If there’s one thing the media love, it’s a “bungling bureaucrats” story. Yep, the FDA, wrapped up with their science dogma, enslaved to Big Pharma, pushing toxic, unnatural chemicals and ignoring safety data. And that’s the story being told about sunscreens:

“Study: Many Sunscreens May Be Accelerating Cancer”
“Did The FDA Ignore Proof That Sunscreens May Speed Up Cancer?”
“FDA Coverup Of Sunscreen Cancer Risk”

What’s a consumer to do? If you only read the headlines, you may get the impression that sunscreens do more harm than good. The impetus was the release of the Environmental Working Group’s (EWG) 2010 Sunscreen Guide. EWG is an environmental advocacy organization that focuses on consumer products, and has been conducting annual reviews of sunscreens since 2007. Of the 500 products it reviewed, it only recommends 8%, or 39 products in total. Why were so many products deemed “not recommended”? Reasons for negative ratings included the following:

• any product containing retinyl palmitate (vitamin A), which is described as a photocarcinogen
• any product containing oxybenzone, called a “potential hormone disrupter”
• any sunscreen packaged as a spray or powder, due to inhalation concerns

EWG also raised concerns about nano-sized particles in sunscreens. But before we dive into the report, let’s consider what we’re trying to do with sunscreen.

Effects of UV Radiation

Ultraviolet radiation that reaches the earth may be divided into UVA (320–400 nm) and UVB (290–320 nm). UVA is further subdivided into UVA I, II and III. A simplified way to differentiate between the two types is to think of UVA as the aging radiation, and UVB as the burning radiation. Your exposure to UV radiation depends on factors such as latitude, altitude, time of year/day, and atmospheric conditions such as clouds and pollution. For example, if you’re on the Mediterranean coast at noon in the summer, the radiation mix is about 95% UVA, and 5% UVB.

UVB has been the traditional focus — stop the sunburn. UVA wasn’t scrutinized. But not only can UVA pass through glass, its rays can penetrate deeper into the skin and are responsible for skin breakdown and thickening. Both UVA and UVB are now implicated as cancer-causing, and UV radiation is considered a carcinogen.

Acutely, we see the effects of UVB. Sunburns can range from mild redness to life-threatening situations. Long term, the skin will show signs of both UVA and UVB damage. Degenerative changes including skin thickening as well as fibrous tissue and circulatory changes follow chronic exposure. And then there’s the big worry: cancer.

Why use Sunscreen?

Sunscreens reduce UV damage by reflecting or absorbing UV radiation:

• Physical (inorganic) barriers (i.e., zinc oxide and titanium dioxide) physically block the skin from sunlight with particulate matter, reflecting and scattering UV rays. Physical barriers are near-perfect sunscreens: they protect against UVA and UVB, they start working immediately, they’re stable and don’t break down in the sun, and they are safe. Their use has traditionally been limited by aesthetic qualities, with formulas that are greasy, white, and opaque.
• Chemical (organic) barriers filter and absorb UV radiation. Their chemical structure converts UV radiation to heat. They vary in their chemical properties, as well as their ability to absorb UVA, UVB, or both.

The Sun Protection Factor (SPF) is a estimate of how effectively a sunscreen will reduce the time to a sunburn. For example, a sunscreen that extends burning time from 10 minutes to 150 minutes has an SPF of 15. Because sunburn is the endpoint measured, SPF is a measure of UVB protection, not UVA protection. While UVA is implicated as a carcinogen, along with UVB, there are currently no well-established short-term endpoints for measuring UVA protection. But this is changing, with the FDA proposing a new set of rules for labeling UVA protection.

There is little difference in sunscreens beyond SPF 15. Consider the following:

• SPF 15 will allow 7% of UVB radiation through to the skin
• SPF 30 will allow 4% of UVB radiation through to the skin
• SPF 60 will allow 2% of UVB radiation through to the skin

SPF values are calculated based on a dose of about 1oz (30mL, or 2 tablespoons) for the entire body — much more than is typically used. In general, insufficient amounts of sunscreen are applied to achieve the labeled UV protection. In real-world observations of use, actual protection is limited far more by the amount applied, and how often it is reapplied, than by the SPF. The EWG report illustrates the consequences of inadequate use of sunscreens, based on applying one-quarter of the recommended amount:

When used properly, SPF 15 provides more than adequate UVB protection for most individuals. EWG recommends that higher SPF products should be avoided if they contain higher concentrations of ingredients they deem potentially hazardous. While it’s unclear how much risk these ingredients truly represent, it’s a fair statement that higher SPF products are more about marketing, rather than meaningful differences in potential sun protection. You get better protection using a sunscreen properly.

Sunscreens and Cancer

There are three major types of skin cancer. Basal cell carcinoma and squamous cell carcinoma are common, but rarely fatal. They often appear on sun-exposed areas like faces and ears, and can be removed easily (though it may be disfiguring). It’s clear that sun exposure is a risk factor for basal cell carcinoma and squamous cell carcinoma, and that sun avoidance can reduce this risk. The third cancer, melanoma, is rare (about 3% of all skin cancers) but frequently fatal, causing 75% of the deaths). When it comes to melanoma, the data on sun exposure are not as clear. There isn’t good evidence to demonstrate that reducing sun exposure has an effect, as chronic sun exposure seems to have a protective effect. However, there is good evidence linking sunburns, and particularly intermittent sun exposure to melanoma. The data with indoor tanning also seem to support a dose-response relationship. Overall, the data points to an association between intentional sun exposure and melanoma, non-intentional sun exposure with squamous cell carcinoma, and basal cell carcinoma likely related to both. (Source)

When it comes to the efficacy of sunscreen to reduce cancer risk, the data are less clear. Most sunscreens didn’t offer UVA protection until recently, confounding studies examining relationships between sunscreen use and cancer risk. Consequently, the evidence linking sunscreen use to reduced melanoma risk isn’t convincing. Studies are confounded by the long latency period for melanoma, the challenges with recall studies, and the changing formulations of sunscreens. One hypothesis for the lack of link is that sunscreen could confers a false sense of security, increasing overall exposure through more time in the sun, and possibly less use of protective clothing. Compounding this would be a relative lack of protection against UVA. Overall, however, there’s good evidence to demonstrate sunscreen use can reduce precursors to cancer, and the incidence of squamous cell cancer. On balance, the data suggest that sunscreens provide protective effects against cancer.

Pharmaceutical Elegance: The Importance of Formulation

One consideration I frequently discuss when counseling consumers about sunscreens are questions and concerns about aesthetics — particularly in products for children. If the product is greasy, opaque, or thick, it won’t be used properly, no matter how effective the product might be. Aesthetics are a function of the vehicle (what the active ingredients are mixed in) as well as the specific characteristics of the compound. Alcohol-based and “dry” versions are also available, but must rely on a smaller number of ingredients because of manufacturing issues.

A related problem is photostability — the ability of sunscreens to remain effective when irradiated by UV rays. Photostability is a function of the vehicle, and the type and concentrations of the different ingredients. Inorganic sunscreens don’t have this problem: not only are they photostable, they are also ideal for those with sensitive skin that may be allergic to organic chemicals.

In general, if the final product doesn’t have great aesthetics, it probably won’t be used properly. And this compromises the point of using sunscreens in the first place.

Sunscreen Risks

Acute side effects of sunscreens are rare and are generally limited to hypersensitivity reactions, such as skin rashes to the chemical (organic) sunscreens. Longer term effects can be categorized into two categories: long term toxicities from the constituents of the sunscreen (the bulk of the Environmental Working Groups’s concerns) and the potential for reduced vitamin D absorption.

While vitamin D production is blocked when UVB-blocking sunscreens are used, the real-world impact isn’t clear. Deficiency is plausible, but there’s little evidence to suggest meaningful deficiencies in vitamin D are related to typical use of sunscreens.

Is Retinyl Palmitate Causing Cancer?

The EWG report evaluates the different ingredients and formulations of sunscreens and uses its own ranking system to assign a score. Their scoring system is internally developed, and has not been validated, but the methodology is reasonably transparent.

Based on the coverage of the EWG’s report, you might get the impression that sunscreens containing retinyl palmitate are causing cancer. Retinyl palmitate is a form of vitamin A commonly used in cosmetic products to reduce wrinkles and fine lines. The EWG points to a 2009 study of retinyl palmitate on mice as their main cause for concern. Treated mice, and a control group were exposed to the equivalent of nine minutes of noontime Florida sun daily, for a year. Compared to the control group, the RP group developed more tumours. That’s adequate evidence to avoid the product says the EWG. But is this finding relevant? The mice were treated with retinyl palmitate — not sunscreen that contained retinyl palmitate. It’s known that retinyl palmitate can be a photosensitizer. When used as a single ingredient cream, as with other forms of vitamin A, you must wear sunscreen, or you’ll burn more easily. So how relevant is this mouse study to human subjects, wearing sunscreens containing retinyl palmitate? It’s difficult to say. Study completion and peer review is expected by 2011. What’s the best approach until then? Well, given that retinyl palmitate isn’t approved as a sunscreen, there’s no compelling rationale for it to be in these products. It’s not unreasonable to avoid it if desired, but there’s no persuasive evidence to suggest its presence is a sound reason to skip sunscreen.

Oxybenzone: Disrupting our Hormones?

Oxybenzone, or more properly, 2-hydroxy-4-methoxybenzophenone, is naturally found in flower pigments and is commercially synthesized as a sunscreen agent and UV stabilizer. Oxybenzone provides UVB and some UVA protection, and stabilizes avobenzone, an effective (but less chemically stable) UVA-sunscreen agent. It has been the target of criticism by those asking for more long-term safety assurances. The CDC recently reported that oxybenzone was detected in 97% of urine samples in a representative sampling of Americans. So it’s in our bodies and in our environment. Is it harmful?

EWG says yes, calling it a “potential hormone disrupter”. Yet oxybenzone hasn’t been linked conclusively to negative health effects. But absence of evidence isn’t evidence of absence, so do consumers have cause for concern? The CDC notes, “Human health effects from benzophenone-3 at low environmental doses or at biomonitored levels from low environmental exposures are unknown.” The European Union’s review is online [PDF], which asks for more information on dermal absorption, yet concludes that in vitro and in vivo data indicate oxybenzone does not possess photo-mutagenic or photo-genotoxic properties.

EWG recommends that oxybenzone should be avoided in sunscreens. However, evidence isn’t yet persuasive that meaningful hazards have been documented. It’s important to recognize that EWG takes a strict perspective on ingredients that is not shared by other organizations. Because something is in the environment at very low doses, it does not mean it is harmful. In addition, the ubiquity of oxybenzone in personal care products makes it very difficult to avoid, as the CDC sampling showed. As the American Cancer Society points out in its discussion of cosmetics,

It’s important to have a sense of the difference between the hazard an ingredient may pose and the risk a person faces from being exposed to it. Scientists use the term hazard to describe the potential of a chemical to cause unwanted health effects. Risk is used to describe the chances of an unwanted health effect in a person from normal use of the ingredient. A substance may be deemed to be potentially hazardous for some reason, but it may pose very little risk to people during normal use.

When it comes to oxybenzone and sunscreens, the myriad of alternatives available mean that it’s possible to avoid oxybenzone if desired, while still finding products that provide good UV protection.

Nano, Nano

If we want to avoid organic (chemical) sunscreens, the inorganic options, titanium and zinc are the attractive alternative. But EWG raises further concerns about new formulations of these products — those that contain nanoparticles. Nanoparticles are a new innovation to deal with the aesthetic drawbacks of the physical sunblocks: Make the particles small enough, and they become translucent and even transparent. Traditional titanium dioxide and zinc oxide have particle sizes of over 200 nm — large enough to reflect visible light, giving the traditional white appearance. Make the particles small enough, and they won’t scatter visible light. (This chart [pdf] nicely illustrates the effect.) EWG is concerned about the risk of absorption of nano-particles and is calling for more research. However, they note the following:

Although we expected to reach a different conclusion at the outset of our sunscreen investigation, when we balanced all factors important in sunscreen safety, our analysis shows that many zinc and titanium-based sunscreens are among the safest and most effective sunscreens on the market.

This statement is evidence-based. Measurable systemic absorption does not seem to occur with titanium and zinc nano-material sunscreens. EWG does flag sprays and powder forms of sunscreens as potentially problematic, particularly the nano-formulations, due to inhalation risks of sunscreen ingredients. While the risk of absorption is certainly greater with aerosols, compared with creams, this can be mitigated by selecting liquid sprays instead of dry powders, and avoiding spraying directly on the facial area. Probably the biggest drawback to nanomaterials is that as the particles get smaller, the UVA protection diminishes. Consequently, ultrafine particles may need to be combined with chemical sunscreens to provide complete (broad spectrum) protection. On balance, the inorganic sunscreens, whether they are nano-sized or not, are excellent sunscreens.

Conclusion

Sunscreen is not a panacea for skin protection. Sun avoidance and physical barriers remain the best approaches to minimizing the acute and long-term effects of UV radiation. The data on sunscreen use and cancer risk are complex, but on balance suggest that the short-term and long-terms benefits of sunscreens significantly outweigh their risks when used during periods of unavoidable exposure. There’s no evidence that vitamin D deficiency is a consequence of safe sun behaviours, and given there are safe and inexpensive methods of obtaining vitamin D (oral supplementation) the rationale for intentional, unprotected sun exposure remains unclear.

Sunscreens remain an important option to help avoid unwanted UV exposure. Overall, the EWG report makes it easy for consumers to differentiate between sunscreens, and make selections based on UV spectrum protection and ingredient preferences. While I’m personally not convinced about the hazards of the current FDA-approved products, I agree with the group’s overall recommendation that physical barriers, containing titanium and/or zinc, have superior risk/benefit profiles. When you look past the headlines, the Environmental Working Group’s analysis isn’t bad. It’s cautious but pragmatic. The bad probably isn’t as bad as they say, but they take a good perspective related to risk/benefit overall.

The scientific understanding of vitamins has evolved over time, from the identification of frank deficiencies, to exploring the value of supplements to prevent chronic diseases. Among health professionals, taking a multivitamin “for insurance” has long been considered to be a reasonable strategy. But as more robust evidence has emerged about the benefits and possible harms of vitamins, even that advice is facing scrutiny.

This Friday, June 11, I’ll be appearing on the Skeptically Speaking radio show, giving a science-based perspective on vitamins. Call in, listen online, or submit your questions in advance. The show is live at 6pm MST (find your time here).

On June 11, 2009 Dr Margaret Chan, the director general of the World Health Organization (WHO) declared that the H1N1 flu that was then spreading around the world was an official pandemic. This triggered a series of built-in responses in many countries, including stockpiling anti-viral medications and preparing for a mass H1N1 vaccination program. At the time the flu was still in its “first wave” and the fear was that subsequent waves, as the virus swept around the world, would become more virulent and/or contagious – similar to what happened in the 1918 pandemic.

This did not happen. At least our worst fears were not realized. The H1N1 pandemic, while serious, simmered through the winter of 2009-2010, producing a less than average flu season, although with some worrisome difference.

The Centers for Disease Control (CDC) estimates:

• CDC estimates that between 43 million and 89 million cases of 2009 H1N1 occurred between April 2009 and April 10, 2010. The mid-level in this range is about 61 million people infected with 2009 H1N1.
• CDC estimates that between about 195,000 and 403,000 H1N1-related hospitalizations occurred between April 2009 and April 10, 2010. The mid-level in this range is about 274,000 2009 H1N1-related hospitalizations.
• CDC estimates that between about 8,870 and 18,300 2009 H1N1-related deaths occurred between April 2009 and April 10, 2010. The mid-level in this range is about 12,470 2009 H1N1-related deaths.

The regular flu season kills about 30,000 Americans every year, and about 250,000 – 500,000 world wide (according to WHO estimates). H1N1 was not as bad as the seasonal flu from pure numbers, but while the seasonal flu kills mainly the elderly, H1N1 had a higher fatality among young adults, pregnant women, and children (partly because older adults were partially protected from flu epidemics earlier in the 20th century).

Interestingly, experts expected the H1N1 pandemic to be in addition to the regular seasonal flu, but the seasonal flu did not show up this year. There were essentially no cases of seasonal flu. There is still no clear answer as to why, and it will probably take a couple of years to sort that out.

The low numbers for H1N1 left much of the public with the perception that the pandemic was a bit of a fizzle, and perhaps the WHO, CDC, and other national centers overreacted. This is more than just a bit of Monday morning quarterbacking, however. But the disconnect has led to questions about the decisions made by the WHO and also to the question of whether or not their decision-making was free of conflicts of interest.

A report in the British Medical Journal last week by features editor Deborah Cohen and investigative journalist Phillip Carter has raised the accusation that the WHO did not handle potential conflicts of interest adequately when dealing with H1N1. This has set off a fresh round of criticism, leading at the extreme end to accusations of a deliberate conspiracy on the part of the pharmaceutical industry.

Several legitimate questions are now being raised (although I must point out that raising a question does not equal guilt, unless you are engaged in a witch hunt). Was the decision by the WHO to declare H1N1 2009 a pandemic justified? Were there any real conflicts of interest among the experts the WHO relied upon? Did the WHO adequately disclose potential conflicts of interest?

Decision to Declare a Pandemic

The WHO actually began its flu pandemic preparedness plans in 1999, when it stated:

“It is impossible to anticipate when a pandemic might occur. Should a true influenza pandemic virus again appear that behaved as in 1918, even taking into account the advances in medicine since then, unparalleled tolls of illness and death would be expected.”

This became the guiding principle of the WHO – flu pandemics are inherently unpredictable, and potentially very serious. They also recognized that any effective action would have to be taken before the full scale of any pandemic was fully realized. Flu viruses have a tendency to mutate throughout an epidemic or pandemic, creating the potential for a virus to suddenly become more virulent. This has happened before, most significantly during the 1918 flu pandemic. But no one can know how bad an epidemic or pandemic will become until it is largely too late to do anything about it. Vaccines take several months, at least, to produce. And medication supplies also will run out quickly during a pandemic unless they are stockpiled.

The precautionary principle therefore holds – prepare for the worst, even while hoping for the best. With H1N1 the pandemic was real and serious, with many deaths, and a higher proportion of deaths among the otherwise young and healthy. But the dreaded mutation to a more virulent strain never happened. There was also the unexpected no-show of the seasonal flu. There was no way for anyone to predict these outcomes.

It seems to me that it is irresponsible for politicians and leaders to scapegoat the WHO now because of their lack of a crystal ball. In attacking the WHO in order to seek political cover themselves they are perhaps making it more difficult for proper precautions to be taken the next time the world is threatened with a pandemic. Experts will be unwilling to stick their necks out if they will get them chopped off if their worst predictions are not realized.

This would be like suing a surgeon for malpractice every time they took out a healthy appendix. This would not be a good thing for future patients with possible appendicitis.

What will best serve the public interest is for world experts to think carefully about how to deal with potential pandemics, given the inherent uncertainties. We don’t want to declare a pandemic every flu season, but we also don’t want to be caught with our pants down. It’s a delicate balance, and it is perfectly reasonable to take a generally cautious approach – meaning to declare more pandemics than will actually manifest as serious killers. The world would rather have a few false alarms than to be caught unprepared for another 1918 pandemic.

One specific point raised by critics is that the WHO changed their definition of pandemic for the 2009 H1N1 declaration – removing the criterion that an epidemic must cause serious harm. The reason for this given by the WHO is that pandemics can become increasingly virulent but preparations cannot wait for that to happen. However, this opened the door for accusations of a conspiracy.

I must also point out that the dire predictions of the critics of the H1N1 vaccine also did not come to fruition. Remember the alarmist warnings about the flu vaccine and Guillaine Barre Syndrome (GBS)? As a result of these fears, the UK and US put in place a careful monitoring system. In the end there were no additional cases of GBS tied to the H1N1 vaccine – no cases of vaccine-induced GBS.

Were There Conflicts of Interest?

The BMJ article raises concerns that many of the experts whose advice lead the WHO to declare a pandemic had undisclosed conflicts of interest. The question of conflicts of interest can be tricky – it is somewhat of a judgment call and different people may have different opinions as to what constitutes a conflict. For this reason medical journals have largely moved to the policy of having authors disclose all potential conflicts and letting readers decide for themselves which are real conflicts.

This kind of policy should be a minimum for an organization like the WHO, but may not be sufficient. There needs to be an assurance that decisions are as free of conflicts as possible, not just disclosed.

But the real question is – what is a conflict of interest. There is a spectrum, and no place to draw a clear line of demarcation.

For example, if an expert is being paid a bribe or kickback in order to give an opinion that is favorable to a company, everyone is likely to agree that is an unambiguous conflict of interest. If an expert owns stock in a company whose profit is affected by the advice or decisions of that expert – that is also a clear conflict of interest. And I think if an expert derives a significant portion of their income, or a large sum of money in any case, from a company, that produces a conflict. There are other similar clear conflicts – any case in which the advice or decisions of an expert will directly affect their income or career.

But there is then a vast gray zone between these clear conflicts and having no industry ties at all. Academics and experts, precisely because they are experts, are often paid to give lectures, are consulted for their expertise, or are paid to design and conduct research for industry. While these are “ties to industry” they are not clear conflicts, because they do not necessarily create a situation where future advice or opinions given by experts with such ties will affect their own income or careers. These are often tenuous ties – even being given a few hundred dollars to give a lecture is often characterized by critics has creating “ties to industry.”

In the case of the experts who advised the WHO on H1N1 the potential conflicts of interest are all of the gray zone variety. There have been no bribes or kickbacks, and no experts who stood to earn or lose money based upon their advice. But many of the experts were previously consulted by industry and some have conducted clinical trials for pharmaceutical companies who make vaccines or anti-virals.

This, of course, has not stopped the most shrill and hysterical critics to distort the situation. Mike Adams of Natural News, for example, falsely asserts that the BMJ exposed “kickbacks” and an actual conspiracy to defraud the public over the H1N1 pandemic (they reported nothing even close to this). If the e-mail I have been receiving over the last two weeks in any indication, the public’s perception of the situation is unfortunately closer to Adams’ distorted version than what the BMJ actually reported.

Just as with the Monday morning quarterbacking, there are potential harms that could flow from treating every tenuous industry connection as if it were a sinister conflict. The public benefits when the best experts in the field are advising both industry and regulatory and other government agencies. They help industry spend their research dollars most effectively. And they help governments make rational evidence-based policy decisions. Again we come to a matter of balance – we want to allow experts to give the public the full benefit of their expertise, without creating real conflicts of interest which compromise their advice. I think the scientific community and governments are still working out how to achieve the optimal balance, and thoughtful reflection is therefore a good thing. But the basics appear to be covered.

Full Disclosure

This brings us to the final question – where to draw the line between conflicts and non-conflicts may be tricky, but it is generally agreed that full disclosure and transparency is appropriate. This is where the WHO seems to have genuinely fallen down. Experts disclosed their potential conflicts to the WHO, but the WHO did not make them public. About this decision, Director Chan explains the purpose:

“is to protect the integrity and independence of the members while doing this critical work — but also to ensure transparency by publicly providing the names of the members as well as information about any interest declared by them at the appropriate time.”

That explanation is not compelling and comes off as tone deaf to the real concerns. Chan is essentially saying – trust us, we will let you know what we think you need to know when we think you need to know it. This attitude just does not cut it in the 21st century.

Conclusion:

We can debate endlessly about the decision to declare the H1N1 2009 pandemic – hindsight, as they say, is 20/20. But the decision was reasonable at the time. More importantly if in the future we find ourselves in the same situation with an impending flu pandemic, a similar response (perhaps there can be some useful tweaks) will be appropriate. Think about the alternatives – would you rather have the world governments overprepare for a pandemic that never fully manifests, or would you rather have millions of preventable deaths because those governments were shying away from possible criticism?

The conversation about conflicts of interest needs to continue. It seems as if the pendulum has swung too far towards considering any industry connection a genuine conflict, making the issue more of a witch hunt than a reasonable precaution. It needs to swing back to a better balance – so that the public can fully benefit from out best experts in important disciplines.

But in any case, there is no downside to full disclosure. True transparency is a starting point.

Birds of a feather flock together. As they investigated the risk factors for cardiovascular disease and diabetes, medical detectives observed that the usual suspects liked to hang out together. Obesity, high blood pressure, abnormal blood lipids, and elevated blood sugars regularly appeared together in the same patient. It looked like a syndrome that might boil down to one underlying cause. They called it “metabolic syndrome” and started applying the concept to clinical practice.

It seemed like a good idea at the time, but now skeptical scientists are expressing their doubts.

What Is Metabolic Syndrome?

A “syndrome” is defined as a group of symptoms and signs that together are characteristic of a specific disorder or disease. All syndromes are not created equal. Some syndromes are well-defined, with known causes, such as Down syndrome, a specific constellation of congenital abnormalities that can be confirmed by genetic tests demonstrating the presence of an extra chromosome (or related chromosomal abnormalities). Others are less well defined, like chronic fatigue syndrome, which consists of fatigue in association with a variable list of symptoms and signs like pain and enlarged lymph nodes. There is no lab test for it, the cause is not known, and the diagnosis itself is controversial.

Metabolic syndrome is a combination of factors that increase the risk of cardiovascular disease and diabetes. It’s also known by other names including syndrome X and insulin resistance syndrome. It has gotten a lot of press in recent decades, but some scientists have questioned whether it really exists. We know many risk factors for cardiovascular disease and diabetes, but when does a group of risk factors become a “syndrome” and when does it become useful for diagnosis, prevention, or treatment?

Metabolic syndrome is differently defined by different organizations. The worldwide consensus definition of the International Diabetes Federation requires central obesity plus any two of: raised triglycerides, reduced HDL cholesterol, elevated blood pressure, and increased fasting blood sugar. The World Health Organization requires diabetes or impaired glucose tolerance along with two of the following: HBP, dyslipidemia, central obesity, and microalbuminemia. The US National Cholesterol Education Program requires three of: central obesity, elevated triglycerides, decreased HDL cholesterol, elevated blood pressure, and elevated fasting blood sugar. The key feature is central obesity in one definition and diabetes in another, but neither is required at all in the third. This is disturbing, to say the least. A patient with elevated blood pressure, low HDL, and elevated triglycerides who is not obese or diabetic would be classified as having metabolic syndrome by the NCEP, but not by the IDF or the WHO!

And so the prevalence of this syndrome varies considerably depending on which definition is used. The overall prevalence of metabolic syndrome is around 25% in the US population. It varies by age and race, and is over 43% for those older than 65.

A New Study

A new study found that metabolic syndrome was associated with a two- to three-fold increased risk of MI, but the same risk was conferred by having either hypertension or diabetes alone. The authors said,

People who advocate for the metabolic syndrome concept believe that when the component risk factors occur together this would have an additive or greater effect on risk, and therefore it is important to identify these individuals. But we didn’t find that. So our study adds to the evidence that a diagnosis of metabolic syndrome is not useful. It is better just to treat the actual risk factors.

They pointed out that there is a dose-response relationship between risk-factor severity and MI risk and that a standard definition of metabolic syndrome loses information because it converts continuous variables into categorical variables. And there are other significant risk factors that metabolic syndrome fails to consider, like sedentary life style and smoking. It would make more sense to replace the categorical definition of metabolic syndrome with a scoring system that assigns a weight based on the level of each risk factor and that uses a regression formula.

A Joint Statement

This is not a new concern. Five years ago, the American Diabetes Association and the European Association for the Study of Diabetes issued a joint statement entitled “The Metabolic Syndrome: Time for a Critical Appraisal.” They reviewed the literature and concluded that

the metabolic syndrome has been imprecisely defined, there is a lack of certainty regarding its pathogenesis, and there is considerable doubt regarding its value as a CVD risk marker. Our analysis indicates that too much critically important information is missing to warrant its designation as a “syndrome.” Until much needed research is completed, clinicians should evaluate and treat all CVD risk factors without regard to whether a patient meets the criteria for diagnosis of the “metabolic syndrome.

They acknowledged that the metabolic syndrome had been a useful paradigm for drawing attention to the fact that some CVD risk factors tend to cluster in patients. But now it is time for a

…serious examination of whether medical science is doing any good by drawing attention to and labeling millions of people with a presumed disease that does not stand on firm ground.

Conclusion

The concept of a metabolic syndrome originally seemed promising: it carried the hope of better identifying patients at risk, contributing to establishing an etiology related to insulin resistance, and determining better routes to prevention and treatment. These ideas haven’t panned out. It is still unclear whether obesity causes the associated findings or whether an underlying condition causes the obesity along with the other findings or whether something else is going on. It is becoming increasingly clear that identifying and managing individual risk factors is the way to go.

Should the concept of metabolic syndrome be abandoned? Probably. But human nature makes us reluctant to abandon any idea after it has rooted itself in our consciousness. The metabolic syndrome has become so well established in the popular medical mind that it will not go without a struggle.

When Daniel David Palmer, the inventor of chiropractic, and his acolytes first took up the practice of chiropractic, around the turn of the last century, they were jailed for the unlicensed practice of medicine. If history had left them there, we might not be fighting a continuing battle with the pseudoscience that is “alternative” medicine today.

Unfortunately, the Kansas legislature intervened on the chiropractors’ behalf and passed the first chiropractic practice act in 1913. Over the years, state by state, the notions that subluxations interfere with nerve flow, causing ill health, and that only chiropractors could “correct” these subluxations, thereby restoring health, were incorporated into state law. As well, chiropractors were given a broad scope of practice and allowed to call themselves “doctor.” In 1974, Louisiana’s passage of a chiropractic practice act made chiropractic legal in all 50 states.

Acupuncturists and naturopaths copied this successful formula by convincing state legislatures to incorporate their pseudoscientific ideas directly into practice acts, thereby managing to become licensed health care providers. Legislative fiat triumphed over scientific facts time after time.

Laws allowing the practice of “alternative” medicine did not totally eliminate resistance to pseudoscientific practices from some quarters. Insurance companies, for example, refused to pay for treatments they considered experimental. Medicare did not cover chiropractic. Labs and x-ray facilities wouldn’t allow use of their services. But for each roadblock science tried to put in the way, state and federal legislators were there to remove it, paving the way toward “acceptance.”

Finally, even medical doctors were unable to resist the enticing smell of money wafting over from “alternative” clinics. Again legislators smoothed the transition from medicine to “alternative” medicine by effectively doing away with a science-based standard of care.

Still, this was not enough in the eyes of some. It deprived those seeking “health freedom” the “right” to choose whatever health care they wanted from whatever practitioner they wanted. So the legislatures of three states — Minnesota (2000),Rhode Island (2002) and New Mexico (2009 ) — came up with an equitable solution by essentially setting up a separate health care profession: the unlicensed practice of health care. In fact, the laws of both Rhode Island and New Mexico are titled the “Unlicensed Health Care Practice Act.” At least they’re up front about it.

(Arizona, California, Idaho, Louisiana and Oklahoma also provide some legal cover for unlicensed practitioners, mainly by protecting them from prosecution for the practice of medicine.)

Ironically, these laws are promoted as public safety measures, so that the state can exercise some control over health care practices not officially licensed. Perhaps some legislators really believe this is effective — as opposed to, say, requiring that all practices have a plausible basis in science and maybe even some evidence of effectiveness.

The acts passed by Rhode Island and Minnesota are almost identical. New Mexico’s is more liberal, but contains many of the same provisions. This suggests these laws are based on templates fed to drafters by promoters of “health freedom” and are passed with few changes.

The statutes contain various provisions common to licensed health care practice acts: a supervisory authority, a bill of rights for the consumer, reporting requirements, confidentiality requirements, prohibitions on sex with patients (who are called “clients” in Minnesota and Rhode Island), and penalties for violations.

On the other hand, no malpractice insurance is required nor is there a specific provision for informed consent of the patient/client. As is common with other licensed “alternative” practitioners, unlicensed practitioners can’t perform surgery, prescribe drugs, invade the human body, use medical devices, or practice dentistry. They also cannot manipulate or adjust the articulations of joints or the spine, obviously in deference to the chiropractic lobby.

Then things get really weird.

First, other than as stated above, there is virtually no limitation on what these unlicensed practitioners can do, as long as it falls into “the broad domain of complementary and alternative healing methods and treatments.” Given the facts that (1) these “healing methods” are made up, and (2) some are of fairly recent origin (e.g., cranial sacral therapy), it appears reasonable to conclude that one can simply create a “healing method,” call it “alternative,” and set up shop. The unemployed should take note.

Specifically mentioned in the statutes as permissible treatments are acupressure, Alexander technique, aroma therapy, ayurveda, craniosacral therapy, crystal therapy, detoxification practices and therapies, energetic healing (as opposed to the lethargic kind, I guess), Rolfing, Gerson therapy, colostrum therapy, therapeutic touch, herbology, herbalism, polarity therapy, homeopathy, nondiagnostic iridology, Qi Gong, culturally traditional healing practices, anthroposophy, folk practices, healing practices utilizing food, dietary supplements, nutrients, and the physical forces of heat, cold, water, touch, and light, healing touch, homeopathy, body work, massage, meditation, mind-body healing practices, naturopathy, noninvasive instrumentalities, holistic kinesiology and other muscle testing techniques. However, it’s made clear in the statutes that this list is not meant as a limitation on the therapies which can be legally offered to the public.

Minnesota and Rhode Island add an extra layer of practitioner protection: having already ok’d unlicensed alternative medicine “healing methods,” these states assure practitioners on the cutting edge of pseudo-medicine that use of a “less customary approach” will not per se subject them to discipline. So now we have conventional alternative medicine and alternative alternative medicine? If the “less customary approach” is used with conventional alternative medicine, should we call it complementary alternative alternative medicine? So much to figure out!

Unlicensed practitioners cannot provide a “medical diagnosis,” or, as New Mexico puts it, the practitioner cannot “make a specific conventional medical diagnosis,” which is “a medical term that is commonly used and understood in conventional western medicine.” In another dig at “conventional western medicine,” plain old prescription drugs become “dangerous drugs” under New Mexico law. A “dangerous drug” is defined as “a drug that is required by applicable federal or state law or rule to be dispensed pursuant to a prescription.” Thus unlicensed practitioners are prohibited from prescribing or dispensing “dangerous drugs.”

To make sure unlicensed practitioners don’t pull one over on the public, Minnesota and Rhode Island (but not New Mexico) list as “prohibited conduct:”

• “Advertising that is false, fraudulent, deceptive or misleading;” and
• “Conduct likely to deceive, defraud, or harm the public.”

Good luck with that!

As further public protection, these states require their own version of a written quack Miranda warning. For example:

THE STATE OF MINNESOTA HAS NOT ADOPTED ANY EDUCATIONAL AND TRAINING STANDARDS FOR UNLICENSED COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONERS BUT WE ARE GOING TO LET THEM PRACTICE MEDICINE ANYWAY.

Actually, I made up that last part, after “PRACTITIONERS.” The rest is right out of the statutes.

As part of disclosure requirements, this must be followed by,

THIS STATEMENT OF CREDENTIALS IS FOR INFORMATION PURPOSES ONLY.

These “credentials” are “the degrees, training, experience, or other qualifications of the practitioner regarding the complementary and alternative health care being provided.” Considering this, the reader might look into investing in the diploma mill industry.

And note that credentials aren’t required — it’s just that if you have some you must let the client know what they are.

Perhaps to prevent their states from becoming havens for parents who want unrestricted access to “alternative” practices for their children, both Minnesota and Rhode Island (but, again, not New Mexico) make clear that “a parent who obtains complementary and alternative health care for the parent’s minor child is not relieved the duty to seek necessary medical care [for the child].” In fact, unlicensed practitioners are required to report to the authorities that a child is not receiving necessary medical care, although if the practitioner’s world view dictates that medical care is unnecessary, what happens then?

Minnesota prevents the unlicensed practitioner from using the title “doctor,” “Dr.” or “physician.” Rhode Island prevents “false or misleading” use of these terms. New Mexico simply prevents the practitioner from describing himself as a “licensed doctor or physician.”

That New Mexico! Here’s what else they do there. The other two states, as might be expected, prevent a person from providing unlicensed services if he has been convicted of a felony. Not New Mexico! The convicted felon is prevented from practicing only until he satisfies the terms of his sentence. After that, it’s back to aromatherapy, iridology, polarity therapy, or whatever else he was up to before his unfortunate encounter with the criminal justice system.

I must ask: Is it really good public policy to allow a convicted thief such easy access to a person’s wallet?

And here’s the best part, saved for last: Minnesota and Rhode Island require the practitioner to provide, in writing, “a brief summary, in plain language, of the theoretical approach used by the practitioner in providing services to clients.” What we wouldn’t give to see that! In fact, if you are ever in either of these states, be sure to have a complementary or alternative health care treatment from an unlicensed practitioner, and be sure to get your written, plain language summary of her “theoretical approach.” Send it to me here. [After, of course, signing a complete release absolving me of all liability for anything bad that happens to you at the hands of the unlicensed practitioner.] If my SBM editors agree to it, I’ll write a post about them. And bonus points for any summary containing the phrase “on a quantum level.”

Jann J. Bellamy is a Florida attorney.  She left the active practice of law in 2006 to form a non-profit, the Campaign for Science-Based Healthcare, which educates the public about “alternative” healthcare claims and advocates for a state law requiring that all healthcare offered in Florida meet a basic scientific standard.  She is also a columnist for Health News Florida.

I don’t want knowledge. I want certainty!

If there’s a trait among humans that seems universal, it appears to be an unquenchable thirst for certainty. It is likely to be a major force that drives people into the arms of religion, even radical religions that have clearly irrational views, such as the idea that flying planes into large buildings and killing thousands of people is a one-way ticket to heaven. However, this craving for certainty isn’t expressed only by religiosity. As anyone who accepts science as the basis of medical therapy knows, there’s a lot of the same psychology going on in medicine as well. This should come as no surprise to those committed to science-based medicine because there is a profound conflict between our human desire for certainty and the uncertainty that is always inherent in so much of our medical knowledge. The reason is that the conclusions of science are always provisional, and those of science-based medicine arguably even more so than many other branches of science.

In fact, one of the hardest things for many people to accept about science-based medicine is that the conclusions of science are always subject to change based on new evidence, sometimes so much so that even those of us “in the biz” can become a bit disconcerted at the rate at which knowledge we had thought to be secure changes. For example, think of how duodenal peptic ulcer disease was treated 25 years ago and then think about how it is treated now. Between 1984 and 1994, a revolution occurred on the basis of the discovery of H. pylori as the cause of most of the gastric and peptic ulcer disease we see. Where in 1985 we treated PUD with H₂-blockers and other drugs designed to block gastric acid secretion, now antibiotics represent the mainstay of treatment and are curative at a much higher success rate than any treatment other than surgery and without the complications of surgery. I’m sure any other physician here could come up with multiple other examples. In my own field of breast cancer surgery, I look back at how we treated breast cancer 22 years ago, when I first started residency, and how we treat it now, and I marvel at the changes. If such changes can be disconcerting even to physicians dedicated to science-based medicine, imagine how much more disconcerting they are to lay people, particularly when they hear news reports of one study that produces one result, followed just months later by a report of a different study that gives a completely different result.

We see this phenomenon of craving certainty writ large and in bold letters in huge swaths of so-called “alternative” medicine. Indeed, a lot of quackery, if not most of it, involves substituting the certainty of belief for the provisional nature of science in science-based medicine, as well as the uncertainty in our ability to predict treatment outcomes, particularly in serious diseases with variable biology, like several types of cancer.

Examples abound. Perhaps my favorite two examples include Hulda Clark, who attributed all cancer and serious disease to a common liver fluke, and Robert O. Young, who believes that virtually all disease is due to “excess acid.” So prevalent is this tendency that Harriet Hall once skewered it in a delightful post entitled The One True Cause of All Disease, where she listed a rather large samplings of things that various quacks have implicated as “the one true cause” of various diseases — or all diseases.

Time and time again, if you look carefully at “alt-med” concepts and the therapies that derive from those concepts, you find utter simplicity (or, more appropriately in many cases, simple-mindedness) tarted up with complicated-sounding jargon. Homeopathy, for instance, is at its heart nothing more than sympathetic magic, with its concept of “like cures like,” combined with the principle of contagion, with its concept that water somehow has a “memory” of the therapeutic substances with which it’s come in contact but, as Tim Minchin so hilariously put it, “it somehow forgets all the poo it’s had in it.” Reiki and other “energy healing” modalities can be summed up as “wishing makes it so,” with “intent” having the power to manipulate some fantastical life energy to heal people. It’s faith healing, pure and simple.

The simplicity of these concepts at their core makes them stubbornly resistant to evidence. Indeed, when scientific evidence meets a strong belief, the evidence usually loses. In some cases, it does more than just lose; the scientific evidence only hardens the position of believers. We see this very commonly in the anti-vaccine movement, where the more evidence is presented against a vaccine-autism link, seemingly the more deeply anti-vaccine activists dig their heels in to resist, cherry picking and twisting evidence, launching ad hominem attacks on their foes, and moving the goalposts faster than science can kick the evidence ball through the uprights. The same is true for any number of pseudoscientific beliefs. We see it all the time in quackery, where even failure of the tumor to shrink in response can lead patients to conclude that the tumor, although still there, still can’t hurt them. 9/11 Truthers, creationists, Holocaust deniers, moon hoaxers — they all engage in the same sort of desperate resistance to science.

Even those who in general accept science-based medicine can be prone to the same tendency to dismiss evidence that conflicts with their beliefs. A while back, I saw an article by Christie Aschwanden discussing just this problem. The article was entitled Convincing the Public to Accept New Medical Guidelines, and I feel it could almost have been written by Mark Crislip or myself, only minus Mark’s inimitable self-deprecating yet cutting sarcasm, or my own alleged talent for nastiness and ad hominem. (I guess I need to become more cuddly.) To set up its point that persuading people to accept the results of new medical science is exceedingly difficult, the article starts with the example of long distance runners who believe that taking ibuprofen (or “vitamin I”) before a long run reduces their pain and inflammation resulting from the run:

They call it “vitamin I.” Among runners of ultra-long-distance races, ibuprofen use is so common that when scientist David Nieman tried to study the drug’s use at the Western States Endurance Run in California’s Sierra Nevada mountains he could hardly find participants willing to run the grueling 100-mile race without it.

Nieman, director of the Human Performance Lab at Appalachian State University, eventually did recruit the subjects he needed for the study, comparing pain and inflammation in runners who took ibuprofen during the race with those who didn’t, and the results were unequivocal. Ibuprofen failed to reduce muscle pain or soreness, and blood tests revealed that ibuprofen takers actually experienced greater levels of inflammation than those who eschewed the drug. “There is absolutely no reason for runners to be using ibuprofen,” Nieman says.

The following year, Nieman returned to the Western States race and presented his findings to runners. Afterward, he asked whether his study results would change their habits. The answer was a resounding no. “They really, really think it’s helping,” Nieman says. “Even in the face of data showing that it doesn’t help, they still use it.”

As is pointed out, this is no anomaly. Aschwanden uses as another example a topic that’s become a favorite of mine over the last six months or so since the USPSTF released revised guidelines for mammographic screening. Take a look at what she says about the reaction:

This recommendation, along with the call for mammograms in women age 50 and older to be done every two years, rather than annually, seemed like a radical change to many observers. Oncologist Marisa C. Weiss, founder of Breastcancer.org, called the guidelines “a huge step backwards.” If the new guidelines are adopted, “Countless American women may die needlessly from breast cancer,” the American College of Radiology said.

“We got letters saying we have blood on our hands,” says Barbara Brenner, a breast cancer survivor and executive director of the San Francisco advocacy group Breast Cancer Action, which joined several other advocacy groups in backing the new recommendations. Brenner says the new guidelines strike a reasonable balance between mammography’s risks and benefits.

I discussed the guidelines in considerable detail twice. Let’s put it this way: I’m in the business, so to speak, and even I was shocked at the vehement reactions, not just from patients and patient advocacy groups, whose reaction I could completely understand (after many years of hearing that beginning mammography at age 40 was critical to save lives), but even from some of my very own colleagues. I was particularly disgusted by the reaction of the American College of Radiology, which was nothing more than blatant fear mongering that intentionally frightened women into thinking that the new guidelines would lead to their deaths from breast cancer. As much as we’d like to pretend otherwise, even science-based medical practitioners can fall prey to craving the certainty of known and accepted guidelines over the uncertainty of the new. And if it’s so hard to get physicians to accept new guidelines and new science, imagine how hard it is to get patients to accept them.

There is abundant evidence of how humans defend their views against evidence that would contradict them, and it’s not just observational evidence that you or I see every day. Scientists often fall prey to what University of California, Berkeley, social psychologist Robert J. MacCoun calls the “truth wins” assumption. This assumption, stated simply, is that when the truth is correctly stated it will be universally recognized. Those of us who make it one of our major activities to combat pseudoscience know, of course, that the truth doesn’t always win. Quite the contrary, actually, I’m not even sure the “truth” wins a majority of the time — or even close to a majority of the time. Moreover, most recommendations of science-based medicine are not “truth” per se; they are simply the best recommendations physicians can currently make based on current scientific evidence. Be that as it may, the problem with the “truth wins” viewpoint is that the “truth” often runs into a buzz saw known as a phenomenon that philosophers call naive realism. This phenomenon, boiled down to its essence is the belief that whatever one believes, one believes it simply because it’s true. In the service of naive realism, we all construct mental models that help us make sense of the world. When the “truth wins” assumption meets naive realism, guess what usually wins? It ain’t the truth.

At the risk of misusing the word, I’ll just point out something about our “truth”: that we all filter everything we learn through the structure of our own beliefs and the mental models we construct to support those beliefs. I like to think of science as a powerful means of penetrating the structure of those mental models, but that’s probably not a good analogy. That’s because, for science to work at changing our preconceptions, we have to have the validity of science already strongly incorporated into the structure of our own mental models. If it’s not, then science is more likely to bounce harmlessly off of the force field our beliefs create to repel it. (Sorry, I couldn’t help it; I’m a hopeless geek.) As a result, all other things being equal, when people see studies that confirm their beliefs they tend to view them as unbiased and well-designed, while if a study’s conclusions contradict a person’s beliefs that person is likely to see the study as biased and/or poorly done. As MacCoun puts it, “If a researcher produces a finding that confirms what I already believe, then of course it’s correct. Conversely, when we encounter a finding we don’t like, we have a need to explain it away.”

There’s also another strategy that people use to dismiss science that doesn’t conform to their beliefs. I hadn’t thought of this one before, but it seems obvious in retrospect after I encountered a recent study that suggested it. That mechanism is to start to lose faith in science itself as a means of making sense of nature and the world. The study was by Geoffrey D. Munro of Towson University in Maryland and appeared in the Journal of Applied Social Psychology under the title of The Scientific Impotence Excuse: Discounting Belief-Threatening Scientific Abstracts.

There were two main hypotheses and two studies included within this overall study. Basically, the hypothesis was that encountering evidence that conflicts with one’s beliefs system would tend to make the subject move toward a belief that science can’t study the hypothesis under consideration, a hypothesis known as the “scientific impotence” hypothesis or method. In essence, science is dismissed as “impotent” to study the issue where belief conflicts with evidence, thus allowing a person to dismiss the science that would tend to refute a strongly held belief. The problem, of course, is that the major side effect of asserting scientific impotence discounting is that it leads a person to distrust all science in general, or at least far more science than the science opposing that person’s belief.

Munro makes the implication of scientific impotence discounting plain:

The scientific impotence method of discounting scientific research that disconfirms a belief is certainly worrisome to scientists who tout the importance of objectivity. Even more worrisome, however, is the possibility that scientific impotence discounting might generalize beyond a specific topic to which a person has strong beliefs. In other words, once a person engages in the scientific impotence discounting process, does this erode the belief that scientific methods can answer any question? From the standpoint of the theory of cognitive dissonance (Festinger, 1957), the answer to this question could very well be “Yes.”

Not surprising, the scientific impotence discounting strategy of denying science permits one to dodge the charge of hypocrisy:

Using the scientific impotence excuse for one and only one topic as a result of exposure to belief-disconfirming information about that topic might put the individual at risk for having to acknowledge that the system of beliefs is somewhat biased and possibly hypocritical. Thus, to avoid this negative self-view, the person might arrive at the more consistent — and seemingly less biased — argument that science is impotent to address a variety of topics, one of which happens to be the topic in question.

To test these hypotheses, basically Munro had a group of students recruited for his study read various abstracts (created by investigators) that confirmed or challenged their beliefs regarding homosexuality and whether homosexuality predisposes to mental illness. It turned out that those who read belief-challenging abstracts were more prone to use scientific impotence discounting as an excuse to reject the science, while those who read belief-confirming abstracts were less likely to subscribe to the scientific impotence excuse. Controls that substituted other terms for “homosexual” demonstrated that it was the belief-disconfirming nature of the abstracts that was associated with use of scientific impotence discounting as a reason to reject the conclusions of the abstract. A second study followed up and examined more subjects. The methodology was the same as the first study, except that there were additional measures performed to see if exposure to belief-disconfirming abstracts was associated with generalization of belief in scientific impotence.

In essence, Munro found that, relative to those reading belief-confirming abstracts, participants reading belief-disconfirming abstracts indicated more belief that the topic they were reading about could not be studied scientifically and more belief that a series of other unrelated topics also could not be studied scientifically. In other words, scientific impotence discounting appears to represent a generalization of discounting of science from just science that challenges a person’s beliefs to more areas of science, if not all science. Munro concluded that being presented with belief-disconfirming scientific evidence may lead to an erosion of belief in the efficacy of scientific methods, also noting:

A number of scientific issues (e.g., global warming, evolution, stem-cell research) have extended beyond the scientific laboratories and academic journals and into the cultural consciousness. Because of their divisive and politicized nature, scientific conclusions that might inform these issues are often met with resistance by partisans on one side or the other. That is, when one has strong beliefs about such topics, scientific conclusions that are inconsistent with the beliefs may have no impact in altering those beliefs. In fact, scientific conclusions that are inconsistent with strong beliefs may even reduce one’s confidence in the scientific process more generally. Thus, in addition to the ongoing focus on creating and improving techniques that would improve understanding of the scientific process among schoolchildren, college students, and the general population, some attention should also be given to understanding how misconceptions about science are the result of belief-resistance processes and developing techniques that might short-circuit these processes.

On a strictly anecdotal level, I’ve seen this time and time again in the alt-med movement. A particularly good example is homeopathy. How many times have we seen homeopaths, when confronted with scientific evidence finding that their magic water is no more effective at anything than a placebo, claiming that their magic cannot be evaluated by randomized, double-blind clinical trials (RCTs)? The excuses are legion: RCTs are too regimented; they don’t take into account the “individualization” of homeopathic treatment; unblinded “pragmatic” trials are better; or the homeopaths’ anecdotal evidence trumps RCT evidence. Believers in alt-med then often generalize this scientific impotence discounting to many other areas of woo, claiming, for example, that science can’t adequately measure that magical mystical life energy field known as qi or even, most incredibly, that subjecting their woo to science will guarantee it to fail because belief is required and skepticism results in “negative energy.” Another common strategy I’ve seen for scientific impotence discounting is to dismiss science as “just another religion,” just as valid as whatever woo science is refuting, or to label science as “just another belief system,” as valid as any other. In other words, postmodernism!

Sadly, though, even physicians ostensibly dedicated to science-based medicine all too easily fall prey to this fallacy, although they usually don’t dismiss science as being inadequate or unable to study the question in question. Rather, they wield their preexisting belief systems and mental frameworks like a talisman to protect them from having to let disconfirming data force them to change their beliefs. Alternatively, they dismiss science itself as “just another belief.” Perhaps the most egregious example I’ve seen of this in a long time occurred, not surprisingly, over the mammogram debate from six months ago, when Dr. John Lewin, a breast imaging specialist from Diversified Radiology of Colorado and medical director of the Rose Breast Center in Denver, so infamously said, “Just the way there are Democrats and Republicans, there are people who are against mammography. They aren’t evil people. They really believe that mammography is not important.”

Wow! A straw man argument (that those who support the USPSTF guidelines are “against mammography”) combined with likening science to just another political viewpoint, and a condescending disclaimer that those who disagree with him “aren’t evil”! Mike Adams couldn’t have said it better. I wonder if Dr. Lewin thinks that Dr. Susan Love is “against mammography,” given that in the very same article it was pointed out that Dr. Love supports the USPSTF guidelines.

I get it. I really do. I get how hard it is to change one’s views. I even understand the tendency to dismiss disconfirming evidence. What I like to think distinguishes me from pseudoscientists is that I do change my mind on scientific issues as the evidence merits. Perhaps the best example of this is the aforementioned USPSTF mammography screening kerfuffle. For the longest time, I agreed enthusiastically with the prevailing medical opinion that screening for breast cancer with mammography beginning at age 40 was almost completely a universal good. Then, over the last two or three years, I’ve become increasingly aware of the problem of lead time and length bias, the Will Rogers effect, and overdiagnosis. This has led me to adjust my views about screening mammography. I haven’t adjusted them all the way to the USPSTF recommendations, but I am much more open to changes in the guidelines published late last year, even to the point that encountering the resistance of my colleagues led me to feel as though I were an anomaly.

Skepticism and science are hard in that they tend to go against some of the most deeply ingrained human traits there are, in particular the need for certainty and an intolerance of ambiguity. Also in play is our tendency to cling to our beliefs, no matter what, as though having to change our beliefs somehow devalues or dishonors us. Skepticism, critical thinking, and science can help us overcome these tendencies, but it’s difficult. Perhaps that’s the most important contribution of the scientific method. It creates a structure that allows us to change our beliefs about the world based on evidence and experimentation without the absolute necessity of taking being proven wrong personally.

When the scientific method is really embedded in the culture of scientists, it leads to the sorts of behavior described by Richard Dawkins where a scientist gives a talk with very solid evidence supporting his conclusions. That evidence, it just so happened, completely disconfirmed the long-held hypothesis championed by a very senior and respected member of his department. When the talk was over, everyone waited to see what this senior scientist would say. Instead of challenging the speaker, the scientist got up and thanked him for having shown him that he had been wrong for these many years because a phenomenon he was interested in was now better understood. True, the story may have been apocryphal or exaggerated, but that is the ideal of science. It is an ideal that is very hard, even for scientists, to live up to, and it’s even harder for non-scientists even to understand.

In the end, though, we need to strive to live up to the immortal words of Tim Minchin when describing how he’d change his mind about even homeopathy if presented with adequate evidence. Actually, as much as I love Tim Minchin’s humorous take on dealing with a woman espousing a panoply of woo that would rival Whale.to’s collection, I’m forced to realize that Minchin is a bit too flippant about the difficulty in changing one’s mind. I know, I know, he’s a comic musician (or a musical comedian); flippancy is part of his job. Even so, show me, for example, strong evidence that vaccines are associated with autistic regression, and I might not “spin on a dime” and change my beliefs, as Minchin put it, but eventually, if the evidence is of a quality and quantity to cast serious doubt on the existing scientific evidence that does not support a vaccine-autism link, I will adjust my views to fit the evidence and science. I’m also under no illusion about how difficult that would be to do or that I might even be prone to using some of the defense mechanisms described by psychologists to avoid doing that, at least at first. But I’ve changed my mind before based on science disconfirming medical dogma that I had long believed on more than one occasion. I can (and no doubt will) do it again.

In the end, I want knowledge, both to provide the best care possible for my patients and just for knowledge’s sake. Science is the best way to get that knowledge about the natural world, and no other methodology has improved the treatment of human disease as fast as science-based medicine. The price is one that I’m willing to pay: Uncertainty and the expectation that much of what I “know” now will one day have to change. What they told me my first day in medical school really is true. Twenty years after I graduated, at least half of what I was taught in medical school has changed or is no longer applicable to patient care, and that’s a good thing.

Certainty is nice, but I’ve learned to live without it.

REFERENCE:

Munro, G. (2010). The Scientific Impotence Excuse: Discounting Belief-Threatening Scientific Abstracts Journal of Applied Social Psychology, 40 (3), 579-600 DOI: 10.1111/j.1559-1816.2010.00588.x