office. Greater attention needs to be paid to their role in communicating science.

Categories: Medicine, Skepticism

Neurosurgeon Thinks the Brain Doesn’t Store Memories

Neurologica Blog - Tue, 12/16/2014 - 07:40

It has been six years since I have written a blog post deconstructing the nonsense of our favorite creationist neurosurgeon, Michael Egnor. In case you have forgotten, he is a dualist writing for the intelligent design propaganda blog, Evolution News and Views. He delights in ridiculing what he calls “materialist metaphysics,” or what scientists call, “science.”

I guess I shouldn’t be surprised that he has managed to outdo his prior incoherent ramblings. In a recent blog post he claims that it is impossible for the brain to store memories, an idea he ridicules as “nonsense.”

As usual, Egnor is playing loose with definitions and logic, tying himself up in a conceptual knot in order to arrive at his desired destination – the idea that the brain cannot account for mental phenomena. His logic train derails pretty quickly:

It has been known for the better part of a century that certain structures in the brain are associated with memory. The amygdala and the hippocampus in the temporal lobe, and some adjacent cortical regions, have been shown to be associated with the act of remembering in animals and humans.

Notice the term “associated” – memory is just “associated” with specific brain regions. Egnor is desperately trying to deny that the association is causal. Similarly he admits that such brain regions are “necessary” for memory, but then insists (without evidence) that they are insufficient.

He is playing the same game of neuroscience denial he has for years – dismiss all of the evidence that the brain is responsible for mental function, such as memory, by minimizing it as mere correlation or association. He thinks the brain is somehow involved in these things, but cannot do them on its own. Something else is required.

To make that case, that the brain is insufficient, he dives deeply into his main bit of illogic.

It’s helpful to begin by considering what memory is — memory is retained knowledge. Knowledge is the set of true propositions. Note that neither memory nor knowledge nor propositions are inherently physical. They are psychological entities, not physical things. Certainly memories aren’t little packets of protein or lipid stuffed into a handy gyrus, ready for retrieval when needed for the math quiz.

When making scientific or philosophical arguments, clear and precise definitions are critical. Often pseudoscientists will give themselves enough wiggle room with vague or ambiguous definitions in order to do a little logical sleight of hand. Egnor is sloppy, to say the least, with his definitions.

I would not define memory as “retained knowledge.” The term “knowledge” is too ambiguous. Also, note that he uses “retained” as if it is any different than “stored.” He goes on to define knowledge as a set of true propositions, which should immediately strike you as a massively insufficient definition for what memory “retains.”

Memories don’t have to be true, and they don’t have to be propositions. You can remember an image, a sound, an idea (true or false), an association, a feeling, facts, and skills, including specific motor tasks.

A far more accurate an useful definition of memory would be stored information. That would not serve Egnor’s purposes well, however. He uses the more vague “retained knowledge” hoping you won’t notice what memories actually are – information.

By pointing out that memories are information the analogy to computers becomes obvious. A hard drive of a computer stores information also. Computer information is stored physically, in the pits on a CD, or magnetic properties of a tape or disk, for example. That information can be used to construct an image, music, a word processor document, or a computer program.

Can the brain store information? Of course it can. The average adult human brain has about 87 billion neurons. Those neurons make connections to other neurons through axons and dendrites. The number, pattern, and strength of those functional connections is information – about 100 trillion connections, with an estimated memory capacity of 2.5 petabytes (million gigabytes).

The brain’s structure and function seems to be for the very purpose of storing and processing information. The claim that it doesn’t, and can’t, store memories is remarkable, to say the least. A memory, despite Egnor’s insistence, is not a “psychological thing” (which he doesn’t even define). Memory is information which is physical.

The train is now flying off the tracks, but let’s watch it crash into the ravine:

Now you may believe — as most neuroscientists and too many philosophers (who should know better) mistakenly believe — that although of course memories aren’t “stored” in brain tissue per se, engrams of memories are stored in the brain, and are retrieved when we remember the knowledge encoded in the engram. Indeed neuroscientists believe that they have found things in the brain very much like engrams of some sort, that encode a memory like a code encodes a message.

You will notice that Egnor does not define “engram,” even though it seems to be the linchpin of his current argument. Perhaps that’s because it really adds nothing to the issue. An engram is an outdated term for the physical substance of a memory in the brain.

Functionally speaking, the engram is the memory. Egnor pretends that they are somehow different, as if “obviously” a memory cannot be stored, but an engram can. It seems that he is making a dualist assumption here, simply assuming and asserting the entire point of his article – that memories and engrams are different types of things.

Finally, the train explodes:

But there is a real problem with that view. As you try to remember Nana’s face, you must then locate the engram of the memory, which of course requires that you (unconsciously) must remember where in your brain Nana’s face engram is stored — was it the superior temporal gyrus or the middle temporal gyrus? Was it the left temporal lobe or the right temporal lobe? So this retrieval of the Nana memory via the engram requires another memory (call it the “Nana engram location memory”), which must itself be encoded somewhere in your brain. To access the memory for the location of the engram of Nana, you must access a memory for the engram for the location for the engram of Nana. And obviously you must first remember the location of the Nana engram location memory, which presupposes another engram whose location must be remembered. Ad infinitum.

This argument represents such a profound ignorance and misunderstanding of our current knowledge of neuroscience it’s frightening to be coming from anyone, let alone a neurosurgeon.

The brain is a massive parallel processor that stores information in overlapping patterns of neuronal connections. Single neurons can participate in many different memories and processes. This is exactly why our brains are so good at pattern recognition, why one thought or memory reminds you of another, why an odor can trigger a flood of memories, etc.

You don’t have to know (nor does your brain) where in your physical brain a memory is located, because you can access that memory simply because it is integrated with so many other memories.

Next Egnor goes for a typical denialist strategy – we don’t currently know everything, therefore I can pretend we know nothing:

To assert that memories are stored in the brain is gibberish. And don’t fall for the materialist invocation of promissory materialism — “It’s just a limitation of our current scientific knowledge, and we promise that science will solve the problem in due time.” The assertion that the brain stores memories is logical nonsense that doesn’t even rise to the level of empirical testability.

Current scientific understanding is always incomplete. However, our understanding of neuroscience is fairly robust and growing steadily. There is no single source that lays out all of the scientific research on memory, but here is one review that goes over a few mechanisms.

Egnor has the nerve to invoke logic and empiricism with respect to modern neuroscience. This is a strategy I have noticed quite a bit among the science deniers – just keep parroting the language of science and skepticism and accusing others of being guilty of your sins.

Returning to his old nonsense, he writes:

How then, you reasonably ask, can we explain the obvious dependence of memory on brain structure and function? While it is obvious that the memories aren’t stored, it does seem that some parts of the brain are necessary ordinarily for memory. And that’s certainly true. But necessary does not mean sufficient.

The obvious dependence of memory on brain structure and function is most easily explained by that brain structure and function being memory. Egnor has put forward no argument against that elegant solution. There is also absolutely no reason not to conclude that the brain is sufficient to explain memory, Egnor simply does not wish it to be so, hence his convoluted poor logic and misdirection.

In fact, we are getting better and better at manipulating memory, not just in humans but in many experimental animals, by manipulating neurons, their connections, and their function. There does not seem to be any limit to this, consistent with the theory that memories are entirely brain function.

Finally we get to Egnor’s brief position:

I hew to Thomistic dualism, which is a coherent view of the mind that takes an Aristotelian perspective and for which the participation of the brain in memory is not problematic at all.

After spending paragraphs unsuccessfully trying to undermine modern neuroscience, Egnor attempts to replace it with a single paragraph. He makes no attempt to establish that his alternate is logically consistent, or that it can be tested empirically. That is the double standard of denialism – hold the denied science to ever higher standards (whatever it takes) in order to cast doubt on the conclusions, then magically substitute your own position without any requirement for logic or evidence.

Thomistic dualism is just another flavor of dualistic nonsense, the notion that there are two kinds of stuff, material stuff and spiritual stuff. Egnor’s preferred version actually solves nothing, it simply asserts that the soul and the material body work together. (OK, problem solved, I guess.)

Conclusion

Egnor is playing word and logic games, not making a serious analysis of the science of memory. In fact, he appears to be largely ignorant of the neuroscience. He uses vague terms in a confusing way (reflecting his sloppy thinking) to force his desired conclusions.

If you are going to write a single essay attempting to refute and entire discipline of science as obvious nonsense, you’re going to have to do much better than Egnor can muster.

Once again, he has just reminded us of the true meaning of “Egnorance.”

Categories: Medicine

Study of “Acupressure” for Constipation

Science Based Medicine - Tue, 12/16/2014 - 03:00

A recent study  in the Journal of Internal Medicine evaluated a treatment for constipation.  It tested whether training patients to massage the perineum (the area between the vagina or scrotum and the anus) would improve their reported bowel function and quality of life at 4 weeks after training. They found that it did.  It’s a simple, innocuous treatment that may be worth trying, but why, oh why, did they have to call it “acupressure”?  That irritated me. Should it have? Why should it matter? Isn’t a rose by any other name still a rose?  Is this a meaningless semantic quibble and hypersensitivity on my part, or am I right to see it as yet another example of quackademia’s attempts to infiltrate science-based medicine? I’ll explain my thinking and let you decide for yourself.

Why perineal pressure?

Constipation is a common complaint that is usually treated with increased dietary fiber and fluids, exercise, stool softeners, and laxatives. There were no previous studies of perineal massage for constipation. Where did the idea of treating constipation with perineal pressure come from? The authors explain that perineal massage is recommended in pregnancy to prevent lacerations and decrease the need for episiotomy. True, but irrelevant. They explain that patients with rectocele or descending perineum syndrome have used perineal or transvaginal pressure to support the weakened rectal wall and aid in defecation. Also true, but irrelevant for most patients with constipation.  They cited a study showing that perineal pressure increases rectal muscle tone by 52%, but the clinical relevance of that finding is not clear.  They cited other research suggesting that perineal pressure might break up hard stools, relax the anal sphincter,  stimulate sacral nerves, and treat hemorrhoids. But none of the studies they cited called it “acupressure.”

How the study was done

The study was randomized with a treatment group and a control group but no blinding. The 100 participants met the Rome III criteria for functional constipation. Both groups received educational materials about constipation and conventional treatment options. The self-acupressure group also received 3-5 minutes of oral instruction with the aid of a plastic anatomical model and were given handouts with written sex-specific instructions. The handout for women explains:

 With two extended fingers (middle and index), you should press on your perineum, pushing toward the back of your body on the skin roughly half way between your vagina and anus. When you sense that you are just about to defecate, your fingers should be able to feel underneath your perineum the stool inside you pushing against your sphincter…you should push on your perineum in repeated pulses. Imagine that you are using your fingers to break up and guide the stool downward inside you. By pushing several times on the skin, you can manually break up the stool before it passes through the sphincter. You should relax your sphincter only when the stool above it is sufficiently soft to pass through.

Subjects filled out questionnaires at the beginning of the study and again after one month. The questionnaires asked about various subjective factors such as ease of defecation, feeling of incomplete bowel evacuation, hemorrhoid symptoms, physical and psychosocial discomfort, worries, satisfaction, quality of life, etc. Eight patients were lost to follow-up and one decided not to practice self-acupressure after instruction, so 91 subjects completed the study.

Study results

It worked! Outcomes for the treatment group were better than for the control group. There were statistically significant differences in 13 out of the 18 primary and secondary outcomes. Patients in the treatment group reported using the technique 3.6 times a week, and 82% said they intended to continue using it.

Limitations of the study

The authors themselves point out several limitations of the study.  The sample size was modest, the randomization left the two groups poorly balanced with regard to gender and baseline scores, and the study was not blinded. Outcomes were not measured objectively but only by subjective patient self-report. A placebo effect and a Hawthorne observer effect may well have influenced results.

There was no comparison with other manual techniques. I wondered if it might be more effective for women to insert a finger in the vagina. Or for either sex to use a lubricated glove or finger cot and insert a finger in the rectum to disimpact the stool directly and stimulate defecation. For that matter, if they’re going to call it acupressure, why didn’t they compare it to stimulation of other acupoints elsewhere on the body that have traditionally been used to treat constipation? (I suspect they knew that would be fruitless.)

Recommendation

In their conclusion, the authors say, “Clinicians should consider incorporating education in perineal self-acupressure as a treatment for constipation, along with conventional interventions such as increased exercise and dietary fiber intake.” The advice to consider trying perineal massage is reasonable, and I have no quarrel with that. My only objection is to calling it acupressure.

What is acupressure?

Acupressure is a variant of acupuncture. Like acupuncture, it is based on the concept that life energy (qi) flows through meridians and obstructions to the flow can be treated by stimulating acupoints. There is no credible evidence that qi, obstructions, meridians, or acupoints even exist. One self-styled world expert on acupressure therapy  recommends that constipation be treated, not by pressure on the perineum, but by pressure at acupressure point CV6 on the abdomen just below the belly button. Other online acupressure advice generally involves points on the hand, with either steady pressure or light repetitive tapping. One acupuncture website  lists a whole slew of acupuncture points for constipation, the particular combination varying according to whether the patient has hot constipation, cold constipation, qi constipation, qi deficient constipation, wind constipation, food constipation, blood deficient constipation, or yin deficient constipation.

There is indeed an acupoint on the perineum, the Ren 1 point. It is said to nourish Kidney Yin and resolve Damp-Heat, and is used for constipation, dysuria, incontinence of feces and urine, hemorrhoids, rectal prolapse, spermatorrhea, impotence, pruritus vulva, loss of consciousness, asphyxiation from drowning, and manic psychosis. When I read that, my imagination ran wild. I couldn’t help envisioning an acupuncturist responding to a drowning emergency by pulling off the victim’s swim trunks and sticking needles in his bottom. Or trying to do that to a psychotic patient in the throes of a manic episode. Could be interesting…

Why did the study call it “acupressure” rather than massage?

I was curious enough to write the lead author and ask him. He replied that they could just as well have called it massage. (So why didn’t they?) He said acupressure was part of the Rome criteria for diagnosis of constipation, but the Rome criteria don’t mention acu- anything. They only include “Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor)”

I exchanged several e-mails with the author in an attempt to understand his reasoning. He directed me to the website for the Center for East West Medicine. When I searched that site for constipation, I found only a reference to the Large Intestine 6 (He Gu) point on the hand.  That point is recommended for headaches and jaw pain in addition to constipation, general pain, and delayed labor. They say it must never be used during pregnancy because it may induce labor; I wouldn’t worry about that.

The author is an MD, JD, and MTOM (Master of Traditional Oriental Medicine) who uses what he calls a “holistic paradigm” to make traditional Chinese medicine diagnoses and treat patients on that basis. He said the study provided a technique that would integrate well with conventional medicine. I think that provides a crucial clue to understanding what is going on here.

Conclusion

The study suggests that perineal pressure or massage might be a useful addition to conventional treatment of constipation.  We don’t usually go by the results of a single study that has not been replicated, but in this case the treatment is harmless and not unreasonable to try. I only wish they had called it “perineal pressure” instead of “acupressure.” I think the use of the word “acupressure” constitutes a deliberate attempt to promote belief in fanciful alternative medicine concepts and to infiltrate them into mainstream medicine.  In my opinion it is a prime example of the so-called “integrative” approach to medicine that science-based medicine so rightfully deplores and that Mark Crislip has compared to mixing cow pies with apple pies.

 

Categories: Medicine, Skepticism

The Mound Builder Conspiracy

Neurologica Blog - Mon, 12/15/2014 - 09:27

Even after a couple of decades as a skeptical activist I can still encounter new dark recesses festering with pseudoscience. The human capacity for nonsense seems endless.

A report in an alternative news outlet from the American Institution of Alternative Archeology (AIAA – the tag “alternative” is a huge red flag) claims that the Smithsonian Institution “destroyed thousands of giant human remains during the early 1900′s.”

Why would they do this? The AIAA has an unconventional view of human history. Apparently based on mention in the bible that giants once walked the earth, they believe that the mound building cultures of the Americas were not the product of early Native Americans but rather an earlier race of technologically advanced giants. Reading the comments after the article, it also seems that the belief these giants were white and Aryan is popular.

This is an excellent example of how a narrative develops from a combination of religious beliefs and cultural biases, and then history is rewritten and conspiracy theories woven out of whole cloth in order to support the preferred narrative. Science and evidence do not guide the narrative, but rather it is the other way around – a hallmark of pseudoscience.

The WorldNewsDailyReport, and the AIAA, would have you believe that (as quoted from AIAA spokesman, James Churward):

“There has been a major cover up by western archaeological institutions since the early 1900′s to make us believe that America was first colonized by Asian peoples migrating through the Bering Strait 15,000 years ago, when in fact, there are hundreds of thousands of burial mounds all over America which the Natives claim were there a long time before them, and that show traces of a highly developed civilization, complex use of metal alloys and where giant human skeleton remains are frequently found but still go unreported in the media and news outlets.”

That the convenient thing about conspiracy theories, they are remarkably immune to facts. You can, in fact, make up whatever facts you wish, and ignore others, all as part of the conspiracy.

According to the AIAA, somehow the Smithsonian was able to monopolize all of American archaeology, to such a degree that they had complete control over evidence from hundreds of thousands of mounds. They allegedly destroyed thousands of giant skeletal remains, important archaeological evidence, because it did not fit the official story.

A comprehensive survey of such mounds was published by the Smithsonian in 1848 (before Darwin published his theory of evolution), a reference still used by archaeologists today. I guess the conspiracy was already underway. and they were supporting the theory of evolution even before they knew it existed.

It is true that when Europeans encountered Native Americans they were largely unaware of who built the mounds. That is because they were built by their ancestors thousands of years ago. The ancestors to modern Native Americans likely arrived around 12 thousand years ago. The exact history is still being worked out. It is unreasonable to assume that there would be continuous cultural knowledge across thousands of years.

It should also be obvious that if there were a race of giant humans walking around, leaving thousands of skeletons behind, no one organization could possibly control such evidence. If the Smithsonian decided to suppress such evidence (itself a bizarre idea), then their competitors in New York or at the Peabody in New Haven could have easily preserved and described the undeniable evidence.

You would have to expand the conspiracy to involve all of archaeology – all museums, universities, researchers, etc.

Of course, all the AIAA would have to do to expose this giant conspiracy and catapult themselves to fame is to produce a single verifiable giant skeleton. Bones from a few thousand years ago would be well-preserved, could not be hoaxed in such a way to evade detailed scientific scrutiny, and would even likely contain DNA. If there are hundreds of thousands of such mounds, it seems likely the Smithsonian goons would have missed a stray femur or skull.

Of course, we always have claims that such things exist. We never get to see them, however. The report also claims that the Smithsonian is being forced by the court to reveal documents that will prove the conspiracy, to be released in 2015. Somehow I suspect that these documents are not going to be what the AIAA would have us believe (if they even exist).

That is also a common feature of such conspiracies – they are always about to be broken wide open with incontrovertible evidence, evidence which somehow never seems to materialize. It’s like a carrot being held in front of the believers, keeping them going for one more cycle. Or it is just a way to get sensationalized articles and headlines – promising dramatic evidence right around the corner, then counting on the short attention span of the public to not follow through.

Conclusion

In the end the giants of the mound building culture is just another bizarre conspiracy theory being supported by rank pseudoscientists. In this case there seems to be a socio-religious belief system driving the conspiracy, one with not subtle undertones of racism.

As is often the case, all the claims and accusations can be settled with one verifiable piece of evidence. In this case it seems particularly implausible that such evidence could not be produced if the claims were true.

 

Categories: Medicine

Hostility towards scientific consensus: A red flag identifying a crank or quack

Science Based Medicine - Mon, 12/15/2014 - 03:00

I have yet another grant deadline to deal with, this time for the Department of Defense Congressionally Directed Medical Research Programs, this time around its Breast Cancer Research Program. Unfortunately, that put a high degree of time pressure on me. Fortunately, there’s still stuff in the archives of my not-so-secret other blog that I deem quite appropriate for this blog and that can be updated with minimal effort. If you don’t know what I’m talking about when I refer to my not-so-secret other blog, then it’ll definitely be new to you. If you haven’t been reading that blog for at least four and a half years, it’ll be new to you as well. And even if you have seen it before, I think it’s worth revisiting.

Why? It came up because of an encounter I had on Twitter with Jane Orient, MD, who, as you might recall, is the executive director of the American Association of Physicians and Surgeons (AAPS). I’ve written about the AAPS before. You can get the details in the link, but if you don’t have time suffice to say that it is an entire organization of libertarian-leaning “brave maverick doctors” who think Medicare is unconstitutional, don’t believe that the government should have much, if anything, to do with regulating the practice of medicine, and reject evidence-based guidelines as an unholy affront to the independence of the physician. Along the way, the AAPS, through its journal, The Journal of American Association of Physicians and Surgeons (often abbreviated JPANDS), promoted antivaccine views, including the discredited concept that vaccines cause sudden infant death syndrome, HIV/AIDS denialism, and the scientifically unsupported idea that abortion causes breast cancer (a topic I might have to revisit, given the activity promoting it recently).

In any case, two or three weeks ago, I was having a bit of an exchange with Dr. Orient over anthropogenic global climate change (often abbreviated as AGW, for anthropogenic global warming, for short), the well accepted science that concludes that CO2 generated by human activity is having a serious warming effect on the earth’s climate. As you might expect, she’s not big on this particular scientific consensus. I forgot about it, but then the other day saw this Tweet exchange between Dr. Orient and Ed Wiebe:

@edwiebe @AAPSonline I can't vote against U.S, bureaucrats, much less UN. 31000 scientists voted against IPCC. http://t.co/fdJDgA5bu6

— Jane Orient, MD (@jorient) December 13, 2014

She’s referring to a project by AGW denialists that’s very much like the Perth Group when it comes to HIV/AIDS denialists and various lists of scientists who purported “dissent from Darwin.” It’s a common tactic used to try to give the appearance of an actual scientific controversy when in fact there isn’t. Not surprisingly, similar efforts are taking place in the AGW community, and, also not particularly surprisingly, JPANDS has been linked to the Petition Project, which has been trying to get signatures from scientists who don’t believe AGW is happening since 1998, while JPANDS itself has published some really bad papers on climate change.

Later in the exchange, Dr. Orient Tweeted:

@edwiebe @AAPSonline You suggested voting on UN IPCC. Glad you agree that alleged consensus on AGW is not science.

— Jane Orient, MD (@jorient) December 13, 2014

This reminded me of an earlier Tweet to me:

@secularbloke @gorskon @AAPSonline Skepticism is the essence of science; consensus is its death

— Jane Orient, MD (@jorient) December 1, 2014

On the surface, Dr. Orient sounds so reasonable, doesn’t she? There’s just one problem. She completely misunderstands skepticism and science.

It has often been written on this blog and elsewhere that the mark of a true crank is hatred of the scientific consensus, be it consensus regarding the theory of evolution, the science that says homeopathy is impossible, the scientific consensus among climate science that concludes that the earth is getting warmer due to human activity; various areas of science-based medicine; or the safety and efficacy of vaccines. Perhaps the most famous expression of distrust of a scientific consensus is the famous and widely quoted speech by Michael Crichton, in which he said:

Let’s be clear: the work of science has nothing whatever to do with consensus. Consensus is the business of politics. Science, on the contrary, requires only one investigator who happens to be right, which means that he or she has results that are verifiable by reference to the real world. In science consensus is irrelevant. What is relevant is reproducible results. The greatest scientists in history are great precisely because they broke with the consensus.

There is no such thing as consensus science. If it’s consensus, it isn’t science. If it’s science, it isn’t consensus. Period.

To which I (and many others) responded, “Bullshit!” (Seriously, anything less is not a strong enough rebuke.)

In fact science is all about coming to a consensus, but it’s about coming to a consensus based on data, experimentation, and evidence, a consensus that has reproducible results that are, as Crichton put it, verifiable by reference to the real world. After all, what is a scientific theory like the theory of evolution or Einstein’s theory of relativity but a statement of the current scientific consensus regarding a major scientific topic? What is peer review but quality control (making sure the scientific methodology is sound) coupled with testing new science against the current consensus to see where it fits in or where it exposes weaknesses? What is science but attempting to forge a consensus regarding theories and statements that most accurately describe the universe in a useful and predictable way?

Of course, questioning the consensus is often necessary in science. Indeed, it is critical to scientific advancement. However, there is a huge difference between questioning a current consensus and producing the data and experimental evidence to show that there is a real scientific reason to question it and JAQing off about science. The latter, raising spurious or already answered questions about a scientific finding or theory one doesn’t like, belongs to the province of cranks and denialists, and it is what they are very good at. The problem is that they aren’t very good at realizing why their questions are not worthy of the attention that they think they are. A few years ago, a lovely example of this showed up on the Discovery Institute’s propaganda arm, its version of Age of Autism, so to speak, namely Evolution News and Views. In it, the Kent Heckenlively of the creationist set, the ever excitable Casey Luskin, penned a typical bit of silliness in which he asks the question, When Is it Appropriate to Challenge the “Consensus”?

If Mr. Luskin had clue one about science, he could answer the question in two sentences and echo how scientists would answer the question: When you have an actual scientifically valid reason, based on science, evidence, experimentation, and observational evidence, to think that the current scientific consensus about something is in error, then it is appropriate to challenge the scientific consensus. When you don’t, then it isn’t. Unfortunately, Casey didn’t; so he couldn’t. Instead, we were treated to a potpourri of pseudoscientific and denialist claptrap that was apparently based on an article in The American by Jay Richards entitled When to Doubt a Scientific ‘Consensus’. In the article, Richards postulates twelve “signs” that should lead one to doubt a scientific consensus, any scientific consensus—although he seemed most concerned with anthropogenic global warming in this particular article, while Luskin is, of course, concerned mostly with “intelligent design” creationism versus the hated (by Luskin) “Darwinism.” There’s just one problem. Not a single one of these “signs” had anything to do with a scientific argument. Richards started out with a reasonable enough introduction:

Anyone who has studied the history of science knows that scientists are not immune to the non-rational dynamics of the herd. Many false ideas enjoyed consensus opinion at one time. Indeed, the “power of the paradigm” often shapes the thinking of scientists so strongly that they become unable to accurately summarize, let alone evaluate, radical alternatives. Question the paradigm, and some respond with dogmatic fanaticism.

We shouldn’t, of course, forget the other side of the coin. There are always cranks and conspiracy theorists. No matter how well founded a scientific consensus, there’s someone somewhere–easily accessible online–that thinks it’s all hokum. Sometimes these folks turn out to be right. But often, they’re just cranks whose counsel is best disregarded.

So what’s a non-scientist citizen, without the time to study the scientific details, to do? How is the ordinary citizen to distinguish, as Andrew Coyne puts it, “between genuine authority and mere received wisdom? Conversely, how do we tell crankish imperviousness to evidence from legitimate skepticism?” Are we obligated to trust whatever we’re told is based on a scientific consensus unless we can study the science ourselves? When can you doubt a consensus? When should you doubt it?

Your best bet is to look at the process that produced, maintains, and communicates the ostensible consensus. I don’t know of any exhaustive list of signs of suspicion, but, using climate change as a test study, I propose this checklist as a rough-and-ready list of signs for when to consider doubting a scientific “consensus,” whatever the subject. One of these signs may be enough to give pause. If they start to pile up, then it’s wise to be suspicious.

So far, there isn’t much here to disagree with. Scientists are human beings; scientific fads come and go. Ditto physicians. Medical fads come and go too. Some scientific consensuses ultimately turn out to be wrong. Virtually all of them undergo significant revisions as new evidence comes in. Moreover, not all consensuses are created equal. Depending upon the field, the strength of any one scientific consensus can vary quite markedly compared to others, depending upon the science, the topic within that science, or even the subtopic within the topic. For example, the scientific consensus supporting the theory of evolution, particularly common descent, is exceedingly strong. Based on multiple lines of converging evidence from many different disciplines, evolution one of the strongest of all scientific consensuses. Similarly, the consensus that natural selection is one major driving force behind much of evolution is nearly as strong.

However, as the discussion devolves into more detailed, specialized areas, inevitably the consensus weakens. Eventually, subsidiary areas of a discipline are reached where the consensus is weak or where there is no consensus. Often these questions are at the frontiers of the science and, because there is not yet a consensus, the most heavily researched and hotly contested areas of the science. Denialists often attack science at the very edges of a field as a proxy for attacking the much more strongly supported core theory. Creationists like Casey Luskin are actually notorious for this, jumping on new findings about, for example, “junk DNA,” whether it has a function, whether it is subject to natural selection, and, if so, how much, as a bit of logical prestidigitation to hide the fact that the core theory of evolution is supported by mountains of evidence and not in doubt by scientists. Cancer quacks like to latch onto the newest findings to try to make it seem as though “everything you thought you knew about cancer is wrong.”

It is also true that peer pressure and groupthink can make persuading scientists that a particular scientific consensus is in error can be a disturbingly slow and messy process at times. However, in the end eventually science almost always wins out. One example (summarized very well by our very own Kimball Atwood IV, MD) is the discovery that most duodenal ulcers are actually caused by a bacterium, H. pylori. Barry Marshall and Robin Warren first reported a curious finding of what they described as “unidentified curved bacilli on gastric epithelium in active chronic gastritis” (not ulcer) in two letters to The Lancet, published on June 4, 1983. They reported that it wasn’t seen using traditional staining methods and suggested that they might be associated with gastritis. By 1992, multiple studies had been published establishing the causative role of H. pylori in peptic ulcer disease, and medical practice rapidly changed. That’s less than ten years, which, given how long it takes to organize and carry out clinical trials, is amazingly fast. Yet somehow a favorite denialist myth is that “dogmatic,” “close-minded” scientists refused to accept Marshall and Warren’s findings. It’s an example of a scientific consensus that deserved to be questioned, was questioned in the right way, and was overthrown.

In other words, it was nothing like Richard’s twelve “signs”:

  1. When different claims get bundled together.
  2. When ad hominem attacks against dissenters predominate.
  3. When scientists are pressured to toe the party line.
  4. When publishing and peer review in the discipline is cliquish.
  5. When dissenting opinions are excluded from the relevant peer-reviewed literature not because of weak evidence or bad arguments but as part of a strategy to marginalize dissent.
  6. When the actual peer-reviewed literature is misrepresented.
  7. When consensus is declared hurriedly or before it even exists.
  8. When the subject matter seems, by its nature, to resist consensus.
  9. When “scientists say” or “science says” is a common locution.
  10. When it is being used to justify dramatic political or economic policies.
  11. When the “consensus” is maintained by an army of water-carrying journalists who defend it with uncritical and partisan zeal, and seem intent on helping certain scientists with their messaging rather than reporting on the field as objectively as possible.
  12. When we keep being told that there’s a scientific consensus.

Oddly enough, most, if not all, of these warning signs apply to denialists and cranks. Richards appeared to have been engaging in a massive case of projection. I’m not going to examine each of the twelve “signs” in detail (that will be left as an exercise for the interested reader), but I will examine a few of the most egregious “signs.” For example, when it comes to ad hominem attacks, Richards writes:

Personal attacks are common in any dispute simply because we’re human. It’s easier to insult than to the follow the thread of an argument. And just because someone makes an ad hominem argument, it doesn’t mean that their conclusion is wrong. But when the personal attacks are the first out of the gate, and when they seem to be growing in intensity and frequency, don your skeptic’s cap and look more closely at the evidence.

Crank movements, of course, excel at the ad hominem attack. Creationists like Casey Luskin, for instance, spit the term “Darwinist” at evolutionary biologists and frequently try to link evolution (and thus its defenders) Nazi-ism and the Holocaust, eugenics, social Darwinism, and all manner of evils. Above all, evolutionists must be atheists, which to many creationists is the worst thing a person can be, given the vehemence of the invective.

Speaking of invective, one crank in particular, J.B. Handley has made a special study of seeing just how nasty his attacks can be. Generation Rescue and its propaganda arm Age of Autism specialize in “venomous invective,” particularly against Paul Offit and anyone else who opposes its anti-vaccine agenda. After all, this is the same man who launched personal attacks on Steve Novella that can only be viewed as more than venomous. This is the same man whose misogynistic attacks on Amy Wallace, a journalist who wrote an excellent article on the anti-vaccine movement, made him infamous throughout the science-based blogosphere. This the same man whose blog posted a Photoshopped picture of Steve Novella, Amy Wallace, Paul Offit, and Trine Tsouderos sitting around the table for a Thanksgiving feast, the main course of which was a baby.

If we look at the “case study” used by Richards, AGW denialists also excel at the same tactics, painting scientists as hopelessly politically motivated, corrupt, and lying. They hack e-mails looking for dirt and try to embarrass scientists by posting them. They attack Al Gore, as the most famous advocate of political action to mitigate the effects of AGW as fat, stupid, and corrupt, as though discrediting Al Gore would discredit AGW. (Hint: It won’t.) The list goes on.

By Richards’ criteria, the vaccine, evolution and AGW denialists send up huge red flags, as a major component of their message consists of ad hominem attacks on scientists. As for “misrepresenting the actual peer-reviewed scientific literature,” what are The Discovery Institute, Age of Autism, NaturalNews.com, and every other denialist website or blog but veritable fonts of misrepresenting scientific literature? Hardly a week goes by, it seems, that I’m not trying to refute some bit of nonsense or other about a scientific study laid down by the anti-vaccine movement or some quack or other. If you count my not-so-secret other blog, actually, hardly a day goes by without my having to do that.

It’s also hard not to note a distinct feeling of repetition in Richards’ list. For example “When ‘scientists say’ or ‘science says’ is a common locution” and “When we keep being told that there’s a scientific consensus” are more or less the same thing. Perhaps the silliest part of this his is this:

A scientific consensus should be based on scientific evidence. But a consensus is not itself the evidence. And with really well-established scientific theories, you never hear about consensus. No one talks about the consensus that the planets orbit the sun, that the hydrogen molecule is lighter than the oxygen molecule, that salt is sodium chloride, that light travels about 186,000 miles per second in a vacuum, that bacteria sometimes cause illness, or that blood carries oxygen to our organs. The very fact that we hear so much about a consensus on catastrophic, human-induced climate change is perhaps enough by itself to justify suspicion.

Now there’s some serious misunderstanding there.

Richards apparently doeesn’t know the difference between scientific theory and scientific fact. That salt is sodium chloride is a fact. That light travels 186,000 miles per second in a vacuum is a measurement and a fact. That blood carries oxygen to our organs is a fact. Of course, no one argues about them; they are well-settled facts, not theories. They are trivially obvious. Arguing about them would be as trivial as arguing about what I had for breakfast this morning or whether the above paragraph by Richards represents the essence of scientific ignorance. A theory is a higher level construct supported by facts, experimentation, and evidence.

Casey Luskin’s and Jay Richard’s tag-team effort demonstrated to me a profound ignorance of science—even an anti-scientific bent. They don’t like science because it either doesn’t support their political beliefs (Jay Richards and AGW) or their religious beliefs (Casey Luskin and evolution). Sure, scientists can at times be as petty as any human being. They are as prone to groupthink and ideology as any group of people can be. But the wonderful thing about being a scientist is that science is a process. Although it is an activity of people it does not depend on any group of people. Eventually, even when scientists go down wrong alleys or succumb to fads, science wins out. It is self-correcting. The process may not be as fast as we like. It may not be as linear as we like. In fact, sometimes it’s damned messy and frustrating. However, it is the best process we have for finding out how our universe works.

Oh, and for building a consensus about how the universe works. It’s perfectly acceptable to challenge such a consensus, but if you don’t have the goods in the form of evidence, experimentation, and data to show that the consensus is in serious error, there is no reason for scientists to take your challenge seriously. As Joshua Rosenau put it:

But moving past those trivialities, Casey and Jay’s underlying point is catastrophically wrong. As John Ziman points out in Reliable Knowledge: “the goal of science is a consensus of rational opinion over the widest possible field” (emphasis original). The beauty of science is precisely that it is rooted in our shared reality, and as such it is subject to the formation of consensus on which new work can build.

Yep, that’s about right. Contrary to what Dr. Orient claims, consensus isn’t the death of science; rather, it’s what science strives to reach in all it’s argumentative, complicated, and, yes, messy glory. Indeed, I can’t resist asking again: What is a scientific theory but a scientific consensus about how one aspect of how the world works?

It should thus come as no surprise that the AAPS is not so fond of evidence-based medicine (EBM), in particular the treatment guidelines that flow from EBM. Indeed, JPANDS has published several articles with titles such as Evidence-based Guidelines: Not Recommended, The Effect of Peer Review on Progress: Looking Back on 50 Years in Science (featuring another scornful dismissal of the “herd instinct” and “conformity” and a fair amount of exaggeration of how much scientific progress is due to “violent confrontation” of old paradigms and how much is due to the slow accumulation of knowledge), and editorials attacking evidence-based medicine. To the AAPS, evidence-based guidelines are unacceptable limits on the autonomy of physicians.

I’d like to finish with an observation. Like Harriet Hall, Steve Novella, and Kimball Atwood, I’m a fellow of the Center for Inquiry, and I was happy to sign a statement from the Committee for Skeptical Inquiry entitled Deniers are not Skeptics. It’s a statement that asks the media to “please stop using the word ‘skeptic’ to describe deniers,” much as I’ve on occasion railed on descriptions of antivaccinationists as “vaccine skeptics” or cancer quacks as “chemotherapy” skeptics, or activists like Vani Hari (a.k.a. “The Food Babe”) as “skeptics” of the food industry. Here’s why:

As Fellows of the Committee for Skeptical Inquiry, we are concerned that the words “skeptic” and “denier” have been conflated by the popular media. Proper skepticism promotes scientific inquiry, critical investigation, and the use of reason in examining controversial and extraordinary claims. It is foundational to the scientific method. Denial, on the other hand, is the a priori rejection of ideas without objective consideration.

Real skepticism is summed up by a quote popularized by Carl Sagan, “Extraordinary claims require extraordinary evidence.” Inhofe’s belief that global warming is “the greatest hoax ever perpetrated on the American people” is an extraordinary claim indeed. He has never been able to provide evidence for this vast alleged conspiracy. That alone should disqualify him from using the title “skeptic.”

The same can be said of all manner of medical cranks, including antivaccinationists, cancer quacks, and the like, all of whom use the same techniques of false argumentation to attack medical consensuses they don’t like, such as the one that concludes vaccines are safe and effective. Unfortunately, physicians are no different. If there’s one thing that identifies a scientific crank or a medical quack, it’s hatred of the scientific consensus. I’m not just talking about questioning a consensus, which scientists and physicians do every day, but attacking the very concept of scientific consensus. Michael Crichton taught me that inadvertently, and Dr. Orient continues to do so. To overthrow an existing scientific consensus requires more than they can give: Lots of evidence and valid scientific reasons to do so.

Categories: Medicine, Skepticism

The Future Threat of AI

Neurologica Blog - Fri, 12/12/2014 - 08:28

Occasional warnings about artificially intelligent robots taking over the world convulse through the media. There is currently a ripple involving prior interviews with Stephen Hawking and Elon Musk. Their names attract attention, and so the issue will provide a media distraction for a day or two.

In an interview with the BBC, Hawking said:

“The development of full artificial intelligence could spell the end of the human race.”

“It would take off on its own, and re-design itself at an ever increasing rate. Humans, who are limited by slow biological evolution, couldn’t compete, and would be superseded.”

In an interview in June with CNBC, Elon Musk said:

“I think there’s things that are potentially dangerous out there. …There’s been movies about this, like ‘Terminator.’ There’s some scary outcomes and we should try to make sure the outcomes are good, not bad.”

Machines that can think are a staple of science fiction, indicating that there is a fascination with the topic. Most often artificially intelligent machines threaten humanity, such as in Terminator, The Matrix, and Battlestar Galactica. In the Dune series humanity is almost wiped out by machines, leading to a ban on any machines that mimic the mind of a person. Even in Star Wars, where droids are the humble servants of biological creatures, we are warned that if droids could think for themselves “we would all be in trouble.”

In Asimov’s Robot series the positronic brains of AI are designed from the ground up with the famous three laws of robotics, the first being that a robot cannot harm a human or allow harm to come to a human.

The problem, of course, is that we are too early in the process of designing true AI – a fully self-aware machine intelligence, to predict what will happen when we cross that threshold. It is certainly reasonable to consider the risks.

There is general agreement that human level intelligence does not represent any real limit, and so once AI achieves this level there is no reason why they won’t just blow past it. If we have a computer that can think as fast and well as a human in 50 years, then in 100 years we might have a machine that can think 1 million times faster, with greater memory and fidelity, purer logic, and unpredictable motivation. It is only reasonable to consider if such AI might pose a threat to humanity.

Those who are optimistic about AI point to the potential boon they can provide to humanity. They can potentially accelerate research and technological development by orders of magnitude.

Also, our civilization is becoming increasingly complex and difficult to manage. AI might be the ultimate tool we need to help us manage our individual lives as well as our growing institutions. This prospect is simultaneously encouraging and frightening, as AI itself. It would be great to have machines doing what people are not good at, such as persistent vigilance and attention to tiny details without letting anything slip through the cracks. At the same time, this can easily lead to a situation in which AI are in charge of our civilization, and we don’t even understand the institutions that control our lives.

This suggests another kind of threat that AI might pose. Science Fiction focuses mainly on AI competing with humanity, enslaving us or wiping us out. AI, however, may also fulfill their role as caretakers of humanity, just too well. They may take a paternalistic approach to this task, protecting us from ourselves, taking away our freedoms to keep us safe and secure. We might become an infantilized species under our robot caretakers.

Still others feel that none of this will happen because we will combine with our AI, not be replaced by it. We will implant supercomputers in our brains, becoming super AI ourselves.

At this point I don’t think we know what will happen. Perhaps at some point every possible outcome will occur to some degree, given enough time. Perhaps it is inevitable that machines will rule the universe, and biology is just a stepping stone. When we finally meet aliens, will they be biological, machines, or a fusion of the two?

We are, however, getting close enough to AI that we need to be thinking about possible outcomes every step of the way. Building in safeguards seems like a no-brainer (pun intended). We need to get creative about what those safeguards might be.

I also think we should avoid the most obvious risky steps, such as creating fully autonomous, self-replicating, AI robots. Putting AI in command of weapons also seems like a horrifically bad idea. Humans always have to be in the loop, with their hand on the plug.

While these steps may seem obvious, my concern is that competition among nations may motivate some to forgo such safeguards, out of fear that their enemies won’t, if nothing else. We may have an AI arms race. International agreements, and a mechanism to enforce them, to avoid such outcomes seems prudent.

The bigger picture is that humans are developing many types of technologies that contain the potential for serious abuse or just unintended consequences, such as the development of nuclear weapons, biological and chemical weapons, and increasingly vital technological infrastructures. Meanwhile our world is anything but universally enlightened and peaceful. We are making progress, but is it fast enough?

Perhaps, as Carl Sagan observed, all civilizations might go through this phase where there is a race between their technological development and their social maturity, with many not surviving. He was referring mostly to nuclear weapons, but there are other threats more subtle and profound.

Categories: Medicine

Homotoxicology

Science Based Medicine - Fri, 12/12/2014 - 03:26

What you’ve just said is one of the most insanely idiotic things I have ever heard. At no point in your rambling, incoherent response were you even close to anything that could be considered a rational thought. Everyone in this room is now dumber for having listened to it. I award you no points, and may God have mercy on your soul.
—James Downey, Billy Madison

My first experience with SCAM was as a first year medical student. I was on the bus to school when the person next to me asked, after looking at my reading material, if I was a medical student. Yes, I am. Why so was he, enrolled at the local naturopathic school. I knew nothing about naturopathy, or medicine for that matter, at the time, so when he told me that warts were not caused by a virus but in fact due to the body walling of toxins and expelling them out through the skin, I did not have much to say. I suspected it was nuts, but lacked the education or understanding of disease to know for sure, and who knew, maybe he was on to something.

When we got to cutaneous diseases I learned that warts were indeed caused by the papilloma virus, not toxins, and the best therapy remained swinging a dead cat in a graveyard at midnight. So I filed that curious incident away as a fluke,  even though it is part of standard naturopathic teaching, which is often separated from reality.

It should not have surprised me that there is a whole field of pseudo-medicine devoted to the pseudo-treatment of pseudo-toxins that goes by the nom de scam of Homotoxicology. Yet another one true cause of all disease. Being a splitter, I think Harriet missed this one. All diseases in this particular SCAM are due the toxins and the bodies attempt to remove them.

Homeotoxicology was invented? Discovered? Created? Concocted? Fabricated? Made up? Pulled out of… thin air, yeah, that’s the ticket, thin air?

I am never certain as to the proper term for the process used by lone fantabulists like DD Palmer or Ignatz von Peczely to create, out of nothing, a complex pseudo-medical discipline and then waste their life, and other peoples time, money, and health, on the pursuit of a pot of SCAM at the end of the rainbow. What is the word for writing fiction but believing it real? Add your own snarky term below, I’m not going there.  I am the last person to resort to extraneous partisan snipings.

Anyway. Hans Heinrich Reckeweg is the person behind Homotoxicology. He was German MD who became a homeopath and had quite the imaginative career. Following his release from captivity in 1946 (by whom and for what I would be curious to know) he started to expand upon classic homeopathy.

Hahnemann was a one symptom/one worthless treatment kind of guy. Reckeweg reasoned that if multiple homeopathic nostrums had the same effect, then they should all be given at once and the body could choose which one it needed. You may scoff, but I get the feeling that is how empiric antibiotics are often given in the hospital. I exaggerate but a little.

But he expanded upon the Caedite eos. Novit enim Dominus qui sunt eius concept of multiple interventions. He gave not only multiple remedies (up to 30), but at multiple potencies (i.e. dilutions.  ‘Potency’ in the homeopathic spiel is as misleading a phrase as ‘integrative’ is at a medical school) of the same preparation, so the body had to choose the medication and the dilution it wanted for a cure. And he got to charge the fee although evidently the body did all the heavy lifting.

He considered it a work of genius with the potential to be

A Bridge Between Allopathic and Homeopathic Medicine.

Only if the bridge crosses the Tacoma Narrows. He was perhaps the Dr. Oz of his day with his interest in combining reality and fantasy based therapies. Not content with a new form of homeopathy, Rekeweg went on to elucidate what he considered to be the cause of all disease and its treatment. No hubris there.

Another website describes homotoxicology as

a biological medicine that is a cybernetic system of information arranged in self-maintaining levels. Each level keeps the one immediately below in homoeostasis. With every disease or imbalance this affects the given level. If the homotoxins are not cleared in the matrix they impregnate the cell. The basic extracellular system is a uniform stable environment, regulated in all the cells of the body.

It is always odd to find a series of words that appear to mean something but have no actual content.

Diseases are caused by homotoxins. What are homotoxins? Substances that are harmful to the body. Or a more (or perhaps less) specific definition

any substance that has a direct or indirect damaging effect on the human organism. Not the substance in itself is the most important. Crucial is its effect on the organism.

A pretty broad definition as at the right concentration or velocity anything can be harmful. One website gave

examples of homotoxins (including) toxic mercury amalgam fillings in the teeth associated with electric currents and voltages, dysbiosis (unhealthy micro-organisms in the gut often due to an unhealthy diet, hormone replacement therapy, and antibiotics), chronic yeast infections (Candida), gas, diesel and petrol fume intolerance, exposure to unhealthy electro-magnetic fields, pesticides, and undiagnosed bacterial (Salmonella paratyphi), or protozoon (Giardia and Amoeba) infections in the gut, possibly picked up on holiday abroad.

It can include geopathic toxins (living in the wrong place) and

an homotoxin can, in its highest state, even be immaterial.

So anything and everything can be a homotoxin, including nothing. It is a dangerous world out there.

Unlike the ‘like curing like’ of homeopathy, homotoxicology postulates a unique cause of and treatment of disease

“diseases” are expressions of the battle of the organism against toxins, in its attempt to counteract and expel them. When the body can no longer expel them, for whatever reason, the organism tries through increased pathological means to make up for the damage already sustained. This process goes in six distinct phases:

  1. Excretion phase or the expulsion of toxins through body orifices, e.g. diarrhea, vomiting;
  2. Reaction phase – where toxins are removed by the body reacting against them, e.g. fever, inflammation and mobilization of white blood cells to consume the toxins;
  3. Deposition phase – storage followed by deactivation of the toxins in connective and fat tissue and in the vascular system;

    The above phases are naturally “reversible.” The following phases become more and more difficult to deal with as in these processes damage occurs to the organs themselves

  4. Impregnation phase – severe disease occurs in a “locus minoris resistentiae”, the body’s weakest organ;
  5. Degeneration phase – the organ is increasingly and irreversibly damaged, with alteration of the cellular enzymes and in the organic structure;
  6. Neoplasm or Cancer phase- the cell genes are damaged.

The International Academy for Homotoxicology produces tables and offers courses in homotoxicology that show the interrelationship of these phases of disease. Beware

The academic and scientific level of the content of these programs is quite high…

Evidently, as they are way over my head, appearing to me to be  a meaningless table of diseases with an arbitrary organization, unhinged from known anatomy and physiology. It is simple but complex: all diseases and symptoms are due to the bodies attempt to expel toxins from the body using the above hierarchy. So in this system, depending on success in removing a toxin, you may end up on the spectrum from difficulty with concentration to meningitis to cerebral sclerosis to migraine to Alzheimer’s to glioblastoma. In the world of homotoxicology all these neurologic diseases are related to degrees of failure in toxin removal. Quite creative and not even wrong.

Homotoxicology offers imaginary treatments for these imaginary diseases, so it is well suited to naturopathic practice. One you discover what phase the patient is in you can then embark on a therapy with the

3 pillars of homotoxicology which are 1. drainage and detoxification, 2. immunomodulation and 3. cell and organ support. These 3 pillars are filled in with medications containing plant preparation groups (PPG), mineral preparation groups (MPG), catalysts preparation groups (CPG) and organ preparation groups (ORPG).

These preparations can reverse the progressive vicariation as the degeneration phases was originally named by Reckeweg.

These nostrums either inactivate the toxins or work through an modulation of the immune system. Being nothing but injected water they do nothing.

One of the foundations of homotoxicology is Madison’s, er, I mean Hering’s Law, a law that is a valid as the laws of homeopathy:

a disease evolving to recovery of health will do this from the inside out, from vital to less vital organs, from the torso to the extremities (centrifugally). A disease that is suppressed or becomes chronic tends to move to deeper lying (organ) tissues (centripetally).

And of course, homotoxicology is quantum. I bet quantum doctors do not get into boxes.

This does explain the theory of warts given to me all those years ago on the bus, why the wart toxins were migrating from the core to the periphery, but in reality what I was told was but a red hering. Sorry. Could not resist.

It is a remarkably complex system of pseudo-medicine and all diseases are explained and treatable within the system. However, it is completely disconnected from reality and that we know about the physiology and treatment of diseases.

It is always a tough call. Do we follow the collected, albeit always evolving, information of modern medicine and science or do we go with the epiphanies of a single person whose ideas of disease and treatment not only run counter to all of medicine, but all other pseudo-medicines?

Despite being a fictional system of diagnosis and treatment, homotoxicology has had time and money wasted on testing its efficacy. To summarize:

Despite mostly positive findings and high ratings on the Jadad score, the placebo-controlled, randomised clinical trials of homotoxicology fail to demonstrate the efficacy of this therapeutic approach.

No surprise there.

I don’t much care for the movies of Adam Sandler, but who knew that Billy Madison was homotoxicology personified? Although a simple “wrong” would’ve done just fine, it would not have been a blog entry.

Categories: Medicine, Skepticism

Another Terrible Anti-Consumer Health Bill

Neurologica Blog - Thu, 12/11/2014 - 08:41

On the desk of New York Governor Andrew Cuomo is a bill that would protect doctors practicing substandard medicine from being investigated by the Office of Professional Medical Conduct. The bill is similar to one unfortunately passed in Connecticut a few years ago – it is meant to protect doctors who prescribe long and recurring courses of IV antibiotics for alleged chronic Lyme disease.

This would be a terrible law on many levels, and I urge Governor Cuomo to veto the bill.

Bad Law

The standard of care in medicine is determined by the consensus of medical opinion and practice, which in turn is based upon the best available evidence. Often this is informed by panels of experts and professional societies who review the evidence and publish practice guidelines or standards.

The standard of care cannot be written in stone because it is a moving target. Scientific evidence is a living changing thing, and so you cannot simply write into law what the standard of care is. Rather the law simply sets up a process by which the standard of care can be determined when necessary.

Further, the standard includes a great deal of wiggle room, especially when evidence is less than definitive or there is a range of opinions as to what constitutes optimal care. Physicians only run afoul of the standard when they practice substantially below the standard in such a way that is unethical, negligent, incompetent, fraudulent and/or harmful to patients.

A state legislature has no business enshrining into law specific details as to what constitutes the standard of care. They lack the expertise as legislators, and such a law would lock into place a specific decision that would then not be able to adapt to evolving evidence.

This bill, however, goes beyond a single issue. While it is being promoted by chronic Lyme advocacy groups, and may have been drafted for that purpose, it is worded as an all-purpose “healthcare freedom” law – shielding all quacks and dubious practitioners from being investigated for practicing substandard care.

The law states that the Office of Professional Medical Conduct cannot investigate a practitioner “based solely on treatment that is not universally accepted by the medical profession.” This is sloppy wording, but it essentially says that doctors cannot be investigated simply for practicing below the standard of care (which is what “accepted by the medical profession” means). This raises the bar for investigation significantly and can be effectively used to shield all manner of quackery. I have encountered this directly myself.

Bad Science

There is no controversy over the existence of Lyme disease – it is an infection caused by the spirochete bacteria, Borrelia burgdorferi. This tick-borne bacteria causes three stages of disease: an acute infectious illness marked by a target-shaped rash around the tick bite, then a disseminated infection, and finally a tertiary infection that can affect the joints, heart, nervous system, and other organs.

The infection can be diagnosed by blood tests (or spinal fluid tests for neurological disease) testing for the antibodies to the spirochete (a Lyme titer) and also for proteins associated with the bacteria itself (the Western Blot). No test is perfect, but the titer followed as needed by the Western Blot is a highly sensitive and specific test. Like all antibody tests, they can be negative initially and may take a number of weeks to become positive.

The controversy comes from those who believe (practitioners and patients) that you can have a chronic Lyme infection even with negative tests for Lyme titer and Western Blot, even without the typical features diagnostic of Lyme disease, and without the usual response to antibiotics. In other words, they are proposing an antibody negative Lyme disease with atypical clinical features and resistant to standard treatment. This is a trifecta of special pleading, explaining away all negative evidence.

Occam’s razor would prefer the explanation for the persistent lack of evidence for Lyme that Lyme is simply the wrong diagnosis.

As a medical hypothesis the idea is not impossible or crazy. Each individual component of the special pleading may be improbable but not impossible. Tests can be false negative, diseases can present atypically, and sometimes they can resist standard treatment. The problem is – there is simply no evidence for any of these claims.

Further, the idea of atypical chronic Lyme has been tested and the hypothesis rejected by the evidence. Most damning are studies looking at the response of patients diagnosed with chronic Lyme to IV antibiotics – showing no benefit. So even if you hold onto a belief in chronic Lyme, the IV antibiotics being used to treat this questionable condition don’t work.

I wrote about the evidence against chronic Lyme disease here. I wrote that in 2009. The evidence has not changed since. Trying to save the Chronic Lyme concept, proponents have proposed that coinfections are the real cause. However, a 2014 systematic review concluded:

The medical literature does not support the diagnosis of chronic, atypical tick-borne coinfections in patients with chronic, nonspecific illnesses.

What about Lyme variants being missed by the test?

In the context of the broader medical literature, it is not currently possible to ascribe a pathogenic role to morphologic variants of B. burgdorferi in either typical manifestations of Lyme disease or in other chronic disease states that are often labeled chronic Lyme disease. There is no clinical literature to justify specific treatment of B. burgdorferi morphologic variants.

The false diagnosis of chronic Lyme and treatment with IV antibiotics is also anything but benign. Chronic antibiotics cause resistance and have side effects and risks. Further, the incorrect diagnosis of chronic Lyme may cause another serious illness to be missed, such as cancer, other infections, or other chronic illness.

Conspiracy Theories

When the science is lacking, enter the conspiracy theories. In this case the conspiracy theories are particularly bizarre. The notion that some patients with chronic symptoms have treatment resistant Lyme disease and need recurrent bouts of IV antibiotics, while wrong, is completely within the standard paradigm of mainstream medicine. There is no East vs West, no life energy or mysterious forces at work, and no threat to “big pharma.”

In fact, if chronic Lyme disease were real it would be a win-win for mainstream medicine. It is, in fact, exactly what proponents of unscientific theories often accuse mainstream medicine of – preferring chronic treatments to keep illness at bay. IV antibiotics are a lucrative procedure. Chronic Lyme disease, in other words, is a money-making machine for mainstream physicians, and would meet an unmet need. So what’s the problem?

The only barrier to accepting and treating alleged chronic Lyme is the scientific evidence coupled with professional ethics. Therefore, proponents have to invent a new conspiracy – led by the insurance companies. Now doctors have a new master cracking their whip, the insurance companies who don’t want to pay for treatment.  Why doctors, the ones who stand to make the money, would side with the insurance companies is never explained. How the insurance companies managed to win this one battle (while otherwise having to pay for evidence-based treatment) is never explained.

This narrative, with the insurance companies cast as the new villain, is simply a made-up fiction. In their pockets, apparently, is the Infectious Diseases Society of America, who have reviewed the evidence and concluded that chronic Lyme is not real and treatment with IV antibiotics not warranted.

Conclusion

This is a clear cut case of a fake controversy being promoted by a special interest group, invoking improbable conspiracy theories to explain why the science does not support their position. The science here is very clear – there is no evidence that chronic Lyme infection is real or that treatment with IV antibiotics is warranted.

Practitioners who prescribe IV antibiotics for this alleged condition do so against the standard of care. They have been unable to defend themselves with scientific evidence or legitimate medical arguments. They have therefore resorted to getting laws passed simply protecting themselves from the evidence and the regulatory bodies whose job it is to defend the standard of care.

It is disappointing that state legislators are so easily duped by such conspiracy theories, and so easily coaxed into stepping way beyond their proper role. It is frightening that such unscientific nonsense can be passed unanimously in both houses of New York’s congress (as it was in CT).

Governor Cuomo seems to be taking his time reviewing the issue. I can only hope that someone who knows what they are talking about got to him. I can only hope that his people are reading the thoughts of doctors and scientists, such as this post, and taking another look as this issue. We will see.

Categories: Medicine

SFSBM Report upsets naturopaths. We’re fine with that.

Science Based Medicine - Thu, 12/11/2014 - 01:00

 

The Maryland Naturopathic Doctors Association is not pleased with the Society for Science-Based Medicine.  Not at all.

That is a good thing, for several reasons. It demonstrates the importance of stopping naturopathic licensing (and practice expansion) legislation in the state legislatures.  It shows how they handle legitimate criticism of their practices.  And it is a lesson in their modus operandi of obfuscating the facts with platitudinous but vague pronouncements about their education, training and practice, pronouncements that wither under criticism.

Why is the MNDA so upset with SFSBM?

We’ll answer that question soon, but some background first. The Maryland Legislature passed a naturopathic licensing bill this year.  Fortunately, as I’ve written, the Legislature didn’t give naturopaths everything they wanted, such as the right to prescribe real drugs.  That’s not stopping them from coming back to the Legislature to revisit the issue.  According to naturopathic school Bastyr’s website:

The [Maryland] law limits some parts of the naturopathic scope of practice — such as intravenous (IV) therapies and prescription drugs — that the state association will work to secure in the future. 

Instead of giving naturopaths their own regulatory board, like they wanted, the Legislature put them under the authority of the Maryland Board of Physicians.  The Legislature created a Naturopathic Advisory Committee to recommend regulations governing naturopathic practice to the Board.  The Maryland Naturopathic Doctors Association (MNDA) states, incorrectly, on its website that the Committee will actually be promulgating the regulations and implementing the law. The statute is quite clear that this is not the case.  Those duties are entirely within the jurisdiction of the Board.

The Committee consists of two medical physicians, two naturopaths and one public member.  It has met several times, with the next meeting scheduled for December 19.

The Society for Science-Based Medicine took this as an opportunity to insert a much-needed dose of reality into the regulatory process. In October, we presented a Report to the Naturopathic Advisory Committee documenting how Maryland naturopaths are currently practicing, even before a licensing law goes into effect, which won’t be until March, 2016.  We also recommended specific regulations. We’ll get to the substance of the report in a minute. (You can access the report on SFSBM’s website.)

The naturopaths and their lobbyist had been meeting with legislators for several years.  From what I can tell, their plan was to present themselves as benign souls who were simply interested in health promotion and disease prevention and were all about collaboration with other health care professions. This is in accordance with the public persona created by such groups as the American Association of Naturopathic Physicians (AANP) and the MNDA, as well as their schools.

The naturopaths also took legislators on a field trip to Casey Health Institute, an “integrative” practice in Maryland which employs a naturopath, Carrie Runde, whom you’ll see again later in this post. One can’t help but notice the tight reins Casey keeps on its staff naturopath compared to the scope of practice allowed in the new law.  According to the website

Dr. Runde works with people to achieve success in the foundations of health and wellness, working on diet, stress management, sleep habits, and movement. 

It will be interesting to see whether Casey allows her to practice to expand to the full extent permitted, such as seeing patients without MD supervision and ordering sophisticated diagnostic tests, in 2016.

Not so pretty

The reality, of course, is much different. Or, as my grandmother used to tell me, “pretty is as pretty does.” As we’ve documented time and again at SBM, naturopaths regularly employ quack treatments and diagnose patients with fake diseases. Even though they are few in number and have few patients, we at SBM have considered naturopaths and their expanding attempts to gain full primary care practitioner status a sufficient concern to warrant numerous posts. No one could come away from Scott Gavura’s excellent series, Naturopathy v. Science, and think naturopaths (including those with a four-year naturopathic “medical” education) are competent to diagnose and treat patients. Or David Gorksi’s chilling post revealing what naturopaths say to each other when they think no one is listening. (And Orac’s as well. Also here.)  Finally, because Maryland naturopaths want the right to perform Pap smears, I’ll mention one more: Harriet Hall’s post on the naturopath who thought she’d cured cervical dysplasia. (She didn’t.)

A few simple internet searches will reveal what they are actually up to. So, that is what we at SFSBM did.  We looked on the MNDA’s website and got the names of their members.  Then we looked at the members’ websites (links for which are provided by the MNDA).  And there it was.  Many of the same unproven and disproven diagnoses and remedies we’ve discussed here at SBM were hiding in plain sight.

I won’t go into all the naturopathic websites, but here are some highlights from state naturopathic leaders. (The websites were accessed in September.  They may have been changed, especially in light of the Report.)

Kevin Passero, ND, Advisory Committee chair:

“Natural treatment of hypothyroidism” includes “herbal therapy, vitamin/nutrient therapy, homeopathy and prescriptive thyroid hormones including natural glandular extracts and compounded thyroid hormone.” Criticizes standard medical diagnosis and treatment of thyroid disease. 

Prescribes “bio-identical hormones” and claims that they do not have the same risks as prescription-only HRT and that their use can “reduce risk related to certain conditions including bone loss and even certain forms of cancer.” 

Emily Telfair, ND, former president, MNDA:

Advertises “Fall Detox . . . adapted from Thorne’s MediClear Detox Plan.” According to the Thorne MediClear Detox website, “The MediClear Plus program is designed to do two things: first, to decrease your exposure to toxins and allergens, and second, to help your body cleanse.” It is a “formula that blends a combination of rice and pea protein with a full complement of vitamins, minerals, amino acids, botanicals, probiotics, and other nutrients for the enhancement of detoxification.”

“Detox add-on kits” are also offered on Telfair’s website, which are “additional supplements to further enhance your detox experience.” These include “Belly Boost: To help aide digestion for those with sensitive stomachs. “Liver Love: To help clear toxins while protecting the liver.

Kristaps Paddock, ND, current president, MNDA:

 “Homeopathy is a system of natural medicine [that] is used to treat a range of illnesses, from simple coughs to chronic conditions. It is known for . . . being able to alleviate symptoms where other treatments have been ineffective.” 

In addition to exposing these practices, the Report provided an explanation, with citations, of what these treatments are and why naturopathic claims for them are unfounded.  The Report does the same thing for each and every diagnosis and treatment quoted from Maryland naturopathic websites.  Not surprisingly, in addition to these examples, we found naturopaths using biotherapeutic drainage, cranial-sacral therapy, alkaline diets, electrodermal screening, autonomic response testing, far-infrared saunas and chelation for improper purposes, use of DMSA challenge protocol, salivary hormone testing and blood nutrition analysis.

Our Report provided the Committee with recommendations for specific regulations to ensure that Maryland patients are not subjected to these fake diagnoses and treatments, some of which are dangerous.  For example, we suggested that all continuing education courses be vetted by the Board.  The MNDA’s CE offerings reinforced our point: “The Top Five Homeopathic Remedies in the Treatment of Depression” and “Naturopathic Treatment of Chronic Kidney Disease.”  (More on the latter here).

The Report also urged the Committee to adopt a regulation recognizing a patient’s right to informed consent, which in Maryland means the health care provider must disclose:

the nature of the ailment, the nature of the proposed treatment, the probability of success of the contemplated therapy and its alternatives, and the risk of unfortunate consequences associated with such treatment. 

Of course, many standard naturopathic treatments would be rejected if this information were given.

As one final example, because of naturopathic opposition to vaccination and other public health measures, the Report recommended that naturopaths be required to refer all questions regarding vaccination to the patient’s physician and that they not be allowed to give advice contrary to evidence-based based health care practices.

All in all, we at SFSBM are quite happy with our report.  25 pages (not including attachments) and 62 citations.  And not a single challenge from naturopaths to our facts or citations of authority. Not bad for our first foray into the regulatory area.

Naturopaths take umbrage

And what was the naturopaths’ reaction to this? Professed shame at their dubious practices and a pledge to clean up their acts?  No.  Enthusiastic adoption of our perfectly reasonable suggestions for regulation? No. Even a teesny-weensy hint that SFSBM might have something worthwhile to say?  No.

The MNDA’s reaction was to fire off a letter to the Board and Advisory Committee attacking the integrity of SFSBM and one of the Committee’s physicians, Gregory S. Pokrywka, MD, a private practitioner and an Assistant Professor of General Internal Medicine at Johns Hopkins, who supported our Report during Committee meetings.

The MNDA challenged the qualifications of Dr. Pokrywka to serve on the Committee and charged him with being “biased.”  It said SFSBM was “comprised of unknown individuals in disparate parts of the country.” [Now, there’s a crime if I’ve ever seen one.]  And they accused us of being founded recently “for unclear purposes.” [Suggestion: check out our website.] Accordingly, SFSBM should be “the subject of scrutiny.” [Fine with us.] We lack, per the MNDA, “an understanding of naturopathic training and practice” thus we “should not be consulted as a resource in the drafting of regulations.”  [Actually, we understand these all too well, and we provided plenty of documentation regarding both.]

This is not the first time naturopaths have taken umbrage at criticism from the science-based community. Of course, what else can they do? I mean, the Report’s discussion of their practices came from their own words.  We didn’t make anything up.  We can’t help it if the authors of the journal articles and other sources we cited looked at the evidence and decided against the naturopaths.  It’s not our fault. We didn’t come up with Avogadro’s number.  Blame him.

We fired right back with our own letter:

we are not surprised that the MNDA has chosen to avoid a discussion of the extensive documentation concerning unproven, disproven and, in some cases, dangerous practices by Maryland license-eligible naturopaths. The MNDA’s recommendations wholly fail to address how the Board might ensure that these practices do not continue.  Indeed, the MNDA’s recommendations would permit these very practices to continue unabated.

The MNDA has instead attempted to divert the attention of the Advisory Committee and the Board by attacking the integrity of both the Society and Gregory Pokrywka, M.D. We do not speak for Dr. Pokrywka, nor is he our representative at Board meetings, as the MNDA implies. We have no doubt he is perfectly capable of defending himself against the spurious charge that he is somehow unqualified to serve on the Advisory Committee or that he is “biased.” His concern for Maryland citizens who seek naturopathic treatment and his respect for the scientific method and evidence-based medicine are not “bias.”

You won’t be surprised to learn that the MNDA has come up with some regulatory suggestions of its own.  They want to default to naturopathic organizations and naturopaths the authority that the Legislature has clearly placed with the Board of Physicians.  Such as, they want all continuing education courses approved by the MNDA and the American Association of Naturopathic Physicians automatically accepted. They want a disciplinary committee made up of two naturopaths and one Board representative, even though the Maryland statutes clearly provide otherwise.

The new law says that their practices must be “consistent with naturopathic education and training” and gives the Board the authority to require additional testing and completion of more education and training before qualification for licensure.  The MDNA wants none of it.  They say it is “not necessary.” They want no restrictions placed on their diagnoses and treatment, except those clearly required by the statute, even though the Legislature has given the Board authority to do so.

The MNDA wants the AANP Code of Ethics, which consists of barely over 2 pages, adopted in their regulations as their ethical rules. And they want the State of Maryland (i.e., taxpayers) to finance, at no interest, their licensing fee ($5,140 initially; $4,000 renewal) over a 2 year period, a privilege not granted other licensed health care professionals nor one which finds any support in the law.

According to a another document submitted by one of the Advisory committee members (Runde, the naturopath), naturopaths want the authority to order

Laboratory testing of all bodily fluids, blood, secretions, excretions, and human tissue . . . [and] obtain specimens for laboratory examination . . .  [including but not limited to] phlebotomy, urinalysis, samples for bacterial culture, endothelial cells for pap test, and others [including] all CLIA-waive tests, which can be performed in-office. 

And to the authority to perform

All tests . . .  to assess and diagnose physiological processes in all bodily systems. 

Diagnostic imaging should, according to the naturopaths, include, but not be limited to

X-ray, ultrasound, mammogram, bone densiometry [sic], CT scan, MRI scan, endoscopic exam, and all other forms of nuclear imaging. 

They are not allowed to interpret these tests, but can interpret the reports.  They also want access to the images themselves.

The definition of “electromagnetic energy” (which they are allowed to employ) should include (but not be limited to), they say

Transcutaneous electrical nerve stimulation, microcurrent electrical muscle stimulation, diathermy, infrared, UV treatments, and other devices which utilize electrical or magnetic force for therapeutic effect. 

This voracious appetite for sophisticated diagnostic tests belies the MNDA’s claim that naturopaths offer “clinical nutrition, herbal medicine, lifestyle counseling, homeopathy, naturopathic physical medicine and pharmaceuticals” (which the MNDA admits they “currently” can’t prescribe.) Why on earth do they need to order CT scans, mammograms and endoscopic exams for those tasks?  (I do hope that, if these regulations stand, the health care professionals who actually perform these tests will refuse to do so without an adequate clinical rationale.)

So what is going on with the Advisory Committee?  (I have not attended but I am relying on staff documents and the accounts of Dr. Pokrywka.)  One of the 2 naturopathic members nominated the other (Passero) for Committee chair and that was seconded by the public member, Eldon Miller, Ph.D, who  apparently is a mathematician.  According to the minutes of the last meeting (Nov. 21), the vote was unanimous for Dr. Passero, although the accuracy of that report will be questioned at the next meeting, December 19.  The Society for Science-Based Medicine’s Report has been ignored, despite protestations from Dr. Pokrywka.  On the other hand, the recommendations of the MNDA and one of the naturopathic members have been embraced.

The naturopaths were livid at the charge that they are anti-vaccination, vigorously denying it even though SFSBM provided copious evidence to the contrary. Dr. Pokrywka, quite sensibly,  wanted a limitation on testing for fake diseases we discussed in the Report.  The naturopaths didn’t.

They defended homeopathy, saying that “obviously” interventions like homeopathy are deemed safe because they are allowed in the statute regardless of SFSBM’s questioning their efficacy.  And just because there is no evidence of efficacy, it doesn’t mean it’s not safe.  In other words, whether it’s effective or not, you can prescribe it anyway.  If that is the case, why bother with all the dilutions and succussions, and the bottling and labeling?  Why not just give patients a glass of water? (Perhaps that would be an overdose?)

In meetings, Dr. Passero has run through the regulations proposed by the Board staff quite rapidly, with little discussion. The naturopaths and the public member have voted in lock step. Dr. Pokrywka and Dr. Suresh Gupta, the other physician on the Committee, wanted regulations that would protect the public from naturopathic practices but were regularly overruled.

Unfortunately, while the staffs’ recommendations are not quite as liberal as the naturopaths’, it appears the naturopaths are getting most of what they wanted.  That is, in part, due to the statute itself, which never should have been passed in the first place.  In giving the naturopaths a broad scope of practice, the Board’s hands are someone tied, although not nearly to the extent the naturopaths would have the Committee think.  But that is a legal argument best left to be made before the Board.

The Committee’s recommended regulations default to the AANP and MNDA to approve continuing education courses, as the naturopaths wanted.  There are no further education and training requirements or limitations on their practice, other than those set by the statute. (Again, despite the fact that the Legislature gives the Board the authority to impose such requirements.)

Here is what is unclear to me at this point.  The staff has provided a packet of documents for the December 19 meeting. One document is labeled “Revised Scope of Practice Definitions” but its source is not clear.  It appears to me to be the work of the staff. If this is true, then it means that the Committee has approved regulations adopting the naturopaths’ recommendations regarding use of diagnostic imaging (including nuclear imaging) and physiological function testing, and its definition of electromagnetic energy. Who knows what quack diagnostic methods and treatments that might engender.

For the next meeting, the naturopaths have also submitted information “FYI” listing the courses they are required to take and the textbooks for that course from Bastyr, a list of course requirements from another naturopathic school, and the CNME’s accreditation standards.  All of these are already available on the internet and tell us little substantively about naturopathic education and training.  It’s simply what the naturopathic organizations are willing for the public to see.  It does not include, for example, a copy of any past NPLEX exam or other sufficient detail for their education and training to be fully analyzed.

Fortunately, what really matters is what the Board does.  It has ultimate authority to accept or reject any or all of the Committee’s proposed regulations.  One hopes that the Board won’t abandon evidenced-base medicine and science for 19th century philosophy.  We’d hoped that debate was settled in the last century.

Categories: Medicine, Skepticism

Risks of CAM Treatments for Cancer

Science Based Medicine - Wed, 12/10/2014 - 08:08

From the US Food and Drug Association article “6 Tip-offs to Rip-offs: Don’t Fall for Health Fraud Scams

“What’s the harm” is an insidious idea when used as a justification for unscientific medical treatments. The argument is typically put forward with the assumption that direct physical harm is the only type of harm that can result from such treatments, so as long as they aren’t toxic there is no downside to trying them. Harm comes in many forms, however: delayed effective treatment, wasted time and energy, financial harm, the psychological harm of false hope, and the downstream effects of instilling unscientific beliefs regarding health care.

One other form of harm is physical but is not due to direct physical damage or toxicity. Rather, it is caused by CAM treatments interacting with proven therapies. A recent survey, presented at the Clinical Oncology Society of Australia annual scientific meeting, explored the potential for such interactions among oncology patients. Lead researcher Sally Brooks found that, in addition to vitamins and minerals, cancer patients were most interested in fish oil, turmeric, coenzyme Q10, milk thistle, green tea, ginger, lactobacillus, licorice, Astragalus and reishi mushrooms.

As I have written many times before, herbs are drugs, but many patients do not treat them as such because they are regulated and marketed as “supplements,” more like food than drugs. There are concerns that many vitamin and herbal products may interact with chemotherapy or radiation therapy in order to reduce effectiveness or even increase side effects.

The research on antioxidant supplementation, for example, raises some concerns, but is equivocal. Part of the effectiveness of chemotherapy comes from increasing reactive oxygen species (ROS) which cause damage to cells. ROS damage both cancerous and healthy cells, and so are part of the desired effects from chemotherapy, but also the side effects. It is therefore possible that antioxidants may decrease the side effects of chemotherapy, but also decrease the effects. The balance between efficacy and side effects is carefully managed in chemotherapy, and if patients are taking antioxidants (especially without telling their oncologist), this can affect that careful balance.

Systematic reviews to date have concluded that the evidence for the net effect of antioxidants in chemotherapy is mixed and of insufficient quality to come to any solid recommendations.

Other effects are also of concern. Turmeric, for example, may decrease the effectiveness of chemotherapy by interfering with the mechanisms by which chemotherapy induces cell-death in cancer cells. Turmeric also interferes with the cytochrome P450 system which is important for the metabolism of many drugs, including some chemotherapy agents, and therefore may increase side effects and toxicity.

Astragalus has effects on the immune system. While preliminary evidence suggests this may be helpful in cancer treatment, it may worsen auto-immune diseases and interact with immunosuppresive drugs.

Overall the evidence for any benefit from the commonly-taken herbal supplements as adjunctive care for any particular cancer is mixed and preliminary. At the same time these agents are drugs that can cause side effects and interact with chemotherapeutic agents, causing photosensitivity, interacting with metabolism and clearance, and perhaps reducing effectiveness. Some may actually prove useful as well, but the complexity of their effects requires careful study, which is often lacking.

Patients often do not disclose supplement use to their physicians, and therefore may not have an opportunity to receive specific advice on such use.

It is also important to recognize that studies involving carefully-standardized supplements are difficult to apply to the real world because the supplement industry is so poorly regulated. Many recent studies have found that supplements are often contaminated, have variable doses, and even contain product substitutions. It is very difficult, therefore, for patients to even know what they are getting.

While further research for each individual herbal product in specific doses for specific cancers and in combination with specific cancer treatments is required before we can make definitive statements about their safety and efficacy, there is also research into the net outcomes of those taking so-called CAM along with their cancer treatments.

What evidence we have is also preliminary, but not favorable. Some studies, for example, show that patients using CAM along with standard cancer treatments have a decreased survival. There are not randomized, and so conclusions regarding cause and effect are difficult, but such evidence does suggest caution.

Other studies find that quality of life, often touted as the main benefit for CAM, is also decreased in cancer patients using CAM.

Conclusion

Overall the evidence for the effectiveness, side effects, drug interactions, and net effects on survival and quality of life with herbs and other unconventional treatments for cancer is of poor quality, showing mixed and complex results. With herbs, since they often have active pharmacological effects, there is the potential for benefit, but also the potential for harm (as with any drug).

The claims made for such treatments often greatly exceed the evidence. Patients, therefore, are generally met with misleading information, suggesting efficacy where the evidence is thin, and downplaying the potential for harm and negative interactions. Because such treatments are promoted as “alternative” patients also are often reluctant to discuss such issues with their physicians, who may be in the best position to advise them on the potential risks and benefits.

As Brooks (the author of the recent survey) and others also point out, unconventional treatments may also present a financial burden at a time when patients are already under financial stress from their illness and perhaps reduced ability to work. They may also experience psychological stress from being pressured by well-meaning but misguided friends and family members pushing them to try unconventional treatments, at a time when they are vulnerable due to their illness.

The underlying source of all this unnecessary risk and stress for cancer and other patients is the basic notion of “complementary” or “alternative” medicine. The marketing of a subset of treatments as CAM creates an artificial double standard, one in which the rules of evidence are altered, informed consent is compromised by misinformation, product standards are lowered, and patients often do not feel comfortable discussing such treatments with their physicians.

Eliminating this double standard could be an effective first step in correcting such problems.

 

 

Categories: Medicine, Skepticism

Pesticides: Just How Bad Are They?

Science Based Medicine - Tue, 12/09/2014 - 03:00

I think everyone would agree that it would not be a good idea to put pesticides in a saltshaker and add them to our food at the table. But there is little agreement when it comes to their use in agriculture. How much gets into our food? What are the effects on our health? On the environment? Is there a safer alternative?

Where should we look to find science-based answers to those questions? One place we should not look is books written by biased non-scientists to advance their personal agendas. A friend recently sent me a prime example of such a book: Myths of Safe Pesticides, by André Leu, an organic farmer whose opinions preceded his research and whose bias is revealed in the very title.

The Foreword and Introduction: A Bad First Impression

The Foreword is by Dr. Vandana Shiva, an environmentalist who blames Monsanto’s GMO seeds and pesticides for causing 284,000 Indian farmers to commit suicide since 1995, a claim that is almost certainly false.  She says pesticides don’t even work in the first place: Roundup is failing to control weeds and is creating superweeds, and “pesticides create pests.” She is an alarmist who cites the Bhopal tragedy and Rachel Carson’s Silent Spring, a book that has been discredited for raising fears based on “gross misrepresentations and atrocious scholarship.”  She says Leu’s book synthesizes the scientific evidence of pesticides’ harm to public health and provides evidence that pesticide-free alternatives are more productive. He does collect a lot of evidence for the harms of pesticides, but he doesn’t balance it with other evidence of benefits and safety. And his evidence for pesticide-free alternatives is far from convincing.

His Introduction begins with his personal observation of “so much illness in our communities, especially cancers, behavioral disorders, and degenerative diseases” and with his personal testimonial of getting sick every spraying season even though no sprays are used on his farm. He set out to find evidence to validate his belief that pesticides were responsible.  Predictably, confirmation bias kicked right in and had a field day.

His bias even interferes with his reading comprehension. He says the US President’s Cancer Panel report of 2010  “clearly states that environmental toxins, including chemicals used in farming, are the main cause of cancers.”[emphasis added] It states no such thing! It says “the true burden of environmentally induced cancer has been grossly underestimated [at 6%],” and even that statement has been challenged by the American Cancer Society, whose representative said the panel restated hypotheses as facts and its conclusion does not represent scientific consensus.    Tobacco causes 30% of all US cancer deaths and another 30% are attributed to diet, obesity, and physical activity; and there are many other causes of cancer including alcohol, sun exposure, radon, medical radiation, infections, and occupational exposures. Pesticides are low on the list.

The Five “Myths”

After finding such obvious errors in the Foreword and Introduction I was tempted to drop the book in the wastepaper basket, but I persevered. Leu proceeds to address 5 “myths” in 5 chapters:

  1. All agricultural poisons are scientifically tested to ensure safe use.
  2. The residues are too low to cause any problems.
  3. Modern pesticides rapidly degrade.
  4. Regulatory authorities are reliable and trustworthy.
  5. Pesticides are essential to farming.

Myth1: All agricultural poisons are scientifically tested to ensure safe use.

Note the inflammatory choice of words: “poisons” rather than pesticides. It is true that many chemicals in use in the US have not been adequately tested for safety, but even he himself admits that pesticides have been studied more than most. He cites several of those studies. For instance, one study found 232 chemicals in the cord blood of newborns; some of those chemicals can harm brain development and the nervous system, but they have never been found to do so in the amounts detected. He criticizes current scientific testing methods as unsound, and he points out that the developing fetus may have special needs. Pesticide exposure has been linked to a number of health problems in children, including lower IQs, autism, ADHD, lack of physical coordination, loss of temper, bipolar illness, schizophrenia, and depression. These are reported correlations, not proven causations. He cites birth defects and gene alterations in mice exposed to pesticides, but there is no comparable evidence for humans. I agree that these studies are cause for concern and further research, but I think it is premature to draw firm conclusions or use that evidence to guide public policy.

Myth 2: The residues are too low to cause any problems.

He says the lowest doses of some chemicals can be more toxic because they begin to act as hormones at those low levels. Several of us have written about endocrine disruptors on SBM hereherehere, and here . Leu reproduces graphs showing increasing rates of diabetes, obesity, and thyroid cancer, and implies that endocrine disruptors are a major cause. He has a whole section on cell receptors that doesn’t make sense; he tries to tell us that “key” molecules can only fit into the “lock” receptors when they are present in small numbers (!?) Yes, there are legitimate concerns about hormone disruption, but so far it’s all hypotheses and no reliable conclusions; and if there is any effect, it is small in magnitude.

Myth 3: Modern pesticides rapidly degrade.

Dioxins are very persistent in the environment, and they can contaminate food. Pesticides can degrade into other chemical compounds that are harmful. Testing is not done on every possible pesticide and metabolite. Washing and peeling produce can reduce pesticide residues, but can’t eliminate them. He says the bulk of pesticides are inside the food, but that is only true for systemic pesticides; other pesticides only affect the surface and can be washed off. For that matter, 99.99% of all the pesticides in our diet are natural components of the food, pesticides that plants produce naturally to protect themselves and that can’t be eliminated.  Any synthetic pesticide residue is a drop in the bucket compared to the much larger concentrations of natural plant pesticides.

Myth 4: Regulatory authorities are reliable and trustworthy

He doesn’t trust authorities. He says, “History shows that regulatory authorities have consistently failed to prevent the contamination of the environment and human health by products previously designated safe, such as asbestos, lead, mercury, dioxins, PCBs, DDT, dieldrin, and other persistent organic pollutants.”

That’s horribly one-sided and unfair. He could have cited some of the many, many successes of government regulation in protecting public health and the environment; some of those successes involve the very contaminants he lists. He faults the government for continuing to allow mercury in fillings and vaccines, not acknowledging that mercury is no longer used in any vaccine but the multidose injectable flu vaccine, and that there has never been any evidence of danger from the use of mercury in vaccines or fillings. He points out variations in regulations between different countries, and his simplistic explanation is “politics.” I think it is more complicated than that.

He particularly targets glyphosphate. He shows nine graphs with correlations between glyphosphate, GMOs, and everything from diabetes to intestinal infection. He omits that now-famous graph showing an almost perfect correlation between autism and organic food.

Myth 5: Pesticides are essential to farming

He cites a number of studies where organic farming practices produced greater yields than conventional methods. He shows evidence that organic crops are more resilient in adverse conditions like droughts, and that good practice organic systems produce higher yields in traditional smallholder farm settings.

Recent advances in organic farming techniques are very encouraging, and anything that reduces the need for pesticides sounds like a good idea. But it remains to be seen whether the techniques can be implemented everywhere, whether “industrialized” large-scale organic farming can adopt them, and whether they are really the most practical way to increase yields and improve safety.  It may be possible for farmers to eschew pesticides; but is it feasible on a large scale, and is it really preferable to judicious use of pesticides following best practices and evidence-based guidelines?  Those are questions that science will be able to answer, but the necessary studies have not been done yet.

Some Facts and Balances

How much pesticide residue is actually present on our foods? The Pesticide Data Program of the USDA has been asking that question for 22 years now. In 2012 they sampled nearly 12,000 foods, and found that residues were below EPA tolerance levels in over 99%. You can read the details here.   They concluded that “residues found in agricultural products sampled are at levels that do not pose risk to consumers’ health (i.e., are safe according to EPA).” The World Health Organization and other organizations around the world are also monitoring pesticide residues and establishing tolerance levels, and there are international databases.

The obvious next question is how are safe levels determined. Here’s how. The details are here.   They don’t just make stuff up, they go by evidence and expert reasoning. Levels change as new evidence warrants. The system isn’t perfect, but it’s reasonably good. A perfect system would be prohibitively expensive if not impossible to carry out to Leu’s satisfaction.

One activist organization reports that 86 pesticides were found on cucumbers. That might sound scary, but what does it really mean? Modern analysis can find tiny trace amounts of lots of things, but remember the old adage “The poison is in the dose.” We know, for instance, that organophosphate pesticides are toxic and workers must take precautions; but we also know that ingesting one single molecule of even the most deadly poison will not result in any detectable harm. There is a legitimate concern that ingesting multiple chemicals at safe levels might add up to unsafe cumulative effects, and that infants and pregnant women might be at higher risk. This doesn’t mean we should reject all pesticides on the precautionary principle; it only means more studies should be done.

It’s important to put the harms of artificial pesticides into context. As Bruce Ames has pointed out:

Carrots, celery, parsley, parsnips, mushrooms, cabbage, Brussels sprouts, mustard, basil, fennel, orange and grapefruit juices, pepper, cauliflower, broccoli, raspberry, and pineapple contain natural pesticides that cause cancer in rats or mice and that are present at levels ranging from 70ppb (parts per billion) to 4 million ppb–levels that are enormously higher than the amounts of man-made pesticide residues in plant foods.

Any discussion of harms from pesticides should weigh the harms against the benefits. There certainly are benefits: pesticides have increased crop yields and helped humans in other ways:

  • Pesticides are the only effective means of controlling disease organisms, weeds, or insect pests in many circumstances.
  • Consumers receive direct benefits from pesticides through wider selections and lower prices for food and clothing.
  • Pesticides protect private, public, and commercial dwellings from structural damage associated with termite infestations.
  • Pesticides contribute to enhanced human health by preventing disease outbreaks through the control of rodent and insect populations.
  • Pesticides are used to sanitize our drinking and recreational water.
  • Pesticides are used to disinfect indoor areas (e.g., kitchens, operating rooms, nursing homes) as well as dental and surgical instruments.
  • The pesticide industry also provides benefits to society. For instance, local communities and state governments may be partially dependent upon the jobs and tax bases that pesticide manufacturers, distributors, dealers, commercial applicators, and farmers provide.

Incidentally, when plants are not exposed to artificial pesticides, they tend to increase their production of natural pesticides. This phenomenon has not been well studied. And the “natural” pesticides allowed in organic farming have not been studied anywhere near as thoroughly as the artificial ones. It is a fallacy to assume they are safer because they are natural.

The news about health effects of pesticides is not all bad. This study concluded:

When compared to the general population total mortality has been found to be consistently lower among pesticide manufacturers as well as among other groups of workers. This observation has been mostly attributed to the ‘healthy worker effect’ or, in the case of agricultural workers, to the healthier lifestyle of farm families. With the exception of deaths by accidental causes, non- cancer causes of death (mainly represented by cardiovascular diseases), were generally found to be less frequent than expected among manufacturers or users of pesticides, in particular among farmers. No consistent evidence of global cancer mortality different from that of the general population has been reported among pesticide manufacturers or applicators. On the other hand, the papers examined have been strikingly consistent in reporting a low overall cancer risk among agricultural workers; life-style, clean air, low prevalence of smoking have been hypothesized so as to explain this observation.

Conclusion

Pesticides are meant to harm weeds and insects, but are they also harming us? Leu demonizes pesticides as “poisons” and argues that the precautionary principle should make us eliminate their use entirely. I think he exaggerates the dangers, especially considering that evolution has equipped the human body to thrive while eating foods with levels of natural pesticides several orders of magnitude greater than the levels of artificial pesticides in today’s foods. I certainly agree with him that there is a need for more research. He says safe pesticides are a myth, but I have to wonder if any evidence of safety would ever satisfy him; he seems to be demanding “perfect” safety like some anti-vaccine activists do. There is a danger to invoking the precautionary principle before insuring that the alternatives are not worse.

This is what typically happens when a layman with an ax to grind ventures into the scientific arena looking for evidence to support his prior beliefs. A good scientist would look just as carefully for any evidence that might prove his hypothesis wrong. Leu’s book stands in stark contrast to another book by a layman, Matt Fitzgerald. Unusually for a layman, Fitzgerald approached his subject without bias and got it right. I reviewed that book here.

Leu’s book is useful, but only as a handy compilation of things we ought to be thinking about. Things that scientists are already addressing.

 

Categories: Medicine, Skepticism

Vani Hari, a.k.a. “The Food Babe,” finally responds to critics

Science Based Medicine - Mon, 12/08/2014 - 03:00

It’s no secret that we here at Science-Based Medicine (and pretty much every scientist and skeptic with a knowledge of basic chemistry and biology) have been veyr critical of Vani Hari, better known to her fans as the Food Babe. The reasons for our criticisms of her are legion. Basically, she is a seemingly never-ending font of misinformation and fear mongering about food ingredients, particularly any ingredient with a scary-sounding “chemically”-sounding name.

Not surprisingly, as the Food Babe has gained prominence her antics have attracted more and more criticism for her toxic combination of ignorance of chemistry coupled with fear mongering. The criticism started with science and medical bloggers and leaked into the mainstream press, most recently in the form of a recent NPR blog entry entitled Is The Food Babe A Fearmonger? Scientists Are Speaking Out that liberally quotes from yours truly and our fearless founder Steve Novella, as well the professor and chair of the Horticultural Sciences Department at the University of Florida, Kevin Folta, who in October complained about the Hari being invited to speak at his university, where she didn’t take questions after spewing her usual disinformation. Indeed, her most recent foray into fear mongering, an attempt to attack Starbucks for its pumpkin spice latte because it not only contains “no real pumpkin” but also contains a “toxic dose of sugar,” and—brace yourself—uses dairy from “Monsanto milk cows fed GMO,” failed.

With a book and media tour scheduled for early 2015, apparently the Food Babe is feeling the heat and has finally responded to criticism on Saturday in a rather long post entitled Food Babe Scam: My Response To The Attacks On Me and Our Movement. Utterly predictably, she started with a quote commonly attributed to Mahatma Gandhi, “First they ignore you, then they laugh at you, then they fight you, then you win.” Never mind that Gandhi almost certainly never actually said it. Rather, Nicholas Klein of the Amalgamated Clothing Workers of America did. It’s also a misquote of what Klein did say. What Klein actually said was, “First they ignore you. Then they ridicule you. And then they attack you and want to burn you. And then they build monuments to you.”

Yes, they did build monuments to Gandhi, but I highly doubt anyone will be building monuments to The Food Babe, either now or many years from now. Her response to criticism is worth examining, however, because her defense itself reveals the many flaws in science and reasoning that led to the criticisms in the first place.

The Food Babe, redux

To be honest, I only became aware of Ms. Hari relatively recently, as in just this year, although apparently she’s been at it for a few years now. Basically, her technique is simply and pithily described by a word that appears to have been coined by Trevor Butterworth but is one that I wish I’d thought of first, namely quackmail. Her M.O. is always the same, with minor variations. First, she identifies a scary sounding chemical in a food item. Then she publicizes it to her generally scientifically ignorant readership and urges them to bombard the food manufacturer or restaurant with complaints and requests to remove said chemical from their product. Up until recently, she has tended to be very successful at this.

One prominent example of The Food Babe’s quackmail (and the one that first brought the Food Babe phenomenon to my attention, thanks to Steve Novella) was her campaign to get Subway to stop using the benign ingredient azodicarbonamide in its bread, a chemical that she characterized as the “yoga mat chemical,” the implication being that by eating sandwiches made with the bread Subway makes you’re somehow eating plastic, with the no doubt intentionally planted mental image of sweaty bodies leaving their residue all over it. Steven Novella discussed the utter ridiculousness of this claim not once but twice, not to mention myself and a certain friend of the blog. It turns out that azodicarbonamide is what’s known as a maturing agent. Basically, when it’s added to flour, it makes bread dough rise better. It also improves the handling properties of doughs, yielding drier, more cohesive doughs that are more pliable, hold together better during kneading, and machine better. Moreover, azodicarbonamide is barely even in the final product. Once flour is wetted with water, reaction with azodicarbonamide with the constituents of flour is rapid. By 45 minutes, there are only trace amounts left.

A second prominent example is one that I discussed extensively, namely Hari’s assault on beer, an assault that led me to dub her the “Jenny McCarthy of food.” You can read the details in the link, but basically her “reasoning” if you can call it that, was to borrow a page from the antivaccine manual and engage in some fear mongering about propylene glycol as “antifreeze,” even though according to brewmasters it isn’t even in the final product. Then, when called on this, Hari conflated propylene glycol alginate, which is used in beer as a stabilizer for foam control, and propylene glycol, even though the two are not the same chemical—or even close to the same chemical—structurally. But hey, the shared words “propylene glycol” must mean they’re they same chemical, right? Only if you have no knowledge of organic chemistry and didn’t bother to look up the chemical structures of the two.

The Food Babe doesn’t limit her scientific ignorance just to food ingredients, however. For instance, she has promoted the unsupported claim that microwave cooking is evil and robs foods of their nutrients, even using vitalistic language about food being “alive” and microwaves “killing” it, as well as promoted misinformation about the flu vaccine cribbed straight from the antivaccine movement. Most recently, science bloggers have dug up an old post from The Food Babe in which she expresses her view about healthy traveling. As Steve Novella put it, her advice contains some major howlers. Perhaps the one that made me laugh the most was this:

The air you are breathing on an airplane is recycled from directly outside of your window. That means you are breathing everything that the airplanes gives off and is flying through. The air that is pumped in isn’t pure oxygen either, it’s mixed with nitrogen, sometimes almost at 50%. To pump a greater amount of oxygen in costs money in terms of fuel and the airlines know this! The nitrogen may affect the times and dosages of medications, make you feel bloated and cause your ankles and joints swell.

Apparently Hari doesn’t realize that normal air contains close to 78% nitrogen, 21% oxygen, with the rest made up of carbon dioxide and other trace gases. Thus, airplane air contains nearly 30% less nitrogen than she normally breathes every day. Yet she seems to think that the airlines are “diluting” their oxygen with 50% nitrogen in order to save money. Personally, I think it’s a good thing that the airlines don’t use 100% oxygen for obvious reasons, not just because of the potential for fire and explosions, but because 100% oxygen is toxic to the lungs. Also, airplane air is recirculated every 3 minutes or so and highly filtered.

The scientific ignorance on display in that article was so epic that, not long after science bloggers started deconstructing it (Folta amusingly parodied it in a post entitled Deadly Aviation Pretzel Gas: Foodbabeliness in Action), Hari removed it from her website and changed her robots.txt file so that Archive.org no longer archives her site. Indeed, it’s been reported on various Facebook pages that she appears to be engaging in quite a bit of sending embarrassing articles like her travel article down the old memory hole. Perhaps this is in anticipation of her higher media profile in 2015 after her book is released, which looks to be more of the same, given the Amazon.com blurb that starts out with, “Did you know that your fast food fries contain a chemical used in Silly Putty?”

No, but if The Food Babe is all worked up about it, somehow I doubt it’s an issue.

The Food Babe responds to critics. Unfortunately, misogyny, too.

When I first saw Hari’s response to her critics over the weekend, I had to wonder: Why now? After all, she’s remained largely silent in the face of scientific criticism, which in retrospect was probably the smartest thing she’s done over the last year. After all, look at how much more ignorant she looked after responding to criticism about “antifreeze in beer” when it was clear that she didn’t know that propylene glycol alginate was nowhere near the same chemical as propylene glycol. I had to wonder whether it had anything to do with the NPR article about her, although the article reported that Hari’s publicist said Hari wasn’t speaking to the media until her new book is released. I can’t help but wonder whether that was the final straw after she had an op-ed published in the New York Times that provoked so much criticism and the backlash that resulted from her being featured on the cover of Experience Life magazine, which published a puff piece about her and her “activism.” The backlash was epic, and rightfully so.

And, in her response, she admits as much:

Part of the reason I am responding now is because their messages have started to infiltrate the mainstream media. Seemingly reputable news organizations like NPR (in a blog post titled “Is The Food Babe A Fearmonger? Scientists Are Speaking Out”) even linked to the hate groups – quoting one of their spokespeople and repeated their ridiculous and biased messages as if they have any merit.

Just as Hari is complaining about ad hominem attacks on her, she’s using ad hominem attacks and poisoning the well to fire back. Clearly, self-awareness, thy name is not Food Babe. Also, apparently Science-Based Medicine is a “hate group.” Clearly, when Hari asserts that it’s about the movement and it’s “not about me,” it really is all about her.

In any case, it’s clear that Hari is feeling harried, a sentiment that is obvious early in her response:

With this much game-changing activism and success in a short period of time, it comes as no surprise that some powerful corporate executives and some “independent” voices they help to finance, disagree with our work. An intelligent debate is welcomed, but not all the discussion has been civil.

There’s a group of aggressive scientists, biased doctors, skeptics, agribusiness publicists, lobbyists (and their anonymous webpages and social media sites), along with in some cases, well intended but misinformed people (influenced by propaganda) attacking our work, other consumer advocacy groups, my partners, my friends and me, personally.

Did you think the powerful chemical companies and food giants of the world were going to let us waltz right into their world and turn it upside down?
No – they won’t and, as I expected, the people who wish to keep the status quo are attacking me personally while simultaneously trying to discredit the entire Good Food Movement.

This is, of course, simply a variation of the pharma shill gambit, in which the food industry replaces big pharma as the shadowy evil corporate cabal that is obviously behind all criticism of The Food Babe, because, obviously, no one who isn’t being paid by the food industry could ever find reason to criticize Hari. Or so Hari apparently seems to think. It’s a very arrogant position to take; Hari is so sure of her righteousness that if you oppose her, you’re either part of the evil food industry cabal or a sheeple who’s been deceived by that cabal. It’s also a convenient excuse not to engage seriously.

There is one aspect of this that must be acknowledged, however, and that’s misogyny. It’s one thing to attack Hari’s ideas and claims. That’s such a “target rich” environment that one could write about it over and over and over and there would still be copious material to refute with science. It’s fair game to call her scientifically ignorant, because she provides copious evidence that she is, in fact, scientifically ignorant with virtually everything she writes. It’s even fair game to create pro-science parodies of her, like Chow Babe, Science Babe, and Food Hunk. What is not fair game are some of the Facebook comments that she includes. They are misogynistic and vile in the extreme, which is something that attractive women who go online face all too frequently. One refers to her as a “stupid female” who should “kill herself.” Another wishes death upon her from something she ate. Yet another makes a not-so-subtle reference to raping Hari’s dead body. None of these misogynistic comments and threats of death is acceptable in any way, shape or form, and I condemn them completely.

Indeed, my likening The Food Babe to Jenny McCarthy is even more appropriate than I had thought at the time I did it. McCarthy, after all, has also been the subject of misogynistic attacks based on her looks and her history as a Playboy Playmate of the Year. In retrospect, long ago I even fell into that trap in that I sometimes mentioned her ditzy blonde image and that she was an ex-Playmate as an introduction to dismantling her claims. I now realize that McCarthy’s history with Playboy has nothing to do with her promotion of antivaccine pseudoscience, and it was neither necessary nor appropriate to reference it. McCarthy provided more than enough fodder that needed refuting without mentioning it. The same is true of Vani Hari. Even though she has chosen “The Food Babe” as her “brand,” that does not excuse misogynistic attacks on her and implied rape threats. If you are a skeptic and have said anything like this to or about Hari personally, you are not my friend, nor are you my ally. Knock it off. Stick to the science.

On the other hand, it is necessary to point out that, as inappropriate and vile as these examples provided by Hari are, she is also clearly taking advantage of them. I can (and do) condemn such attacks, and will continue to do so. However, I also can’t help but notice that she is intentionally conflating these vile comments with the reasoned, science-based criticism that she’s been receiving from many bloggers, including us at SBM, all in order to tar reasoned criticism of her fear mongering with the brush of the sorts of misogynistic slurs featured in her response, all (or so it is not-so-subtly implied) orchestrated by her enemies in the food industry.

The Food Babe responds “substantively” to criticism. Hilarity ensues.

So, what about the substance of her responses? Let’s just say that the same flaws in thinking that have led to all the criticism are on full display here. I’ll pick some examples. Perhaps my favorite example is how she responds to the criticism of her chemical ignorance embodied in her “antifreeze in beer” nonsense:

What they say: I exaggerated claims about the ingredients in beer – from Propylene Glycol and it’s derivatives to Isinglass (fish swim bladders).

The truth: The beer campaign was all about transparency and we have the right to know what we are drinking.

For decades the multi-billion dollar beer industry (along with the entire alcohol industry) has gotten away with not disclosing their ingredients and I find this appalling. That’s why I started a petition to ask the 2 largest beer companies to disclose their ingredients. I pointed out several of the ingredients beer manufacturers are allowed to use in our beer according to the Treasury Department, where beer is regulated. I listed these ingredients in the video I created for my petition that received over 40,000 signatures in 24 hours and that ultimately forced Anheuser-Busch and Miller Coors to start disclosing their ingredients for the first time in history. Propylene glycol (which is found in airplane deicing liquid, aka “anti-freeze”) and propylene glycol alginate that is derived from kelp are both allowed to be used in alcohol. In fact, Fireball Whisky recently had to remove it’s products from shelves in Europe because it contained too much propylene glycol (the antifreeze variety). Corona beer uses propylene glycol alginate. Regardless of which propylene glycol ingredient is used in an alcohol product, I believe we have the right to know what ingredients we are consuming. The same goes for “Isinglass” – which is made from fish swim bladders. I know this ingredient has been used for centuries and not harmful, but this is a real issue for vegans & vegetarians. They deserve to know if an animal product was used in its production. Along with these ingredients, I have exposed several other very controversial chemicals in beer my detractors fail to mention, like caramel coloring level IV, carrageenan and high fructose corn syrup. Who will hold the alcohol industry accountable for transparency, if we don’t?

Notice that she’s still confusing propylene glycol and propylene glycol alginate (“regardless of which propylene glycol ingredient is used in an alcohol product”) without acknowledging that they are two very different chemicals and is still mentioning that propylene glycol is in airplane de-icing fluid. Funny, but shouldn’t she also mention that propylene glycol is also of a class of ingredients that the FDA calls “generally recognized as safe” and that large quantities of it can be consumed without causing toxic effects? That’s what I call selective reporting of information, coupled with ignorance of chemistry, given that propylene glycol alginate isn’t even the same chemical. As for Isinglass, as I’ve described before, that’s basically what I like to call an “appeal to yuckiness.” Because fish bladders sound yucky, they must be harmful. That bit about vegans is a nice touch, but that wasn’t part of her original argument. She only thought that up after it was pointed out to her that Isinglass has been used in beer production since the 19th century. She also neglects to mention that Isinglass is removed from the beer before it is sold. While it is true that there is a question among some vegans whether mere contact of one’s food or beverage with animal matter and the possibility that trace amounts of animal matter might remain in it are enough to make such foods or beverages off-limits. However, if that’s the case then vegans shouldn’t drink most beers because many of which use gelatin instead of Isinglass as a clearing agent. There are also a huge number of foods in whose manufacture gelatins from various sources are used.

Basically, here The Food Babe’s response boils down to: Ignore my chemical illiteracy. It’s all about “transparency.” Of course, she doesn’t seem to realize that her case for transparency was very much undermined by her chemical illiteracy.

Another here’s a hilarious one:

What they say: The phrase “If you can’t pronounce it, you shouldn’t eat it” is not scientific.

The truth: I didn’t come up with this clever phrase, but think it’s great advice.

This idea actually originated with Michael Pollan in his prominent book “In the Defense of Food” and later on in “Food Rules” where in rule #7 he stated “Avoid food products containing ingredients that a third-grader cannot pronounce.”

I love this advice and I think it works well in the majority of cases when reading the ingredient label on food products in the grocery store. Not everyone has the time to tirelessly review all the ingredients allowed in our food system. This simple rule makes it easy for the average person to avoid processed food, which I think everyone can benefit from!

If you can’t pronounce it that probably means the material has been part of the human diet for a minute period of time in terms of the human evolutionary or developmental process. Using many of these substances is a grand experiment that many people would prefer not subjecting themselves or their children to.

In other words, Hari is doubling down on what can only be described as one of the dumbest things I’ve ever heard. The only appropriate response to this is along the lines of a meme that’s been going around Facebook and elsewhere (as always, click to embiggen):

And another:

Obviously, Hari should never, ever eat a banana or take vitamin B12.

The list goes on and on and on, with Hari listing criticisms of her and then trying to “refute” those criticisms by, in essence, doubling down on the same misinformation that was being criticized in the first place. For instance, she claims she’s “not antivaccine,” contrary to the evidence in her post on the flu vaccine that argues that she is. Basically, she says she isn’t against all vaccines (while declining to say which vaccines she would recommend) then uses the antivaccine ploy of argumentum ad package insert and cites antivaccine sources, such as Mark Hyman (who recently co-authored a book with—yikes!—antivaccine activist Robert F. Kennedy, Jr. and appeared with him on The Dr. Oz Show) and Joe Mercola, a purveyor of “alternative” medicine and antivaccine activist who has supported the antivaccine group National Vaccine Information Center with considerably cash and co-sponsored with her “Vaccine Awareness Week,” which is designed to make people aware of the fictitious links between vaccines and autism and various other diseases. Elsewhere, Hari claims that she isn’t afraid of answering questions after her talks, when Kevin Folta has clearly described otherwise. Hari even argues:

What They Say: Our findings are based on pseudoscience or we hate science and we are “fear mongering”.

The Truth: If our findings didn’t have any concerns, do not have a solid basis in fact, why are companies willing to drop these controversial chemicals?

As I’ve pointed out before, it has nothing to do with science or pseudoscience. Companies can live and die by public perception of their products. To them, even if their position is rooted in solid science (and we know that The Food Babe’s position almost never is), sometimes it’s far easier and less expensive for them just to give in to a quackmailer like Hari than to try to resist or to go to the considerable effort and expense necessary to counter her propaganda by educating the public. And, make no mistake, quackmail is exactly what Vani Hari is about. I was only surprised and gratified that Starbucks didn’t cave. Maybe that’s a sign that companies are finally getting wise to Hari’s tactics.

Building the brand

Hari is about nothing if not about building The Food Babe brand. Clearly, she was finally goaded to responding (poorly) to legitimate criticism because that criticism has finally crossed over from the realm of science and medical bloggers and skeptics into the mainstream media. Now it’s hurting that brand. With the release of her book a mere two months away, she probably had little choice but to respond somehow, and that’s consistent with her scrubbing her site of the most egregiously embarrassing posts and setting it so that it is no longer archived and deleted posts can no longer be so easily recovered. I have no doubt that she started out sincere. Misguided and scientifically wrong, but sincere. She’s probably sincere. Certainly she sees herself that way:

What They Say: I’m in it only for the money or I’m a snakeoil salesman

The Truth: I left a secure career without any guarantee or safety net that this new role as a full time food activist would ever support me.

The people who use this attack don’t know me or my story. When I quit my secure corporate job, in December of 2012, I wasn’t making any money blogging. Everyone needs to find a way to make a living and I feel very lucky that I’ve figured out how to do that without compromising my values. I have now dedicated my life to create a better food system and I feel good knowing my work contributes to the knowledge of others and their quality of life.

I work harder now, than I ever have in my life. I spend my days investigating, writing, meeting with experts and consumer organizations, traveling to conferences, speaking, and attending food trade shows.

Note that her being in it for the money and selling snake oil are not incompatible with her having started out sincere and still viewing herself as a shining white knight battling the evil food industry. Clearly, that’s how Hari views herself, and humans consistently underestimate how much their behavior is affected by money. There’s plenty of evidence in her response that she views this as a Manichean struggle of good (her and her “Food Babe Army”) versus evil (the food industry and its minions). The difference is that, unlike two years ago when she got started, now she makes considerable cash at it. She’s become quite the entrepreneur:

In less than two years, Hari, 35, has gotten a book contract with Little, Brown (“The Food Babe Way,” due out in February, on her organic lifestyle), a William Morris Endeavor agent to handle her TV appearances and a website packed with advertising and product endorsements. You can even buy an eating-plan subscription for $17.99 a month.

Like other well-trafficked sites, the Food Babe is an affiliate of Amazon.com: If you click on a product and it takes you to the shopping site, Hari gets a percentage from your purchase as well as a percentage from anything else you buy during the same visit.

Google Analytics shared by Hari show an average of 5.3 million page views and 2.4 million unique visitors a month since mid-March. She logs 600,000 “likes” on Facebook, mostly from women between 25 and 34 years old. Her Twitter page shows 64,000 followers.

And:

Being a consumer advocate, which is what Hari calls herself, appears to be lucrative. While Hari declined to disclose what she makes from the website, she and her husband, Finley Clarke, both left what she says were “six-figure incomes” as technology consultants to work full time for foodbabe.com.

In other words, the Food Babe brand has become lucrative. Viewed through this prism, Hari’s antics are more understandable. She needs media attention, and she needs to fire up her fans. More importantly, she needs to prove that she’s “somebody,” even better somebody her enemies and the enemies of her followers fear. If she can’t keep demonstrating that the food industry fears her by trumping up false controversy and activism against them, she loses her influence and thus her power and, even worse, her earning potential. Again, I’m not saying that she’s in it only for the money. Clearly that’s not the case. She’s an ideologue with no understanding of science or chemistry. Worse, she’s a telegenic and charming ideologue. Through a perfect storm forged in the confluence of her ideology, ignorance, and budding media savviness, she’s used misinformation and pseudoscience to become an Internet star and a media sensation. She could even be on the cusp of becoming a real star, given her book deal. It’s quite possible she could use her talent for food quackery in the same way Dr. Oz has used his talent for medical quackery to become a daytime TV star.

Sincerity aside, The Food Babe’s business model is described in this article, Activist or Capitalist? How the ‘Food Babe’ Makes Money. In this article, E. J. Schultz and Maureen Morrison are more explicit about how Hari monetizes her activities:

Ms. Hari declined to answer a question about why she incorporated in Delaware. She also declined to reveal her annual revenue from the site, including how many food guides she has sold or how many brands with which she has business relationships. “This is information that is not important to my activism and my work,” she said, noting that she discloses partner brands when she mentions them in posts. “In order to be an activist you do need funds to do your work, and this is the most honest way that I think I can do that,” she said.

Part of her business model appears to be rooted in her affiliate-marketing partnerships. One of the companies she has recently plugged on her site is called Green Polka Dot Box, which sells home-delivered natural, organic and non-GMO foods. The company’s affiliate partners can earn 30% of the company’s annual $49.95 per-person membership fee for each person referred, plus $2 for every food purchase that person makes as long as they are a member, according to terms of the program listed on the company’s website.

Obviously, Hari incorporated in Delaware for a very good reason, the same reason many corporations choose Delaware to incorporate in: It’s a corporate tax haven, where corporations are “minimizing taxes, skirting regulations, plying friendly courts or, when needed, covering their tracks.” Delaware regularly tops the list of domestic and foreign tax havens because it allows companies to lower their taxes in the state in which they actually do business by shifting royalties and similar revenues to holding companies in Delaware, where they are not taxed.

Another interesting example is Hari’s relationship with a company called The Maca Team, which sells organic raw maca powder. On her site, Hari wrote that the plant can reduces stress, “improve mental clarity,” and “treat PMS.” It turns out that The Maca Team’s affiliate program lets partners earn 20% on each sale they refer. The Federal Trade Commission requires that bloggers disclose paid endorsements “clearly and conspicuously” on their blogs and websites. Although Hari does generally disclose such relationships, Schulz and Morrison questioned whether she met the “clear and conspicuous” standard.

In any case, whenever I’m accused of being a “pharma shill” by someone like Hari or accused of being “in it only for the money” by her supporters or supporters of, say, Mike Adams, I take great pleasure in pointing out that, in contrast to me, Hari makes quite a healthy living selling products and, above all, her brand. She’s not alone, either—unfortunately. I have no doubt that Hari didn’t start out being in it for the money, and I’m guessing she still probably isn’t. That doesn’t mean that money isn’t an important consideration in determining her behavior. It’s a consideration that can be very easily rationalized as being necessary for her to continue to wage her war against what she sees as nasty unpronounceable ingredients in food. (After all, more money equals more fame and power, which would allow her to be a more effective advocate.) Hari might not be in it only for the money, but she’s definitely in it for the money far more than most of her critics, which is why I view her extravagant use of the pharma shill gambit in her response to skeptical bloggers who criticize her pseudoscience and ignorance of chemistry as likely a rather obvious case of projection.

Categories: Medicine, Skepticism

No, the CDC did not just “admit” that this year’s flu vaccine doesn’t work

Science Based Medicine - Sun, 12/07/2014 - 00:01

Since the press release was originally issued on Thursday by now surely most of you have seen the news stories that popped up beginning yesterday morning with headlines like CDC Warning: Flu Viruses Mutate and Evade Current Vaccine and Flu vaccine protects against wrong strain, US health officials warn, Flu shots may not be good match for 2014-15 virus, CDC says, and Health Officials Warn This Year’s Flu Vaccine Won’t Prevent New H3N2 Strain Of Influenza. You get the idea. This year, apparently, the flu vaccine isn’t as effective as health officials and physicians would like. How could this have happened?

Those of you who are knowledgeable about the flu vaccine know that, as useful as it is, it’s not one of the greatest vaccines as far as effectiveness. Actually, that’s not true. Its effectiveness can and does vary considerably from year to year. The reason is simple. There are many strains of influenza, and the vaccine as currently formulated generally only covers a handful of strains. Basically, every year the World Health Organization, in collaboration with the CDC and other health organizations throughout the world, has to make an educated guess which strains of influenza will be circulating the following winter. Many months’ lead time is required because vaccine manufacturers require it to develop and test the new formulations and then to ramp up their manufacturing capabilities and distribute the vaccine. Generally, the WHO chooses three strains it deems most likely to cause significant human suffering and death in the coming flu season. Specifically, the chosen strains are the H1N1, H3N2, and Type-B strains thought most likely to cause significant human suffering in the coming season, although, starting with the 2012–2013 Northern Hemisphere influenza season, the WHO has also recommended a second B-strain for use in quadrivalent (four strain) vaccines. Basically, the WHO coordinates the contents of the vaccine each year to contain the most likely strains of the virus to attack the next year. Wikipedia has a helpful article that lists the formulations of all the flu vaccines recommended for the Northern and Southern Hemispheres dating back to 1998, to give you an idea what’s been recommended in the past. Also, there are exceptions. In the 2009-2010 season, for example, the H1N1 pandemic was occurring, and it was recommended that everyone be vaccinated against H1N1 in addition to the normal flu vaccine.

As you can imagine, predicting many months in advance which strains will be circulating in the following flu season is a dicey proposition under the best of circumstances. When the WHO gets it right, the flu vaccine is maximally effective. When it doesn’t, we have a situation in which the vaccine is not as effective as we would like. As this news story relates:

Much of the influenza virus circulating in the United States has mutated and this year’s vaccine doesn’t provide good protection against it, federal health officials are warning.

Flu season’s barely starting, but most cases are being caused by a strain called H3N2 this year, the Centers for Disease Control and Prevention said in a health warning issued to doctors Wednesday night.

The flu vaccine protects against three or four strains of flu — there’s always a mix of flu viruses going around — and H3N2 is one of them. But the strain of H3N2 infecting most people has mutated and only about half of cases match the vaccine, CDC said.

Basically, all the news stories to which I linked above report a the issue in a similar way. One of the major strains in the vaccine is H3N2, a strain that normally circulates in pigs and can cause serious outbreaks. Unfortunately, based on its initial observations and data collection, the CDC has concluded that the H3N2 strain that’s causing most of the disease has undergone what is referred to as “genetic drift,” changes in the genetic makeup of the virus that make them different from the strain used many months ago to determine the recommended formulation. Personally, when I see stories like this, I like to go to the source. When the story is about a scientific study, that source is the original peer-reviewed scientific article. When it’s about something like this, the source is the CDC press release:

So far this year, seasonal influenza A H3N2 viruses have been most common. There often are more severe flu illnesses, hospitalizations, and deaths during seasons when these viruses predominate. For example, H3N2 viruses were predominant during the 2012-2013, 2007-2008, and 2003-2004 seasons, the three seasons with the highest mortality levels in the past decade. All were characterized as “moderately severe.”

Increasing the risk of a severe flu season is the finding that roughly half of the H3N2 viruses analyzed are drift variants: viruses with antigenic or genetic changes that make them different from that season’s vaccine virus. This means the vaccine’s ability to protect against those viruses may be reduced, although vaccinated people may have a milder illness if they do become infected. During the 2007-2008 flu season, the predominant H3N2 virus was a drift variant yet the vaccine had an overall efficacy of 37 percent and 42 percent against H3N2 viruses.

“It’s too early to say for sure that this will be a severe flu season, but Americans should be prepared,” said CDC director Tom Frieden, M.D., M.P.H. “We can save lives with a three-pronged effort to fight the flu: vaccination, prompt treatment for people at high risk of complications, and preventive health measures, such as staying home when you’re sick, to reduce flu spread.”

I can see what’s coming. In fact, I’m very surprised that, as I write this, it hasn’t come already. If there’s one vaccine that antivaccinationists love to hate, it’s the flu vaccine, because, compared to other vaccines, it’s the easiest target, given that it tends not to be as efficacious as many other vaccines. Heck, it’s the vaccine that Bill Maher likes to hate on (or at least show contempt for). Contrary to what antivaccinationists and cranks like Bill Maher would have you believe, the flu vaccine is not dangerous, and it does work. It might not work as well as some vaccines, and, until a universal flu vaccine is developed that targets antigens common to all strains of flu is developed, it never will be. But it’s still worth getting.

No, the flu vaccine is not worthless, but you know that hysterical antivaccine articles claiming that to be the case are coming.

For completeness’ sake, I’ll just mention that the quadrivalent flu vaccine for the 2014-2015 flu season is targeted to these strains:

  • A/California/7/2009 (H1N1)pdm09-like virus
  • A/Texas/50/2012 (H3N2)-like virus
  • B/Massachusetts/2/2012-like virus.
  • BBrisbane/60/2008-like virus (only included in some vaccines)

As this story on how this happened relates:

Since Oct. 1, 82% of the influenza virus samples subjected to laboratory testing have been H3N2 viruses, according to data from the CDC. And only 48% of these samples are closely related to the A/Texas/50/2012 strain that was picked for the flu vaccine distributed in North America.

Most of the rest of the H3N2 samples were similar to another strain called A/Switzerland/9715293. That strain was picked for the flu vaccine for the Southern Hemisphere, but not the one here.

Unfortunately, although the “drifted” A/Switzerland/9715293-like (as in genetic drift) strains were detected in late March 2014, which was after the World Health Organization (WHO) recommendations for the 2014-2015 Northern Hemisphere vaccine had been made in mid-February, their prevalence increased enormously by September, by which time it was far too late to revise this year’s flue vaccine formulation for the Northern hemisphere:

Health experts charged with monitoring flu viruses first detected strains of the A/Switzerland virus in the U.S. in March, Frieden said. By then, “it was already too late to include them in this season’s vaccine,” he said.

Besides, at that time, the A/Texas strains were still “by far the most common of the H3N2 viruses,” he said. The A/Switzerland strains didn’t appear in large numbers until September, he said.

Twice each year, the World Health Organization issues a recommendation for a flu vaccine — one for the Southern Hemisphere and one for the Northern Hemisphere. This approach gives health planners two opportunities to plan a vaccine.

Putting it all together, what this all means is that the remaining 18% plus the remaining 48% of the H3N2 strains that are close matches to the vaccine H3N2 strain (0.48 x 0.82 = 0.39 or 39%), for a total of 57% constitute a good match for what’s out there. How did this happen this year? The same way it happens on any year when the flu vaccine isn’t as good a match as we would like to the strains circulating: Health officials made the best prediction they could at the time, but the virus changed in the six or seven months between when they had to commit to a formulation of the flu vaccine and the start of the flu season.

Another aspect of this is that it is likely that the H3N2 component of this year’s flu vaccine is still good enough to confer partial immunity to the A/Switzerland/9715293-like strains, so that, while it doesn’t protect against becoming sick by these strains it could make the illness less severe. This is important because the H3N2 strains tend to be associated with severe flu seasons.

Surprisingly, as I write this, the antivaccine crank blog Age of Autism has published only one brief mention of this news story in a link roundup and no characteristic screed about how this means that the flu vaccine is “worthless.” On the other hand, not surprisingly, everyone’s favorite quack, antivaccinationist (but I repeat myself), and all-purpose conspiracy theorist, Mike Adams, has weighted in under a rather restrained (for him) title, CDC issues flu vaccine apology: this year’s vaccine doesn’t work!, complete with a link to this video:

Contrary to what Gary Franchi of NextNewsNetwork claims, it should be emphasize that, no, the CDC did not just “apologize” and “admit” that the flu vaccine doesn’t work. It really didn’t. It just said that we can expect it to be less effective this year because it’s not as good a match as we would like. What’s with this concrete thinking among quacks? It’s the Nirvana fallacy in action: If a “Western” medical intervention isn’t 100% effective, to them it must obviously be pure, dangerous crap. Funny how they don’t apply that standard to the woo they normally like to pedal. On second thought, no it isn’t.

But back to Adams. Hilariously, after touting a “story” from a crank news source and criticizing the CDC for supposedly producing a defective vaccine and then using its ineffectiveness to sell help drug companies sell Tamiflu at a high cost, Adams pivots to promoting his own execrable science. Truly the man is without self-awareness:

Mercury tests conducted on vaccines at the Natural News Forensic Food Lab have revealed a shockingly high level of toxic mercury in an influenza vaccine (flu shot) made by GlaxoSmithKline (lot #9H2GX). Tests conducted via ICP-MS document mercury in the Flulaval vaccine at a shocking 51 parts per million, or over 25,000 times higher than the maximum contaminant level of inorganic mercury in drinking water set by the EPA.(1)

The tests were conducted via ICP-MS using a 4-point mercury calibration curve for accuracy. Even then, the extremely high level of mercury found in this flu shot was higher than anything we’ve ever tested, including tuna and ocean fish which are known for high mercury contamination.

In fact, the concentration of mercury found in this GSK flu shot was 100 times higher than the highest level of mercury we’ve ever tested in contaminated fish. And yet vaccines are injected directly into the body, making them many times more toxic than anything ingested orally. As my previous research into foods has already documented, mercury consumed orally is easily blocked by eating common foods like strawberries or peanut butter, both of which bind with and capture about 90% of dietary mercury.

This was, of course, one of the silliest things Adams ever did with his new toy (his mass spectrometer). If you don’t believe me, you should read why in detail here.

Adams then goes on to tick off a litany of antivaccine misinformation, using a typical antivaccine technique known as “argument by package insert.” The central fallacy of such an argument is that package inserts are legal documents, not so much scientific documents, and are thus hyper-conservative in listing any reaction that’s ever been reported after a drug or vaccine, whether there is good scientific reason to believe that reaction is due to the vaccine or drug or not. He trots out the old claimed link with Guillain-Barre syndrome that is almost certainly not real. He even trots out the formaldehyde and toxin gambit!

It all builds up to a crescendo of Mike Adams spittle-flecked invective belied by the relatively tame (for him) title of his post:

Trusting a flu shot made by a corporation of felons is a lot like trusting the purity of heroin you buy from a street dealer. Both flu shots and street heroin have at least one thing in common, by the way: neither has ever been tested for safety.

We also know that flu shots contain neurotoxic chemicals and heavy metals in alarming concentrations. This is irrefutable scientific fact. We also know that there is no “safe” form of mercury just like there is no safe form of heroin — all forms of mercury are highly toxic when injected into the body (ethyl, methyl, organic, inorganic).

The only people who argue with this are those who are already mercury poisoned and thus incapable of rational thought. Mercury damages brain function, you see, which is exactly what causes some people to be tricked into thinking vaccines are safe and effective.

Technically, you’d have to be stupid to believe such a thing, as the vaccine insert directly tells you precisely the opposite.

At least Adams always entertains. No one can quite reach the level of ranting faux outrage with such hyperbole, with the possible exception of his mentor Alex Jones. But notice his not-so-subtle sucking up to his audience. Adams (and, by extension, those who believe him) are not “sheeple”! They’re not “brain-damaged” by mercury! Oh, no! Only they understand and avoid the evil pharma cabal. Everyone else is a mercury-damaged sheeple lining up placidly to receive more poison. (Look for some antivaccine activist to quote mine that last sentence.) Meanwhile, elsewhere, another antivaccine rant, Flu Shot Fail: Vaccine Chiefs Forced to Admit it Won’t Work, even tries to paint a blog post by a certain friend of this blog as “feverish attempts by pro-pharma internet gatekeepers to save the flu shot’s sinking reputation.”

It’s good to be recognized, isn’t it?

This year’s flu vaccine might well be suboptimal. Unfortunately, until there is a universal vaccine that targets parts of the virus that don’t mutate so rapidly, the flu vaccine will always be suboptimal. Of course, companies and scientists are frantically working on just such a vaccine. If it weren’t so incredibly hard to do, they would have produced one already. In the meantime the flu vaccine, as imperfect as it is, is the best we have, and it is still very much worth receiving because the flu still can kill healthy individuals.

Categories: Medicine, Skepticism

Outcome Bias in Clinical Decision Making and the Assessment of Our Peers

Science Based Medicine - Fri, 12/05/2014 - 08:00

There are many mental pitfalls and logical stumbling blocks faced by healthcare professionals when attempting to untangle the complex web of patient history and physical exam findings. They can impede our ability to practice high quality medicine at every step in the process, interfering with our ability to establish an accurate diagnosis and to provide comfort or cure. And we are all susceptible, even the most intelligent and experienced among us. In fact, having more intelligence and experience may even enlarge our bias blind spots.

Steven Novella discussed the complexities of clinical decision making in early 2013, specifically tackling some of the more common ways that physicians can come to a faulty conclusion in the third installment of the series. One cognitive bias yet to be specifically addressed on the pages of Science-Based Medicine, and it is one that I encounter regularly in practice, is outcome bias. Simply put, outcome bias in medicine occurs when the assessment of the quality of a clinical decision, such as the ordering of a particular test or treatment, is affected by knowledge of the outcome of that decision. We are prone to assigning more positive significance to a decision when the outcome is positive, and we often react more harshly when the outcome is negative. This bias is particularly obvious when the result of a decision largely comes down to chance.

I see outcome bias rear its ugly head in two contexts for the most part: the Lucky Catch and the Bad Call.

The Lucky Catch

From Scrubs season 8 episode 6 “My Cookie Pants“:

J.D.: I don’t know who you think you are. But I promise you, you are gonna regret this mistake For the rest of your—-

Nurse: Sorry to interrupt. Great call ordering that endoscopy, Dr. Mahoney. Mr.
Lawton has stomach cancer.

J.D.: Jo, I’m sorry. I thought you were being callous with Mr. Lawton, And you were just being thorough.

Most doctors have their own personal lucky catch or “great call” story, or at least can easily recount one that was passed down to them at some point in their career. A patient presents with an unusual symptom or syndrome, and in a seeming flash of inspiration a particular lab or imaging modality is requested that reveals the rare or unlikely diagnosis. What tends to follow is some degree of awe at the clinical acumen of the ordering physician, and in some cases more than a bit of hindsight bias. (“Well of course that’s what the guy had! The clues were right in front of them the whole time.”)

In reality, medical mystery type lucky catches like this are the exception rather than the norm. The much more common version, but one less likely to achieve legend status in a physician’s personal narrative, tends to occur when we’ve dusted off the diagnostic shotgun. Shotguns disperse multiple pellets in a wide pattern in order to increase the likelihood of making contact with the target. So does an ordering physician when they request a large number of tests thoughtlessly.

Sometimes, depending on the severity of the patient’s illness, the diagnostic shotgun is a necessary tool in our armamentarium. A critically ill patient unable to provide a personal medical history, for example, often deserves a more substantial initial work-up. A rapidly approaching death may preclude a tiered approach to testing. More often than not, however, the shotgun approach is unhelpful and merely increases the chance of mistakenly assuming that a false positive finding is playing a role in the patient’s illness. It can also result in an incidental but real finding that exposes a patient to the risks of additional testing and treatment for something that may have never been a problem. And yes, sometimes a shotgun approach uncovers a surprising cause of the patient’s complaints.

Outcome bias kicks in when we look back at the decisions that occurred prior to the lucky catch, or positive outcome, and judge them more positively, even when the care in question was of poor quality. We often forget or even fail to acknowledge when a test or treatment had an unfavorable risk versus benefit ratio. This bias can reinforce the drive to perform more unnecessary testing in the future, not only by the directly involved parties but also any impressionable learners hearing the tale for years to come.

The Bad Call

From Scrubs season 5 episode 20 “My Lunch“:

J.D.: There’s no way you could have seen that coming. I mean, rabies? Come on, there’s, like, three reported cases a year. In fact testing for it would have been irresponsible. You would have wasted time those people didn’t have.

Dr. Cox: I was obsessed with getting those organs.

J.D.: You had to be. The fact is, those people were going to die in a number of hours and you had to make a call. I would have made the same call.

….

Dr. Cox: Aw, come on. Come on, Come on! GOD! GOD, GOD!

(Dr. Cox throws the paddles at the defibrillator and smashes the machine against the wall. Carla and the other nurses clean up and exit. Mr. Bradford’s body vanishes and Dr. Cox is left standing alone. J.D. enters.)

Dr. Cox: He wasn’t about to die, was he, Newbie? Could have waited another month for a kidney.

(Dr. Cox exits the room and removes his gloves.)

J.D.: Where are you going? Your shift’s not over. Hey! Remember what you told me? The second you start blaming yourself for people’s deaths…there’s no coming back.

Dr. Cox: (faces J.D.) Yeah…you’re right.

Okay, that was a bit melodramatic. It is a TV show after all. But outcome bias can also lead physicians to judge their own decisions, or the decisions of others, more harshly when a bad outcome occurs. It can even result in being less likely to recommend appropriate science-based tests or treatments in the future. When a pharmaceutical agent or surgery is indicated, even strongly recommended, it will never be without some degree of risk but it can be very difficult to separate the decision from the outcome in a rational way when a patient has suffered.

It’s easy to be hard on ourselves, but even easier to be hard on other physicians that we don’t have a personal relationship with. Jousting is a term that in a medical context occurs when one physician speaks poorly of another, or in some way implies that a decision made by another caregiver was inappropriate. It is very hard to avoid jousting because it often happens without us even realizing we are doing it. One doesn’t have to say that Dr. A is an idiot in a “Dr. House” style rant to effectively undermine a fellow doctor and increase the risk of both parties being involved in malpractice litigation. Off hand comments can be just as effective. (“Oh, I’ve never heard of that approach to this condition.” or “I can’t believe something wasn’t done sooner.”)

Another cognitive hiccup that can add to the impact of outcome bias when evaluating the decisions of other healthcare professionals is the fundamental attribution error. When a negative outcome is known, we tend to immediately blame some internal factor in the involved physician. Incompetence or intellectual laziness, for example. And we downplay or completely ignore situational or external factors that were out of their control and may have played a role. We are quick to blame a surgeon for a complication, for example, even when there may be a known rate for that complication that is not affected by procedural skill.

Conclusion

Some days it seems that the deck is stacked against us. Outcome bias and the fundamental attribution error are just two of many biases that can alter our perception of reality. In the case of outcome bias, it not only can affect how we judge our own actions but also the actions of others. And as if that weren’t enough, it has the potential to change how we practice medicine in the future because of our flawed assessments of prior decisions. As always, the key to combating errors in thinking like these is knowing that they exist in the first place. With that knowledge in place, when we are called upon to review the management performed by a peer, or reflect on our own decisions, these biases should be easier to reduce or maybe even avoid altogether.

Categories: Medicine, Skepticism
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