The development of drugs and other treatments for specific symptoms or conditions relies heavily on either serendipity (the chance finding of a beneficial effect) or on an understanding of underlying mechanisms. In pain, for example, there are limited ways in which we can block pain signals – such as activating opiate receptors or inhibiting prostaglandins. There are only so many ways in which you can interact with these systems. The discovery of a novel mechanism of modulating pain is therefore most welcome, and has the potential of leading to entirely new treatments that may have better side-effect profiles than existing treatments and also have additive clinical effects.

A recent study by Nana Goldman et. al., published in Nature Neuroscience, adds to our understanding of pain relief by identifying the role of adenosine in reducing pain activity in the peripheral nervous system. The researchers, in a nice series of experiments, demonstrated that producing a local painful stimulus in mice causes the local release of ATP (adenosine triphosphate) that peaks at about 30 minutes. This correlates with a decreased pain response in the mice. Further, if drugs are given that prolong the effect of adenosine, the analgesic effect itself is prolonged.

Also, if drugs are given that activate the adenosine A1 receptor, the observed analgesic effect is replicated. When these experiments are replicated in knockout mice that do not have the gene for the adenosine A1 receptor, there is no observed analgesic effect.

Together these experiments are fairly solid evidence that local pain results in the local release of adenosine that in turn binds to the adenosine A1 receptor inhibiting the pain response. This is potentially very exciting – it should lead to further investigation of the adenosine A1 receptor and the effects of activating and inhibiting it. This may lead to the development of drugs or other interventions that activate these receptors and may ultimately be a very useful addition to our ability to treat acute and chronic pain.

Now Comes the Spin

In a rational science-based world, the above would be the end of this blog entry. But that is not the world we currently live in. In this study, the chosen method of provoking pain was the insertion of an acupuncture needle into the “Zusanli point” of the lower extremity and rotating it. This allowed the authors of this study to spin the results as if they were validation for acupuncture itself – and the mainstream press dutifully followed suit.

The introduction to this study is an apology for acupuncture itself, and sets the tone for the rest of the paper as well as the press release and comments to follow:

Acupuncture is a procedure in which fine needles are inserted into an individual at discrete points and then manipulated, with the intent of relieving pain. Since its development in China around 2,000 B.C., acupuncture has become worldwide in its practice. Although Western medicine has treated acupuncture with considerable skepticism, a broader worldwide population has granted it acceptance. For instance, the World Health Organization endorses acupuncture for at least two dozen conditions and the US National Institutes of Health issued a consensus statement proposing acupuncture as a therapeutic intervention for complementary medicine. Perhaps most tellingly, the U.S. Internal Revenue Service approved acupuncture as a deductible medical expense in 1973.

That this paragraph appears in a high-impact peer-reviewed journal is very curious (to put it mildly). It is full of misinformation and logical fallacies. Acupuncture is used for more than pain relief, and so making statements about the efficacy of “acupuncture” go way beyond the scope of this study, which involves only pain. The authors should have specifically pointed out that this study cannot be used to explain any indication for acupuncture that does not involve local pain relief. Acupuncture as it was practiced in China 4,000 years ago bears little resemblance to what is practiced today, and may have been more of a form a bloodletting.

The authors then make a false dichotomy between “Western medicine” and, presumably, “Eastern medicine” – which is an anti-scientific and culturally bigoted point of view. This is followed by an argument from popularity, and a particularly bizarre argument from authority – noting that the IRS accepts acupuncture as a medical expense. I was unaware that the IRS is a scientific medical organization.

The authors also fail to put this study into its proper context by reviewing existing evidence – the more traditional use of the introduction to peer-reviewed research. The clinical research on acupuncture, which is quite extensive, finds that any measured symptomatic effect is almost certainly due mostly or entirely to placebo effects. Further, it does not matter where you stick the acupuncture needle, nor even if you do not stick the needle through the skin. Twisting toothpicks against the skin in random locations has the same effect.

My interpretation of the research is that acupuncture (placing needles at specific acupuncture points to manipulate chi) does not work. There may, however, be non-specific physiological responses to the mechanical stimulation of sticking needles at random locations, or just poking toothpicks. This study, if anything, supports this interpretation – it, in fact, has identified a local mechanism of analgesia that can help explain a non-specific response to acupuncture, sham acupuncture, or placebo acupuncture and therefore is consistent with the clinical evidence showing no difference among these interventions.

This is also not the first study to identify potential local mechanisms of pain relief from mechanical stimulation. A 2002 study correlated insertional activity (depolarization of muscle fibers in response to needle insertion) or electrical stimulation with pain relief. This would explain why, in this study, constant twisting of the needle was needed to provoke pain relief – perhaps insertional muscle activity is needed to release adenosine, or increases its release.

By focusing on what is really going on here we can best understand how to develop methods to capitalize on these local mechanisms optimally for pain relief. It must be noted, however, that needle insertion gives very unimpressive results in clinical trials. It may be that the effect is too temporary to be worthwhile, at least as mechanically provoked – pharmacologically activating the adenosine A1 receptor may be a better strategy. Also, it is very difficult to extrapolate from mouse data as the subjects are much smaller than humans, and therefore their nerves and motor end-plates (the locations where the nerves innervate the muscles) are much closer together and superficial – closer to the skin.

Mechanisms are interesting, but net clinical outcomes in humans are the only kind of scientific data that really tells us if a modality works or not.

Conclusion

Finally, it has to be emphasized that this study says nothing about acupuncture itself, except for providing a possible mechanism for a non-specific local response. The term “acupuncture,” in fact, is becoming increasingly problematic and is confusing the scientific literature, not to mention the public. What is acupuncture? If we use the term broadly enough to mean any use of needles, with or without electrical stimulation, at any points, with or without skin penetration, etc. then the term is too broad to be useful. If we use the term narrowly – to mean sticking needles to a certain depth in specific acupuncture points that work through a novel mechanism specific to those locations, then we can say, based upon extensive research, that “acupuncture” does not work and its proposed underlying mechanisms are nothing more than pre-scientific superstition.

This study is an excellent example of the mischief caused by confusing the non-specific use of the term “acupuncture” with its more traditional use. Research involving acupuncture in its vaguest sense is used to promote “acupuncture” in the traditional sense. This is highly deceptive and scientifically sloppy.

The researchers of this current study could have used other controls to see if the effect they discovered is in any way specific to any acupuncture variables. For example – they could have used a non-acupuncture point as a control, or other forms of mechanical pain production that do not involve needles. I suspect any local pain production or mechanical trauma beyond a certain threshold would result in the same adenosine response – which certainly seems like a non-specific mechanism to modulate pain.

Because the authors did not do this, they did not actually research “acupuncture”. The description of this research in the published paper and in the press should have been as I discussed in the opening of this post. Instead, genuinely interesting research that may lead to novel pain treatments is being diverted as propaganda for an ancient superstition.

What evidence standard should exist for health products sold in pharmacies? That’s today’s bleg, and I’m seeking your input.

In most countries, pharmacy is a registered, self-regulated health profession, with a responsibility to optimize the use of drugs. Pharmacist education consists of several years of university-level education and practical training in real-world health care settings. Pharmacists with advanced degrees and post-graduate residencies are common. Not all pharmacists work in community (retail) pharmacies, but that’s where many pharmacists end up, and it’s the public face of the profession.

In most countries, pharmacies are private businesses, either owned by a pharmacist or by a corporation. They are granted a privileged and exclusive right in the provision of health care: certain health products (both prescription and non-prescription) are only available in pharmacies, because pharmacist consultation and availability has been deemed necessary to maximize the safe use of these products. While it’s a setting for health care (and often the first point of contact into the system), retail pharmacy is a business. Pharmacies count on the retail sale of products for revenue and traffic. And in general, pharmacies have the legal right to stock and sell whatever products they want. Tobacco is one exception, where it is no longer sold in most Canadian pharmacies, but remains prevalent in American pharmacies. And as I discussed in a prior post, when we look internationally there can be considerable differences between which drugs are prescription, and these that can be sold over-the counter.

How Much Evidence?

The evidence standard for products sold in pharmacies is facing increasing scrutiny. Concerns have been raised in several countries that pharmacies may be taking advantage of their privileged status as provers of prescription drugs, and are selling products that aren’t supported by good scientific evidence. Some recent examples:

• Australian Skeptics awarded pharmacists their Bent Spoon Award in 2006 for selling “quackery and snake oil.” They recently published an open letter to pharmacists criticizing the sale of ear candles, noting, “Pharmacies need to make a profit, but this should not be done through quack products and bad advice. To regain the status a pharmacy should have – a place to get sound advice and effective medicine, supported by scientific and clinical evidence – we implore our pharmacists to stick to worthy products sold by knowledgeable staff.”
• In New Zealand, some are asking, What are homeopathic remedies doing in New Zealand Pharmacies?
• In Canada, pharmacists have been advised not to sell natural health products that are not approved for sale by Health Canada. While this sounds promising, it does not establish a rigorous evidence standard, as Health Canada approves and regulates products such as homeopathy.
• In the United States, the FDA warned consumers in 2009 to stop using Zicam intranasal products, commonly sold in pharmacies, because of serious adverse effects.
• In the United Kingdom, as part of the Evidence Check into homeopathy, the Professional Standards Director for Boots, a British pharmacy chain, made the following admission: “There is certainly a consumer demand for these products. I have no evidence to suggest they are efficacious. It is about consumer choice for us and a large number of our customers believe they are efficacious.”

Establishing a Standard?

Is it possible to define a minimum evidence standard for products sold in pharmacies? Here are some possible thresholds:

• Copper bracelets, magnets, homeopathy, and similar implausible products without any persuasive evidence of effect
• Products with biological plausibility, but without any clinical data (positive or negative) in humans
• Plausible products, (e.g., some herbal remedies), supported by anecdotal evidence, case reports, or very weak RCT data
• Products with evidence of benefit and possible harms (e.g.,  some vitamins)
• Products that may not be helpful, but are generally regarded as safe (e.g., cough and cold products)
• Products backed with robust evidence, approaching the standard used for prescription drugs (e.g., antibiotics, analgesics)

Other Considerations

In the United Kingdom, the Evidence Check into homeopathy made the following recommendation:

Although the availability of homeopathic products in pharmacies could be interpreted by patients as an endorsement of efficacy, in our view it would be pointless to seek to remove homeopathic products from sale in pharmacies. Many pharmacies sell ranges of non-evidence-based products and homeopathic products are easily available over the internet in any case. We consider that the way to deal with the sale of homeopathic products is to remove any medical claim and any implied endorsement of efficacy by the MHRA—other than where its evidential standards used to assess conventional medicines have been met—and for the labelling to make it explicit that there is no scientific evidence that homeopathic products work beyond the placebo effect.

Is the sale of homeopathy, or any other product acceptable in a pharmacy, if there is full disclosure about the level of evidence supporting efficacy claims?

In Canada, the United States, and some other countries, pharmacies can be part of large retailers like Walmart. Should there be a different threshold in these types of pharmacy settings?

Where do you see the line being drawn between the right of a retailer to sell a product, and the responsibility of a health professional to sell credible products?

Focusing the Question

Let’s keep the discussion focused on products intended or marketed for therapeutic or health use. That is, set aside the sale of chips, tobacco, cosmetics, televisions, donuts, or propane. We’re discussing products intended for therapeutic use, that may be legally sold.

Assume for this exercise that pharmacies that restrict the sale of certain products don’t interfere with market access through other retailers, like vitamin shops.

Pharmacy practice varies by country and even by state. Describe the current standard you observe in pharmacies, and what you think the standard should be.

Let’s leave aside discussion about prescription drug access. Focus only on products available for self-selection (over-the-counter).

Conclusion

Pharmacies play an important role in the health care system by providing access to pharmacists and therapeutic products to support health. If our intent is to support self-selection of science-based products supported by good evidence, what evidence standard should be applied in pharmacies? I look forward to your comments.

Opium derivatives—and later, synthetic opioids—have probably been used for millennia for the relief of pain. Given human biology, they’ve probably been abused for just as long. Opiate use disorders are a daily fact for primary care physicians; the use of these drugs has become more and more common for chronic non-cancer pain. These medications are very effective in the treatment of pain, but come with a lot of undesired effects, not least among them the potential of developing a substance use disorder. They also have considerable street value, with Vicodin selling for $5-$10 per tablet on the illicit market.

But our options for the treatment of pain are not unlimited. Non-steroidal anti-inflammatory medications such as ibuprofen are not safe in all patients, and are not always effective. A multi-modal approach to the treatment of chronic pain can be very helpful, but many patients do not have access to this expensive treatment, and many more simply want instant relief, something which opiates can provide, but with a price.

The abuse of prescription opiates is on the rise. Continuing with Vicodin as an example, 9.3% of American 12th graders reported using Vicodin illicitly in a recent survey. From 1994 to 2002, the mention of hydrocodone—the narcotic in vicodin–in emergency center charts increased 170%. This is a big problem.

So we have two big problems: chronic pain, and narcotic abuse. How can we treat chronic pain and avoid contributing to substance use disorders and drug diversion? One strategy has been the use of so-called narcotic contracts, which we’ve discussed at length. But absent from that discussion was the evidence.

Before we look at this evidence, we must re-examine our reasons for using these contracts. In my own practice, we generally use them to protect ourselves from becoming involuntary drug dealers, and to prevent patients from abusing the narcotics we prescribe. So how are we doing with that?
I can’t answer the first question, but the second was subjected to a systematic review published in the current issue of Annals of Internal Medicine. One of the primary findings of this review was that this question has not been well-studied. The few studies that are out there do not measure some of the most important end-points, such as abuse, dependence, overdose, and death. They also don’t focus on primary care offices, the setting in which these drugs are often prescribed. The limited data available point toward a reduction in narcotic misuse with the use of treatment contracts. They conclude:

Our systematic review reveals that weak evidence supports the use of opioid treatment agreements and urine drug testing to reduce opioid misuse, despite the theoretical benefits of these strategies. This lack of evidence may explain in part why they have not been widely adopted in primary care.

I’m not as optimistic as the authors that it is the lack of evidence driving practice here. Leaving that aside, they make some interesting points regarding plausibility, attitudes, and the use of evidence. With regard to narcotic treatment contracts and urine drug testing they write:

Even in the absence of strong evidence, several compelling reasons for physicians to consider implementing these strategies exist. First, primary care providers who use opioid treatment agreements report improved satisfaction, comfort, and sense of mastery in managing chronic pain. Second, management strategies that include treatment agreements have been associated with reductions in emergency department visits in observational studies. Third, cross-sectional studies and a case series have demonstrated that urine drug testing is a valuable tool to detect use of nonprescribed drugs and confirm adherence to prescribed medications beyond that identified by patient self-report or impression of the treating physician. Finally, implementing routine urine drug testing may improve the provider-patient relationship and clinic morale, as suggested in a letter to the editor.

This is a clearly written and subtle approach to the use of a plausible but not-yet-proved modality, and is a nice example of one way to approach the dark zones of data in science-based medicine. They give a rationale for pursuing further research (the importance and scale of the problem of narcotic misuse, and the dearth of good evidence for current practices). And they give some plausible reasons why we might continue to use this as-yet unproved modality. But they do not overplay the current state of research, or make hyperbolic conclusions.

Science-based medicine does not always give us clear guidelines to care, but often leaves us with more questions to answer. This is one way to approach a difficult problem with incomplete data.

References

Starrels JL, Becker WC, Alford DP, Kapoor A, Williams AR, & Turner BJ (2010). Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Annals of internal medicine, 152 (11), 712-20 PMID: 20513829

I’ll start this post by admitting right up front: I blatantly stole the idea for the title of this post from Mark Crislip’s most excellently infamous post Nine questions, nine answers. Why? Because I really liked that post and felt like it. Also, there seems to be something about the number nine among anti-vaccine zealots: Nine “questions.” Nine circles of hell.

Nine straw men.

I’m referring to an amazing post that appeared on the anti-vaccine crank blog Age of Autism over the weekend by contributing editor Julie Obradovic entitled The Difference Between You and Me. In this post, Julie describes not one difference, but nine differences, that she perceives between herself (and, apparently, by generalization other parents who have become believers in the myth that vaccines cause autism) and people like SBM contributors and (I hope) the vast majority of our readers, who support science-based medicine, understanding that correlation does not necessarily equal causation and that, most importantly, science not only does not support the belief that vaccines cause autism but provides us with copious evidence that there almost certainly no link between the two. Actually, there are more than nine differences, as Ms. Obradovic packs multiple apparently related differences around each of her nine “differences” and then complains that Alison Singer and, apparently by generalization the rest of us who support SBM and oppose the anti-vaccine movement, misrepresent the reasons why she and her merry band of anti-vaccine activists reject the science that has failed spectacularly to validate their deeply held belief that vaccines cause autism and all sorts of other health consequences. Her post ends up being a collection of straw men constructed to Burning Man size, each of which she then applies a flamethrower of burning nonsense to with self-righteous gusto.

Although no doubt Ms. Obradovic won’t see it that way, the reason I chose her article as an introduction for this post is not to pick on her (although if you look at her other posts on AoA, particularly her equally large city of straw men entitled How to Actually Save the Vaccine Program) she certainly deserves some picking on for her combination of pseudoscience, logical fallacies, and straw men). Rather, it’s because her collection of straw men are highly illustrative of what supporters of SBM have to deal with when dealing with pseudoscience and quackery. Ms. Obradovic’s “nine differences” may be all about vaccine-autism mythology and victimization that those mean and nasty scientists don’t take her beliefs seriously, but they could be about almost any form of non-science-based medicine. If you don’t believe me, do this simple thing. Wherever Ms. Obradovic writes “vaccines,” insert your favorite woo du jour and then channel the all-purpose quackery crank site Whale.to or NaturalNews.com. It doesn’t work for all of them (the part about the government “mandating” vaccines, for instance), but it works for enough of them to show my point.

Another reason why I’m going to discuss Ms. Obradovic’s collection of massive straw men peppered with other logical fallacies is that her attitude is not unique. What she writes demonstrates some key attitudes and belief systems towards science and points out many of the obstacles that those of us who try to promote science over pseudoscience, whatever the field, be it vaccines or any other area of quackery or pseudoscience, must address and overcome.

Straw men on flame with logical fallacies (apologies to Blue Öyster Cult)

Ms. Obradovic appears to be very incensed about a talk that Alison Singer, President of the Autism Science Foundation, arguably the only truly science-based autism charity in existence at the moment, and she uses a talk by Singer that was lambasted by Generation Rescue big macher J.B. Handley in three parts, as her jumping off point:

I am growing increasingly tired of the real reasons there is such controversy regarding vaccines and Autism being misconstrued to make me look pathetic. Alison Singer’s attempted explanation at Yale earlier this month (HERE) is a perfect example.

Contrary to what she suggests, our differences are not due to the internet. They are not due to desperation or the traumatization of having a child with Autism coupled with the need to blame someone. They are not due the media or the anti-establishment-toxic-earth movement. They are not due to the dismissive attitude of society and physicians who for years believed bad parenting was to blame. They are not due to an inability to simply accept clear science. They are not due to lack of an education or ability to think rationally. They are not due to being taken advantage of. They are not due to the cult of celebrity.

Wrong. Sorry. Not even close.

Actually, all of the above are excellent partial explanations for why parents like Ms. Obradovic refuse to accept science and continue to believe that vaccines cause autism. The reason Ms. Obradovic “looks pathetic” is not because some cabal of scientists are trying to make her look pathetic; it’s because she does an excellent job by herself of making pathetic arguments.

As I pointed out above, the rest of Ms. Obradovic’s post is structured as nine descriptions of what scientists and those of us who accept the science that doesn’t support her belief that vaccines cause autism believe, and her responding, “I don’t,” followed by a heapin’ helpin’ of what she does believe. Unlike Mark’s post, I’m not going to cover each and every one of these fallacies one by one in detail the way Mark did. I will note that upon rereading the post I just realized that Ms. Obradovic forgot a #3, disobeying the rule regarding the Holy Hand Grenade of Antioch: “Three shall be the number thou shalt count, and the number of the counting shall be three. Four shalt thou not count, neither count thou two, excepting that thou then proceed to three.” Of course, Ms. Obradovic has two straw men #5; so it all evens out to nine straw men again.

So let’s start with straw man #1:

1. You believe the government (the Department of Health and Human Services) has the legally protected right to research, develop, patent, license, supervise, judge, approve, recommend, mandate, and profit from a product (vaccines) that they produce in partnership with a private entity (the pharmaceutical industry). You further believe they have the right to simultaneously oversee the quality, safety and efficacy of this product, and that they objectively do so. You even further believe that they have the right to fund and conduct studies used to defend their product and policy in a court that they serve as judge and jury over in the event you are harmed by it; and moreover, that if they do find in your favor, they have the right to award you compensation at their discretion using money that was secured by a tax you paid on the product when you purchased it and/or were mandated to use it. And finally, you believe this should be protected by law; that neither the government nor the private entity should be held criminally or financially responsible for negligence in the event it maims or kills you.

I don’t.

See what I mean? Straw man #1 is in reality several straw men prefaced by misrepresentation of Ms. Obradovic’s opinion as fact. The fct is that the government does by law have the power to fund the development of vaccines, purchase them for government-run vaccination programs, and recommend them. Note also how Ms. Obradovic is specifically castigating the federal government (DHHS is a federal, cabinet-level department) when in reality the federal government has relatively little power to mandate vaccines in the civilian sector. (If you don’t believe that, check out how few Americans were vaccinated against H1N1 last year despite a massive government effort to persuade Americans to be vaccinated). It is the state and local governments that set specific vaccine mandates required of children. True, they usually use the recommendations made by the CDC and AAP, but it is not primarily the federal government that “mandates” vaccines.

As for compensation, Ms. Obradovic is referring to the Vaccine Court. While it is true that the government requires that claims against vaccine manufacturers first be adjudicated through the Vaccine Court, as has been described on this blog and elsewhere, the Vaccine Court is actually a complainant-friendly venue, where the Daubert rule for scientific evidence is usually not enforced and it is not necessary to prove negligence. Moreover, for purposes of the Vaccine Court, there are a set of “table injuries,” which are in essence recognized potential complications from vaccines that are automatically compensable. These injuries are simply assumed to have been from vaccines, based on science documenting these as potential complications from vaccines. Also, unlike regular courts, the Vaccine Court will pay attorney’s fees and reasonable expenses even to losing petitioners. A petitioner need only demonstrate that the petition was filed in good faith and that there was a reasonable basis for the claim, the idea being to make it as easy as possible for ordinary citizens to seek compensation for vaccine injuries without incurring huge legal bills or being unable to find a lawyer to represent them on a contingency basis. Indeed, attorneys like Clifford Shoemaker have made quite the cottage industry of bringing claims before Vaccine Court, knowing that their expenses will be paid, win or lose. Finally, if an action fails in Vaccine Court, the parent is perfectly free to pursue it in the regular courts.

What straw man #1 reveals is that, like many supporters of pseudoscience and crankery, Ms. Obradovic views science and the government as being arrayed against her, all in cahoots with big pharma. Whatever the short comings and misbehavior of big pharma, some of which I’ve personally documented right here on this very blog, cranks like Ms. Obradovic go far beyond reasonable concerns about big pharma, as we will see.

On to straw man #2:

2. You believe the only protection the consumer needs to be afforded in the aforementioned situation is trust. People should simply trust that those given such enormous power and protection are honorable, ethical, and responsible human beings with families of their own who would never abuse it or put profit over safety primarily because they are smart, went to prestigious medical institutions, and are at the top of their field. You do trust them. And you trust that there are just too many of them involved to all be bad, somehow making the system safe from corruption based on numbers. This is the one point people rely on to debunk the “conspiracy theorists”.

I don’t.

First of all, trust is earned. So is respect. I don’t care what letters you have after your name. You’re smart? Great. So am I. I’m not impressed, nor am I intimidated. Smart doesn’t mean ethical. And some of the smartest people I know are also those with the least common sense.

Does this sound familiar? It’s very much the same anti-intellectual attitude that J.B. Handley once bragged about. Here’s a hint for Ms. Obradovic. Being “smart” isn’t what matters. “Common sense” isn’t what matters. Understanding and accepting the scientific method and how science works does. Ms. Obradovic honestly seems to believe that the reason the scientific community doesn’t accept her wild beliefs that vaccines cause autism is because of a lack of ethics, plus the government, big pharma, and scientists being all in some grand conspiracy, not because the scientific evidence doesn’t support her belief. Unlike the case for scientists, it never occurs to Ms. Obradovic that she might be wrong or that the reason her belief that vaccines cause autism are not taken seriously by scientists is because, well, she is wrong. But not just wrong, spectacularly and arrogantly wrong about the science. It is the the pure arrogance of ignorance, born of anti-intellectualism.

In brief, I’m not in the least bit impressed by Ms. Obradovic’s trumpeting of her being so “smart.” She has not earned respect in any scientific discussion–quite the contrary. She has proven time and time again that she does not know what she is talking about when it comes to science and that her emotion and distrust of science trump all. Contrary to Ms. Obradovic’s apparent belief that the science behind vaccines is rotten to the core, in actuality it is scientists, not misguided conspiracy mongers like Ms. Obradovic, who point out the shortcomings in the vaccine program.

Next, I’ll skip ahead a bit, because it’s a lot more of the same ranting about the government and the scientific community, and it can all be boiled down to straw man #5-1 (given that there are two straw men #5) anyway:

5. You believe the science funded and conducted by the DHHS, pharmaceutical companies, vaccine patent holders and government witnesses (there exists no widely accepted study without this level of participation and conflict) thus far on the potential role between vaccines and the onset of Autism Spectrum Disorder and other health outcomes (for which they will be held accountable) is objective and adequate as it stands right now in both quantity and quality to dismiss a link between the two.

I don’t.

There is not enough space in this article to explain why, but a detailed explanation can be found through the series of articles I wrote here at Age of Autism on the 14 Studies. I’ve read, analyzed and presented every single study multiple times. What you call clear science, I call crap. And no, I’m not willing to accept crap when it comes to my child.

The problem is, of course, that Ms. Obradovic doesn’t have the background to determine whether a scientific study is “crap” or well-designed, well-executed, and reliable. It is the arrogance of ignorance once again asserting itself. In addition, it is a straw man to claim that we supporters of SBM believe that the science “funded and conducted by the DHHS, pharmaceutical companies, vaccine patent holders and government witnesses” is adequate because there’s so much more than evidence funded by the U.S. government. There’s more to the world than just the United States, you know. There have been many studies not just in the U.S., but in several other countries, including Denmark, Canada, the U.K., Japan, Italy, and elsewhere that have failed to find a link between thimerosal in vaccines and autism or between vaccines and autism. Surely all these countries can’t be in on the conspiracy, can they? A much more accurate way of saying this, without the intentional use of the logical fallacy of poisoning the well, is that the totality of the scientific and clinical evidence, when taken as a whole, does not support a link between either thimerosal in vaccines and autism or between vaccines and autism. In contrast, by mentioning the execrable Fourteen Studies website, Ms. Obradovic demonstrates that what she views as “good science” is any science that reinforces her belief, no matter how biased it is or poorly designed and executed, as Steve Novella, Mark Crislip, and I have all demonstrated in our deconstructions of that particularly misinformation-packed Generation Rescue-sponsored propaganda effort. Let’s just put it this way. Anyone who doesn’t easily see through the distortions and misinformation in the Fourteen Studies website has forfeited any claim to an understanding of scientific studies adequate to make grandiose statements about the validity of existing science, such as what Ms. Obradovic makes in straw man #5-2:

5. You believe everything about Autism is a coincidence: the dramatic rise in incidence; the parallel increase in vaccinations given at the same time; the similarities to mercury poisoning; the ratio of boys to girls; the identification of this new disorder in 1943; the timing of the onset of symptoms; the anecdotal evidence of parents; the original CDC findings; the recovery of children who are treated medically; and more.

I don’t.

Science is rooted in observation, and yet, every observation here listed is casually tossed aside as a cosmic lining up of the stars. There is nothing scientific about calling all of this coincidence and explaining it away with unproven excuses (see your list in the second paragraph)…and crap.

This particular straw man demonstrates a misunderstanding of epidemiology so profound as to be beyond belief. In actuality, Ms. Obradovic’s “observations” are nothing more than the blatantly obvious confusing of correlation with causation. As has been pointed out time and time again, mercury poisoning and autism do not resemble each other that strongly. The “dramatic rise” in autism incidence can be largely (although it is unclear if it can be completely) explained by widening of the diagnostic criteria and diagnostic substitution. Also, an example I’ve used before is the Internet. The rise in Internet use beginning in the early 1990s very closely parallels the rise in autism diagnoses and autism prevalence. Surely, by Ms. Obradovic’s logic, the Internet should be just as plausible as a cause of autism as vaccines.

She’s also dead wrong that the hypothesis that vaccines cause autism has been “casually tossed aside” as coincidence. In fact, scientists have studied extensively vaccine safety, looking for a linkage between vaccines and autism, largely driven by the concerns of mothers like Ms. Obradovic. They haven’t found any. In fact, I can retort that one difference between someone like Ms. Obradovic and someone like me is that she doesn’t understand that correlation does not equal causation and that, when science has failed to find a linkage between two things, when that the most likely explanation for any linkage between the two is coincidence. It’s a really hard concept for most people to accept, particularly when they have an emotional investment in a claim of causation, but it’s true. Confusing correlation with causation, confirmation bias, and a number of other cognitive factors conspire to prevent people from easily accepting that sometimes bad things are a coincidence.

One excellent example came from an article about the H1N1 vaccine using the example of H1N1 vaccination and heart attacks.Given that there are this number of people having heart attacks each and every day, during the months when so many people were being vaccinated against H1N1, it was inevitable that there would be dozens, if not hundreds of coincidences a day in which something bad happens to a person after having the H1N1 vaccine. If you’re one of those people, it will seem all the world as though the vaccine caused the badness to happen. It’s not because these people are stupid or ignorant; it’s because, not knowing the expected rate of these coincidences, most people assume that the rate of coincidence is far lower than it truly is. They assume that the rate is close to zero, that such a coincidence would be rare, but that assumption is wrong when dealing with large numbers.

Yes, that’s one difference between Julie Obradovic and me. I understand that. She doesn’t. She thinks herself to be too “smart” ever to make the mistake of mistaking correlation for causation. One of my favorite movie quotes of all times comes from, of all places, a Dirty Harry movie, specifically, Magnum Force. In it, Dirty Harry Callahan says at one point, “A man’s got to know his limitations,” and at another point, “A good man always knows his limitations.” This applies to women as well as men, and Julie Obradovic doesn’t know her limitations with respect to science. From my perspctive, if Obradovic’s world view were more accurate than mine, if big pharma really did have the power to fake research findings all over the world, I’d have to wonder: Why bother to put all those alleged “toxins” in vaccines? Why not use homeopathic vaccines, something harmless but ineffective, and then make up evidence to make it look as though they work?

I think that, in the end, the difference between Ms. Obradovic and someone like me, a supporter of science-based medicine, is that there is evidence that, if produced, would change my mind about whether or not there is a link between vaccines and autism, and I know what that evidence would have to be right now. All it would take would be a couple of well-designed, well-executed, well-analyzed epidemiological studies showing a strong link between vaccines and autism. Produce those, and I would start to reconsider my position. Or, as Tim Minchin put it so brilliantly about homeopathy in his nine minute beat poem Storm (please be warned that Minchin is fond of the f-word):

Science adjusts its beliefs based on what’s observed
Faith is the denial of observation so that Belief can be preserved.
If you show me
That, say, homeopathy works,
Then I will change my mind
I’ll spin on a fucking dime
I’ll be embarrassed as hell,
But I will run through the streets yelling
It’s a miracle! Take physics and bin it!
Water has memory!
And while it’s memory of a long lost drop of onion juice is Infinite
It somehow forgets all the poo it’s had in it!

You show me that it works and how it works
And when I’ve recovered from the shock
I will take a compass and carve Fancy That! on the side of my cock.

The same goes for me and not just homeopathy, but the belief that vaccines cause autism. I’d be embarrassed as hell for having been wrong, and I might resist changing my mind for a while, but eventually science would win out, and I’d realign my beliefs to conform with science. I would, however, abstain from bringing any sharp instruments anywhere near my genitals, and I’m not sure if I’d go running through the streets yelling, “Vaccines cause autism!” I would, however, write about it right here on SBM, minus the use of the f-word. In contrast, there is clearly no evidence that will ever change Ms. Obradovic’s fanatical belief that vaccines cause autism. Just try asking her if you don’t believe me.

The question that remains is: Why do people like Julie Obradovic refuse to accept the science that shows that vaccines are safe and effective and that they are not associated with autism? I’ve already pointed out one reason: Failure to understand that correlation does not equal causation, coupled with failure to let go of a belief that isn’t supported by science. Obviously, though, that alone is not sufficient to explain the intensity of her reaction.

Next week (or the week after if something comes up that catches my fancy), I’ll consider mechanisms by which we protect irrational beliefs from science.

The W^5/2 Hits Double Figyiz!

OK, I gotta admit that my friend Orac moved me to render this Special 10th Edition of the W^5/2™ (after a brief hiatus) by mentioning it today in the context of an article that used, er, the topic of our venerable game to great advantage! Some of it is brilliant, unprecedented even:

Perhaps most tellingly, the U.S. Internal Revenue Service approved acupuncture as a deductible medical expense in 1973.

My hat is off to whoever came up with that one! Hey, y’gotyer basic logical fallacies, right? Y’gotyer appeal to tradition, yer appeal to popularity (or, as Orac put it, yer argumentum ad populum—sheece, is he a snob er what?), yer appeal to authority, which, I shpoze, an appeal to the IRS is a species of, as it were (hmmm: is that appeal heard in Tax Court?)…but there’s something just a little more special about this than just that. Therefore I propose, in the Tremendous (and Trendy!) Tradition of Trademarked Titles™ long associated with the Wonderful W^5/2™, a bran’, spankin’ new fallacy of its own, presented, of course, in a tasteful Madison Avenue format:

Are you unsure about your cure? Has that acupuncture juncture got you in a funk, sir? Don’t be waverin’ when you could be savorin’!

For Facts to the Max, consult the Sheriff of the Tariff!©

(Or, in the hifalutin’ language favored by the sniffing Orac, argumentum ad yer-workin’-for-nobody-but-meum).

Last Week’s Entry

But enuffa that. Let’s lookit the translations submitted for ‘last week’s’ entry, which, as y’ll recall, was itself submitted by loyal W^5/2™ gamer Wertys! Not that you need reminding, because it’s obviously fresh in your minds, but that entry is once again topical thanks to Harriet Hall’s most recent post, seein’ as how it was all about “palpatory literacy”—in the chiropractic sense, that is.

First off, I gotta gently chide a fewayuz who just seemed to wanna scold. I mean, lighten up a little, OK, Dr Benway, Perky Skeptic, MedsVsTherapy, and Jurjen S.?

Then there’s an intriguing comment by AppealToAuthority suggesting that just maybe the authors of the entry were attempting, in a chiropractic journal, to appeal to rationality, or, even better, to write a satire. Either one seems doubtful, but I gotta admit I hadn’t thoughta that, even if I totally agreed with Stu (m’man!).

As always, of course, the real kudos have gotta go to translators who really put their hearts’n’souls into it, ifya know wuddeye mean: Joe (even if he did nominate himself, f’cryin’ outloud), Mojo, Sastra, Blue Wode, mmarsh, and Stu (m’man!), using (what else?) the Power of Simple Substitution first unveiled right here on the Award-Winning, Wondrous and Wonderful W^5/2™!

Allatheez translators hit the proverbial nail on its proverbial head, but for my money the grand prizathaweek goes to…

Michelle B, for makin’ me laugh the most.

This Week’s Entry: Alan Sokal, Cultural Studies, and…Homeopathy

Most readers of this blog are probably aware of the “Sokal Hoax” of the mid-90s: Alan Sokal, a physicist at NYU, wrote a satirical article titled “Transgressing the Boundaries: Towards a Transformative Hermaneutics of Quantum Gravity.” As you may gather from that title or already know, Sokal wrote the article in the style recently favored by a strain of “post-modern” academics. He did it, in extreme summary, to protest the burgeoning nonsense portrayed, by that set, as scientific knowledge. Here is a juicy sample from Sokal’s piece:

But whose mathematics? The question is a fundamental one, for, as Aronowitz has observed, “neither logic nor mathematics escapes the ‘contamination’ of the social.” And as feminist thinkers have repeatedly pointed out, in the present culture this contamination is overwhelmingly capitalist, patriarchal and militaristic: “mathematics is portrayed as a woman whose nature desires to be the conquered Other.” Thus, a liberatory science cannot be complete without a profound revision of the canon of mathematics. As yet no such emancipatory mathematics exists, and we can only speculate upon its eventual content. We can see hints of it in the multidimensional and nonlinear logic of fuzzy systems theory; but this approach is still heavily marked by its origins in the crisis of late-capitalist production relations. Catastrophe theory, with its dialectical emphases on smoothness/discontinuity and metamorphosis/unfolding, will indubitably play a major role in the future mathematics; but much theoretical work remains to be done before this approach can become a concrete tool of progressive political praxis.

The hoax occurred when Sokal’s article was accepted and published, with an entirely straight face, by the trendy “cultural studies” journal Social Text. A few months later Sokal revealed the hoax in another journal, Lingua Franca. After that, as they say, all hell broke loose. You can read all about the affair here (it’s worth doing, for entertainment value as well as for a scary look at academic culture of only a few years ago).

In my opinion, the “Sokal Hoax” is one of the best things that has happened during my lifetime. The reason that it pertains to this week’s W^5/2™, however, stems from Sokal’s explanation, after the fact, of the style that he had had to learn in order to write the satire, and how difficult that had been for him to do:

Like the genre it is meant to satirize — myriad exemplars of which can be found in my reference list — my article is a mélange of truths, half-truths, quarter-truths, falsehoods, non sequiturs, and syntactically correct sentences that have no meaning whatsoever. (Sadly, there are only a handful of the latter: I tried hard to produce them, but I found that, save for rare bursts of inspiration, I just didn’t have the knack.) I also employed some other strategies that are well-established (albeit sometimes inadvertently) in the genre: appeals to authority in lieu of logic; speculative theories passed off as established science; strained and even absurd analogies; rhetoric that sounds good but whose meaning is ambiguous; and confusion between the technical and everyday senses of English words.

It seems to have been much easier for those that Sokal satirized to write such drivel, as he demonstrated in numerous quotations throughout his satire. Here is Sokal citing one such author:

Along parallel lines, Donna Haraway (1991, 191-192) has argued eloquently for a democratic science comprising “partial, locatable, critical knowledges sustaining the possibility of webs of connections called solidarity in politics and shared conversations in epistemology” and founded on “a doctrine and practice of objectivity that privileges contestation, deconstruction, passionate construction, webbed connections, and hope for transformation of systems of knowledge and ways of seeing.”

Here he quotes verbatim from English professor Robert Markley:

Quantum physics, hadron bootstrap theory, complex number theory, and chaos theory share the basic assumption that reality cannot be described in linear terms, that nonlinear — and unsolvable — equations are the only means possible to describe a complex, chaotic, and non-deterministic reality. These postmodern theories are — significantly — all metacritical in the sense that they foreground themselves as metaphors rather than as “accurate” descriptions of reality. In terms that are more familiar to literary theorists than to theoretical physicists, we might say that these attempts by scientists to develop new strategies of description represent notes towards a theory of theories, of how representation — mathematical, experimental, and verbal — is inherently complex and problematizing, not a solution but part of the semiotics of investigating the universe.

Yup, language matters. There is an intimate relation between style and honesty. In Lingua Franca, Sokal wrote:

In short, my concern over the spread of subjectivist thinking is both intellectual and political. Intellectually, the problem with such doctrines is that they are false (when not simply meaningless). There is a real world; its properties are not merely social constructions; facts and evidence do matter. What sane person would contend otherwise? And yet, much contemporary academic theorizing consists precisely of attempts to blur these obvious truths — the utter absurdity of it all being concealed through obscure and pretentious language.

Social Text’s acceptance of my article exemplifies the intellectual arrogance of Theory — meaning postmodernist literary theory — carried to its logical extreme. No wonder they didn’t bother to consult a physicist. If all is discourse and “text,” then knowledge of the real world is superfluous; even physics becomes just another branch of Cultural Studies. If, moreover, all is rhetoric and “language games,” then internal logical consistency is superfluous too: a patina of theoretical sophistication serves equally well. Incomprehensibility becomes a virtue; allusions, metaphors and puns substitute for evidence and logic. My own article is, if anything, an extremely modest example of this well-established genre.

On, then, to the fun! Several weeks ago, spurred by this and similar comments, I was temporarily inspired to write a satirical homeopathy treatise employing the sort of verbiage quoted above (I even suggested to SD that he might do it, for it seemed that he’d already demonstrated the knack, but he didn’t reply). Well, it proved to require more than a trivial effort and I kinda forgot about it for a time, and then one day it was just STARING ME IN THE FACE! Not, alas, as a satire, but, as had been Alan Sokal’s initial experience, as a completely serious composition, fully formed! Aha, the cognoscenti among you are thinking, I musta read something by Lionel Milgrom. Good try, but nope; this is even better:

Time-Logics of the Quantal Base State in Homeopathic Potentization

Potentizing homeopathic substances beyond the Avogadro limit is a critical-state coherent process, wherein an element of active information cannot be considered identical to itself. Temporal ordering is paramount in transferring such information to and from the quantal base state, and requires m-valued logics and skew-parallel geometries to represent the identity transparency produced by the active temporal operators. In order to model the turbulent dynamics of dilution-succussion, the Hilbert space of quantum theory must be modified under m-valued logics such that a multivalued reference space becomes the informational ground, or quantal base state, decomposed and recomposed by operator-time. Such temporal operations inherently involve complex angular momentum exhange via “imaginary time”. This temporal-spin is a generalization of Dirac’s “spin coordinate” and offers insight into how homeotherapeutic potency sustains itself indefinitely.

In homeopathic potentization the dilution-succussion process…becomes a water-borne stack of crisis states that cascade highly organized (i.e., coherent) time-pattern shapes through the nested collection of “acetate” clock-sheets constituting the transparent information ground.

—Pensinger W, Paine D, Jus J. Journal of the American Insititute of Homeopathy 90(2): 77-88 (1997)

Truth sure is stranger than fiction, i’nit? Happy Waluating!

The General Chiropractic Council, a UK-wide statutory body with regulatory powers, has just published a new position statement on the chiropractic subluxation complex:

The chiropractic vertebral subluxation complex is an historical concept but it remains a theoretical model. It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.

They remind chiropractors that they must make sure their own beliefs and values do not prejudice the patient’s care, and that they must provide evidence-based care. Unfortunately, they define evidence-based care as

clinical practice that incorporates the best available evidence from research, the preferences of the patient and the expertise of practitioners, including the individual chiropractor her/himself. [emphasis added]

This effectively allows “in my experience” and “the patient likes it” to be considered along with evidence, effectively negating the whole point of evidence-based medicine.

As I’ve pointed out numerous times this week, anti-vaccine loons, led Generation Rescue and a “health freedom” group, have organized an anti-vaccine rally in Grant Park in Chicago from 3 PM to 5 PM CDT. Andrew Wakefield himself will be the keynote speaker, and there will even be some very bad music promoting the anti-vaccine message. The rally, with its wonderfully Orwellian title, The American Rally for Personal Rights, will be pure anti-vaccine activism in support of pseudoscience on display.

Those supporting science-based medicine plan, led by Skepchick Elyse Anders, to be there to promote science over the conspiracy theories and fear mongering that the anti-vaccine movement uses to frighten parents out of vaccinating their children. I realize it’s short notice. I realize that you very likely will be outnumbered, given the combination of short notice and the fact that the anti-vaccine zealots have been organizing and promoting this rally for weeks, if not months. Nonetheless, you’ll be doing me a particular solid if you can show up there. Details are here. There are also going to be satellite rallies in New Jersey, Washington, and New York. They look as though they’ll be much smaller; so, as P.Z. Myers points out, even if a couple of people can go it could have an effect.

Oh, and if you see J.B. Handley, Jenny McCarthy (I don’t know if she’ll be there or not but thought I’d mention her anyway), Andrew Wakefield, Kim Stagliano, or any other prominent anti-vaccine loon with whom I’ve tussled from time to time here and elsewhere, please tap him or her on the shoulder, smile broadly, and tell ‘em Dr. Gorski says hi.

Particularly J.B. Handley, for at least three reasons^1,2,3.

In 1952 Martin Gardner, who just passed away this week at the age of 95, wrote about organic farming in his book Fads and Fallacies in the Name of Science. He characterized it as a food fad without scientific justification. Now, 58 years later, the science has not changed much at all.

A recent review of the literature of the last 50 years shows that there is no evidence for health benefits from eating an organic diet. The only exception to this was evidence for a lower risk of eczema in children eating organic dairy products. But with so many potential correlations to look for, this can just be noise in the data.

Another important conclusion of this systematic review is the paucity of good research into organic food – they identified only 12 relevant trials. So while there is a lack of evidence for health benefits from eating an organic diet, we do not have enough high-quality studies to say this question has been definitively answered. It is surprising, given the fact that organic food was controversial in the 1950s, that so little good research has been done over the last half-century.

It should be noted that we only recently had any rules in the US regarding the label “organic”. According to the USDA:

The Organic Foods Production Act (OFPA), enacted under Title 21 of the 1990 Farm Bill, served to establish uniform national standards for the production and handling of foods labeled as “organic.”

The definition of organic entirely relates to the method of production, not the final product. It involves three principles. One is sustainable farming that is optimal for the environment. That question is beyond the scope of this medical blog. Many people do advocate organic farming for this reason alone, and many of the principles of sustainable farming are being incorporated more generally into agriculture and animal husbandry.

The second principle is the establishment of an ecosystem, using cover crops, crop rotation, and other methods. Again – I want to set aside the environmental questions and focus on the nutritional claims: Does organic farming result in produce that is more nutritious? There are different ways we can approach this question. One is addressed by the systematic review above: Can we measure a health advantage to eating an organic diet? The answer to that question at the present time is “no.” This could be due to the fact that there is no health benefit, or that any benefit is smaller than the studies currently available could detect. Long term modest health benefits are very difficult to detect with clinical trials, and it is therefore difficult to rule out such benefits, but at present there is no evidence of health benefits from an organic diet.

The second way to approach this question is to evaluate the food products themselves: Are they more nutritious? The most recent systematic review of the evidence concluded:

On the basis of a systematic review of studies of satisfactory quality, there is no evidence of a difference in nutrient quality between organically and conventionally produced foodstuffs. The small differences in nutrient content detected are biologically plausible and mostly relate to differences in production methods.

There is also a recent study concluding that birds prefer seed that is conventionally produced over seed that is organically produced – likely because conventional production methods result in a 10% higher protein content.

The third issue with organic food is what is not in, or on them – pesticides, hormones and antibiotics. Here, again, we can take the same two approaches as with nutrition: Is there any evidence of a difference between organic and conventional produce, and is there evidence for a health benefit? There seems to be a consensus on the first question. There are lower levels of synthetic pesticides in organic produce and lower levels of hormones and antibiotics in organic meat than in conventionally grown equivalents.  But is this safer for health? The review cited above is also relevant to this question, and essentially there is no evidence for greater safety of organic food over conventional food.

With regard to pesticides, it must also be noted that organic farming, while using methods to minimize pests and the need for pesticides, still uses organic, rather than synthetic, pesticides. For example a rotenone-pyrethrin mixture is commonly used. Such pesticides are not as well studied as synthetic pesticides, often require more applications, and may persist longer in the soil. In fact the use of “natural” pesticides is nothing more than an appeal to the naturalistic fallacy – there really is no evidence for superior safety, and they have not been adequately studied.

There is a recent study which has garnered a great deal of press linking organophosphates – a type of synthetic pesticide – to higher prevalence of ADHD. However, this is a preliminary observational study. While interesting, it really can only be used to justify further research, not any conclusions regarding the effects of organophosphates. (I discuss this article in more detail here.)

It does seem reasonable to minimize human exposure to pesticides. This can be accomplished, at least in part, however, by simply washing all produce thoroughly. I could not find any direct comparisons of organic produce to thoroughly washed conventional produce, but what evidence we do have suggests that residue levels are below safety limits and can be lowered further by washing. This is an area that does require continued monitoring and research, however.

Conclusion

Overall there does not appear to be any advantage for health to organic farming (sustainability and environmental effects being a separate issue). However, despite the fact that organic farming has been around for over 50 years, there is a surprisingly small amount of quality research available. The organic farming industry and popularity of organic products is growing. Organic products are more expensive, and questions remain about whether or not such methods would be adequate to supply our food needs. There may also be hidden health risks or unintended consequences to relying upon organic farming. There may also be benefits that have not been adequately documented. Therefore, this is one area where I think it is reasonable to conclude more research is genuinely needed.

Dr. Andrew Wakefield was almost single-handedly responsible for frightening the public about a possible association between autism and the MMR vaccine. His alarmist recommendations directly led to lower vaccination rates and a resurgence of measles to endemic levels in the UK. The MMR/autism interpretation of his 1998 article in The Lancet was retracted by 10 of his 12 co-authors. The article itself was “fully retracted from the public record” by The Lancet. And now Wakefield has lost his license to practice medicine after the General Medical Council’s exhaustive 2½-year review of his ethical conduct.

His career was in shreds and there was only one way left for him to fight back: to write a book. Callous Disregard: Autism and Vaccines — The Truth Behind a Tragedy has just been published. I tried hard to read it with an open mind and to understand his point of view. He did make some points that I will accept as valid unless they can be refuted by the others involved. Some of what he said and did was apparently misinterpreted and distorted by his critics. But the book did not convince me that he was an ethical, rigorous scientist or that MMR is linked to autism or to bowel disease. In my opinion the book does nothing to scientifically validate his beliefs or to excuse his behavior, but rather boils down to self-serving apologetics and misleading rhetoric. It also undermines his claim that he is a good scientist by showing that he values anecdotal evidence (“listening to the parents”) over experimental evidence.

The preface is by Dr. Peter Fletcher of the UK’s Committee on Safety of Medicines. Some of what he says is demonstrably wrong. He alleges that vaccines have only been “minimally investigated,” that concerns about anaphylaxis have been neglected (Wakefield also stresses the danger of anaphylaxis), and that the mortality rate from MMR vaccines approaches the pre-vaccination mortality rates for measles. These allegations are ridiculous and easy to disprove with a couple of minutes’ Googling. (In an Australian study of 1.7 million school children vaccinated with MMR, there was only one anaphylactic reaction and no deaths. Before the introduction of vaccines, measles used to kill 100 people in the UK every year and MMR vaccine has never been known to kill anyone.) Fletcher also offers his unsupported opinion that the subjects in Wakefield’s study had “a complex new syndrome” whose root cause is “almost certainly vaccines.”

The foreword is by Jenny McCarthy, who offers the tired old “listen to the parents” argument and calls Wakefield “the symbol of someone who stood up for truth.”

Wakefield starts the book with an anecdote about a mother who killed herself and her autistic child: moving, but irrelevant to the questions of whether Wakefield was unethical or whether vaccines cause autism.

Wakefield does not recognize that he has done anything wrong. Instead, he accuses the regulatory authorities of callous disregard of children’s safety; he accuses his accusers of having personal motivations to destroy him and to maintain the vaccine party line at all costs; he accuses Brian Deer, the investigative reporter who exposed him, of getting the facts wrong; he accuses others of not reporting their own conflicts of interest, etc.

He accuses the regulators and the vaccine industry of “ruthless, pragmatic exorcism of dissent” and tries to show that they are effectively anti-vaccine because they have caused the decrease in public confidence that is the greatest threat to the vaccine program. He says if consumers don’t get the answers they want (presumably a guarantee of 100% safety), they should trust their intuition, because

Maternal instinct… has been a steady hand upon the tiller of evolution; we would not be here without it.

These are not the words of a critical-thinking scientist; they sound more like something Jenny McCarthy might say.

Then he claims that the US vaccine court has been compensating for cases of vaccine-caused autism and secretly settling cases out of court. This is not true. The only source he gives for this misinformation is this report from CBS News that distorts the facts, confusing vaccine injury with encephalopathy and mitochondrial disorders with injury from autism. In reality, the vaccine court has evaluated the best test cases lawyers could come up with and has determined that there is no evidence for vaccines causing autism.

He stresses that the paper itself did not claim that MMR caused autism. That’s true. The problem was not the paper itself, but Wakefield’s interpretation of it in his press conference, where he advised against the MMR and recommended single vaccines instead. His comments at that press conference were what led to the public rejection of MMR vaccines and the resurgence of measles in the UK. He devotes a whole chapter to the press conference. He gets bogged down in minutiae about what the dean thought he was going to say and who knew or said what and when. He cannot justify his recommendation of single vaccines instead of the combined MMR, and he doesn’t address the fact that he had filed a patent application for his own single measles vaccine, a clear conflict of interest that he failed to disclose.

He has a whole chapter on the UK government’s delay in rejecting a particular brand of MMR vaccine that had been withdrawn in Canada. That episode says nothing about vaccines and autism and is not justification for Wakefield’s actions.

He denies that the lawyer funded the 1998 Lancet study, but admits that the lawyer was already funding a related measles virus study of Wakefield’s at the time. He offers convoluted explanations of how the subjects came to him. He denies that they were sent by the lawyer or that they were litigants at the time of the study. While that may be technically true, Wakefield was already known for his criticism of the MMR vaccine and for his hypotheses about measles virus and bowel disorders, and he readily admits that his reputation led a network of concerned activists to direct patients to him. These were not simply patients who presented to the clinic in the normal course of things. He says he was not required to report this sort of thing as a conflict of interest under the rules in effect at that time, but that the rules subsequently changed. Whether it was a requirement or not, it is something I would have wanted to know when I originally read the study.

He still doesn’t understand what was wrong about paying children to let him draw blood samples at his son’s birthday party. He doesn’t understand why scientists don’t usually use “samples of convenience” like this for a control group, and he doesn’t understand the element of coercion. He doesn’t even have the decency to apologize for making fun of the children in public, joking about them crying, fainting, and vomiting. He just doesn’t get it.

He tries to claim that doing invasive procedures like colonoscopies and lumbar punctures (LPs) on the subjects in his study was not for research but something that should have been done on every autistic child for the child’s clinical benefit. He doesn’t make a convincing case. Certainly the majority of clinicians who evaluate autistic children do not do these studies routinely.

He says that autism must not have existed in 19^th century Paris because Charcot did not describe it! He implies that the rise in autism was temporally associated with the introduction of MMR vaccine; but a recent study showed that the prevalence of autism in adults was equal to that in children and did not decrease with age, even in those over 70 who were far too old to have been exposed to any of the modern children’s vaccines.

He says his findings of a new gastrointestinal syndrome related to measles virus and autism have been replicated around the world. They have not. He cites a few papers that seem to support his hypothesis but fails to cite the bulk of data that refutes it. For instance this study showed no association between autism and overall incidence of gastrointestinal symptoms. This one showed no autism/GI connection either. And this study showed strong evidence against association of autism with persistent measles virus RNA in the GI tract or with MMR exposure.

He tries to demolish the GMC’s case against him. If he could do so in a book, one can only wonder why he didn’t present his evidence at the hearing. He goes into excruciating, mind-numbing detail about points that are really peripheral to the central issues.

He dissects a newspaper article by Brian Deer, but most of what he calls “false allegations” amount to trivial nitpicking about wording or interpretation. Some of it is reminiscent of a certain former president’s quibbling about what the meaning of the word “is” is. Deer made many other allegations in his exposés that Wakefield does not mention or attempt to refute, such as the apparent attempt to hide his source of funding (for a different study?) by funneling the lawyer’s payments through a company of Wakefield’s wife. There are many unanswered questions.

Perhaps the most unfortunate chapter in the book is “Poisoning Young Minds,” a prime example of Godwin’s law. He describes how a math question in schools in Nazi Germany used Jews as an example, thereby sowing the seeds of anti-Semitic propaganda into young, fertile Aryan minds. He compares this to a question on a UK biology exam that used Wakefield’s study as an example, asking students whether it was reliable scientific evidence or might have been biased. This takes up a whole chapter!

In his concluding epilogue, he says

In the battle for the hearts and minds of the public, you have already lost… Why? Because the parents are right; their stories are true; their children’s brains are damaged; there is a major, major problem. In the US, increasingly coercive vaccine mandates and fear-mongering campaigns are a measure of your failure — vaccine uptake is not a reflection of public confidence, but of these coercive measures, and without public confidence, you have nothing.

How ludicrous: he is clearly the one who undermined public confidence, not the scientists and agencies that are doing their best to reduce the incidence of preventable diseases and to protect the public from alarmists like him.

In my opinion, the whole book is an embarrassing, tedious, puerile, and ultimately unsuccessful attempt at damage control. Wakefield has been thoroughly discredited in the scientific arena and he is reduced to seeking a second opinion from the public. Perhaps he thinks that the truth can be determined by a popularity contest. Perhaps he thinks the future will look back at him as a persecuted genius like Galileo or Semmelweis. Jenny McCarthy thinks so; I don’t.

Carlyle said “a lie cannot live.” It shows that he did not know how to tell them.

— Mark Twain

There is an infamous hoax from last century called The Protocols of the (Learned) Elders of Zion, an anti-Semitic text purporting to describe a plan to achieve global domination by the Jewish people. Despite the fact that the Protocols is a work of fiction, there have been and still are folks who believe it to be real, from Hitler on down. (Or is that “on up”? Can one be lower than Hitler? And have I already committed a breach of Godwin’s Law?)

Inventing apparently legitimate information is a useful propaganda device not limited to anti-Semites. Having people appear evil or uncaring using their own words is far more effective than calling them evil and uncaring.

There are many in the community who suffer from a variety of complaints that I cannot diagnose, and, as people do not like uncertainty about their health, they will find someone who will give them a diagnosis. Not infrequently they will come upon the idea of chronic Lyme disease.

I do not think that the data supports the concept of chronic Lyme disease, and being a Tool of the Medical Industrial Complex (TMIC®), that is just what you would expect me to say. But despite the paucity of data to support chronic Lyme, there is a contingent of patients and doctors who feel that the disease is real.

In the battle to win the hearts and minds of those who are unconvinced about chronic Lyme, those in favor of the syndrome have several options.

1) They could argue the science. That would be a losing technique as the totality of the published literature is against them.

I would rather tell seven lies than make one explanation.

— Mark Twain

2) They could demonize the opposition. If the speaker is an evil TMIC, then the speaker’s message is evil as well. You are more likely to dismiss the message if you can dismiss the messenger. Certainly anything Rush Gore says is automatically nonsense since Rush Gore is a moron at best and evil at worst. It is a simple and common mental shortcut.

But doctors still have a degree of respect, deserved or not, in society. I think mostly deserved. Most of the people I work with are caring, compassionate people who work hard for the betterment of their patients. Not all. But most.

So you can call me a TMIC, but it will not stick most of the time. The process of calling people names can make the caller look petty, especially of they do it without cleverness. I am made of rubber, you are made of glue, what bounces off of me, sticks to you. It is true at 5 and at 50.

The glory which is built upon a lie soon becomes a most unpleasant incumbrance. How easy it is to make people believe a lie, and how hard it is to undo that work again!

— Mark Twain, Eruption

It would be better is to find examples of your opposition being a TMIC and display it for all the world to see. Hoist them on their own petard (a Star Trek reference; you have not enjoyed Hamlet unless you have read it in the original Klingon). What if you can’t find examples?

That is where you become a lying liar using lying lies. The Internet era makes it easy to rapidly transmit information. What often seems to be lacking is the ability for people to take just a little bit of time to fact check the information they get. People do not bother to double check the truthiness of the information they get. Hoax’s propagate endlessly on the interwebs, ranging from Captain Kangaroo’s war record to Nigerian money transfers. All easy to fact check. It is easier to believe what you read, especially if it supports you prior convictions. And lies are forever.

One of the most striking differences between a cat and a lie is that a cat has only nine lives.

— Pudd’nhead Wilson

PalMD received an open letter from the IDSA about Lyme disease and he thought it smelled funny, and not ha ha funny. More like boiling melana funny. PalMD has a good nose, and a quick email to the IDSA confirmed the letter is a hoax. I am sure that many will get a copy of this letter and be angered at their suffering being called delusional. If I thought I had chronic Lyme and read the tripe that follows, it would fry my bacon. Most will not bother to check the legitimacy of the letter. It is, in a word, a lie.

A lie can travel halfway round the world while the truth is putting on its shoes.

— Mark Twain

What follows is a hoax, lying lies from a lying liar.

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Open Letter to the Mental Health Community from the Infectious Diseases Society of America

May 24, 2010

Delusional Chronic Lyme Syndrome (DCLS) affects tens of thousands of new victims every year. This debilitating mental illness is destroying the emotional and financial livelihood of families across our country.

As the Infectious Diseases Society of America (IDSA), we see firsthand the damage inflicted by this illness. Its sufferers frequently seek medical help from our member’s practices; however, we are powerless to cure its underlying roots, as this mental illness exists well outside our domain knowledge of pathogens and human infection. Therefore, we are strenuously imploring the mental health community to take up research action in earnest. After our Lyme disease treatment review panel concluded last month, it is now indisputably self-evident that DCLS has reached epidemic proportions and its yearly growth rate is alarming.

The historical duration, demographic breadth, and geographical extent of this mass psychogenic illness is a fascinating and unprecedented event in the history of our country, perhaps in the history of mankind. It has persisted for four decades, affects all ages, and exhibits an intriguing geographic clustering phenomenon. The intensity of its delusions drives sufferers to such extremes as self-mutilation via catheterization and sometimes suicide. Currently, there is no formal diagnostic classification or treatment regimen for DCLS. Meanwhile, this is empowering opportunistic medical doctors to prescribe improper and costly pharmaceutical treatment. This only furthers delays patients from seeking out the mental health professionals they so desperately need. Unfortunately, general awareness within the mental health field is virtually nonexistent.

As president of the IDSA, I bear some responsibility for this ignorance, by not encouraging more cross-discipline pollination of our medical information. As this crisis has illuminated, the IDSA has not been true to its stated core value to “promote collaboration and cooperation among other professional colleagues.” In response, I passionately pledge to our members and public constituents to reverse this myopic trend within our esteemed organization.

IDSA member, Dr. Gary Wormser, has been a tireless crusader in promoting awareness of this emerging illness. I owe him immense gratitude for keeping true to his values as a physician in the face of sometimes caustic opposition to his fresh ideas. We beseech mental health researchers to carry on the torch ignited by Dr. Wormser and create pervasive, national recognition for this destructive disorder. By doing so, you will bring hope and compassion to those afflicted by this strange and insidious illness.

To actualize this crucial transfer of information, the IDSA will be hosting free workshops on DCLS for mental health professionals at our upcoming annual meeting. This meeting will be hosted on October 21st through 24th, 2010 in Vancouver, Canada. We look forward to bringing the mental health community up-to-date on all relevant research and known data for DCLS. For more information, please contact the DCLS workshop coordinator at (xxx) 299-0200.

Sincerely,

Richard J. Whitley, MD

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If only those were real HTML tags.

The most outrageous lies that can be invented will find believers if a man only tells them with all his might.

— Mark Twain

In 1996 the American Physical Society, responding to a request from the National Research Council, was asked to examine the potential health hazards of power lines. One of the concerns was that electromagnetic background fields of 2 milligauss might cause cancer (for comparison the earth’s magnetic field is 500 milligauss and fields generated by human physiological processes are hundreds of thousands of times less than 2 milligauss). Monitors of outdoor exposure for children to wear were marketed to parents. “Some city regulations sought to constrain B fields to less than 2 milligauss”. The report, which was a comprehensive study of the alleged dangers, included both molecular and epidemiologic studies and found that no adverse health effects could be attributed to these low fields.

One of the conclusions emphasized that physical calculations rule out carcinogenic effects because at physiological temperatures thermal noise fields in human cells are larger than the background fields from power lines.^{1, 2} Thus the political agenda, concerned with fear of carcinogenic mechanisms arising from low level magnetic fields, lost credibility. However, about 10 years later claims for health effects from mattress pads equipped with small magnets were marketed. A study of this was funded by National Institute of Health’s Center for Complementary and Alternative Medicine and claims for their benefits were published in alternative medicine journals.³

Some of the rationale for the claims were ludicrous. I attended one sales pitch which claimed their mattress magnets were better because they incorporated only North Poles. About  the same time, small 300 gauss magnets, began to appear on the shelves of drug stores. In 2007 a lawsuit brought by the National Council against Health Fraud against advertisers of these products was successfully settled. I was one of the persons who agreed to appear as an expert witness if needed. The Federal Trade Commission also threatened to prosecute purveyors who claimed healthful benefits for these products.

Amazingly, in the last few years the health and medical and nursing communities in their ‘integrated medicine’ outreach are now marketing the unsubstantiated claims that healing fields of 2 milligauss are emitted from the hands of practitioners.^4,5 This belief in distance healing, Therapeutic Touch, Reiki, and Qiqong cobble the language of physics with the language of physiology, misleading the patient. For example, in Therapeutic Touch the protocol requires that a therapist moves his or her hands over the patient’s “energy field,” allegedly “tuning” a purported “aura” of biomagnetic energy that extends above the patient’s body. This is thought to somehow help heal the patient. (Curiously, the rubrics never define what may happen if the practitioner is inept.) Although this is less than one percent of the strength of Earth’s magnetic field, corresponding to billions of times less energy than the energy your eye receives when viewing even the brightest star in the night sky, and is billions of times smaller than that needed to affect biochemistry, the web sites of prominent clinics nevertheless market the claims⁶ This belief has been published in the peer reviewed medical literature.⁷ Silence on this issue by the major scientific societies is a serious compromise of the scientific endeavors of those of us who work at the frontier of physics, medicine and biology.

The terms, energy and field, are used by alternative medicine practitioners, and integrative medicine physicians without any understanding of their meaning — their on-line and public lectures impart the pretense that fields are unknown philosophical constructs. Invited speakers at medical meetings at major academic institutions philosophize relationships between phenomena of many different magnitudes and sources, such as dark matter and biochemistry. The laws of quantum mechanics and electromagnetism are responsible for the biochemical bonding of molecules. Scientists understand that the discovery of dark matter is associated with the gravitational forces in our universe. No formulation of the properties of dark matter could have any observable effects between individual molecules in a cell.

What follows is a tutorial on fields:

Transmission of a force when objects are not in contact is represented by a set of vectors defined at all points in space which enumerate the direction and magnitude of the force. This set of vectors constitutes the field. There are four fundamental forces: gravitational, electromagnetic, weak nuclear and strong nuclear. Other fundamental forces have been looked for and not found. Scientists cannot rule out the possibility that science may one day find a new force field, but should such a discovery occur it will be through using the tools and methodology of science. Theorists understand that the strength of such a force must be much less than our weakest known force.

We live in a gravitational field which causes an object near the surface of the earth to fall with acceleration such that its velocity increases each sec by 32 feet per sec. Further out from our planet this number is less. Place signs with these numbers all over space and you have a picture of the field and its associated ‘action at a distance’ force. Knowing these numbers allows us to build rockets and satellites and explore outer space.

Similarly we know the numbers for electromagnetic fields. This allows us to build MRI machines. Ultrasonic imaging arises from us knowing the numbers at the level of cells to image the densities in tissues. We are constantly bathed in electromagnetic fields from communication devices.

Studies of equations for these forces and the enumeration of the strength of their fields underlie our current technology. When energy fields are used as a medium for conveying information, scientists ask and answer the following key questions: How large is the signal? What is the transmitter located in the source, and what and where is the receiver? How can the device be tuned and detuned? Lastly, how can one replicate this by a device to be used for medical intervention?

The alleged source of TT’s purported biomagnetic field is the practitioner, and the alleged receiver is the patient. Beyond this, TT practitioners fail to give detailed and plausible answers to the key questions above. TT practitioners’ adoption of the scientific term “biomagnetic” field, without an equation to describe the field and without any grounding in known physics and biochemistry, conveys the impression of scientific respectability to claims that have no scientific basis. Its claims are anecdotal and no measurements such as blood work or respiratory function are made.

I’m sure your ENT or GP would never suggest visits to a TT practitioner to cure a hearing loss. Practitioners of alternative medicine never recommend it as an  intervention for a condition that  has an easily measurable physiological response. The clinical trials using TT associated with the 1.8 million dollar NIH grant, which were to measure the health of women with cervical cancer, were completed in 2006 and 2007⁸ but a recent search using Clinical Trials .gov data base yields no reported results. Curiously, expert scientific opinion, and inventions using fields are welcomed by the evidence-based medical community but rejected by the integrative medicine community when this knowledge contradicts belief systems purported to be medically healing.

Notes

1. David Hafemeister, “Resource Letter BELFEF-1: Biological effects of low-frequency electromagnetic fields,” American Journal of Physics 64(8), 974-981 (1996).
2. Robert K. Adair, “Constraints on biological effects of weak extremely-low-frequency electromagnetic fields,” Physical Review A43(2), 1039-1048 (1991).
3. Static Magnetic Fields for Treatment of Fibromyalgia: A Randomized Controlled Trial
   Alan P. Alfano, Ann Gill Taylor, Pamela A. Foresman, Philomena R. Dunkl, Geneviève G. McConnell, Mark R. Conaway, George T. Gillies. The Journal of Alternative and Complementary Medicine. February 2001, 7(1): 53-64. doi:10.1089/107555301300004538.
4. A report detailing the current claims, authored by myself and Derek Araujo, was issued by the Center for Inquiry, on September 28, 2009.
5. “Healing Touch is performed by registered nurses who recognize, manipulate and balance the electromagnetic fields surrounding the human body, thereby promoting healing and the well-being of body, mind and spirit.” Scripps Institute website: http://www.scripps.org/services/integrative-medicine/services
6. Affiliated with Harvard Medical Center is Brigham Hospital’s Osher Center. Course offerings have featured Reiki: “During this class you will receive a reiki level one attunement. This attunement enables you to become a channel for this universal healing energy which will be with you for your lifetime. From this point on you will be a reiki practitioner. With level one reiki you will be able to do healing on yourself, friends, family and pets.” See http://hms.harvard.edu/hms/home.asp; see also http://www.brighamandwomens.org/medicine/oshercenter/
7. Journal of Orthopaedic Research 26(11), 1541-1546 (2008).
8. Clinicaltrials.gov NCT 00065091

About the author:

EUGENIE VORBURGER MIELCZAREK is Emeritus Professor of Physics at George Mason. Her experimental researches in materials science, chemical physics and biological physics have been published in The Physical Review, the Journal of Chemical Physics and the Biology of Metals. She has been a visiting scientist at the National Institutes of Health, and a visiting Professor at the Hebrew University of Jerusalem. She is a recipient of the Distinguished Faculty Award at George Mason University. She has advised National Public Radio, judged the U. S. Steel-American Institute of Physics prize for science journalism, and written book reviews for Physics Today. She was the primary editor of Key Papers in Biological Physics. She is the author of a popular science book, Iron, Nature’s Universal Element: Why People Need Iron & Animals Make Magnets. Her most recent article was a review of research frontiers linking Physics and Biology. In May 2009 she was honored by the Washington Academy of Sciences for ‘Distinguished Research in Biological Physics’.

Parts of this blog post also appeared in the April 2010 Newsletter of the Forum on Physics and Society of the American Physical Society

Red meat consumption has been linked to diabetes, cardiovascular disease, and several types of cancer (breast, colorectal, stomach, bladder, prostate, and lymphoma). There are plausible mechanisms: meat is a source of carcinogens, iron that may increase oxidative damage, and saturated fat. But correlation and plausibility are not enough to establish causation. Is red meat really dangerous? If so, how great is the risk? A couple of recent studies have tried to shed light on these questions, but they have raised more questions than they have answered.

A Systematic Review and Meta-Analysis

A new study in Circulation, “Red and Processed Meat Consumption and Risk of Incident Coronary Heart Disease, Stroke, and Diabetes Mellitus. A Systematic Review and Meta-Analysis,” by Micha, Wallace and Mozaffarian, is a systematic review of the literature. It analyzed 17 prospective cohort studies and 3 case-control studies, with a total of 1.2 million subjects. As far as I can judge, it appears to be a well-done systematic review with excellent methodology and multiple precautions. They even looked for things like publication bias (which they did not find).

They found that the consumption of processed meats, but not red meats, is associated with a higher incidence of coronary heart disease and diabetes. (Processed meats include bacon, sausage, ham, hot dogs, salami, luncheon meat and other cured meats.) The increased risk per 50 gram serving of processed meats per day was 42% for heart disease and 19% for diabetes. Unprocessed red meats were not associated with CHD and were associated with a nonsignificant trend towards higher risk of diabetes. They found no association with stroke, but this was based only on 3 studies.

They commented that

“…each of these individual studies has potential limitations, and our findings should be interpreted in that context. On the other hand, this represents the most complete worldwide evidence to date of the potential effects of red and processed meat consumption on incidence of CHD, stroke, and diabetes mellitus.”

A Large Study of Meat and Mortality

A 2009 study in the Archives of Internal Medicine, “Meat intake and mortality: a prospective study of over half a million people,” by Sinha et al., was more comprehensive in that it looked at many different conditions like cancer and cardiovascular disease, and it measured various causes of mortality as well as all-cause mortality.

The half a million subjects were 51-70 years old and were from various geographic locations in the US. They filled out a questionnaire that asked about their usual consumption of foods and drinks and portion sizes over the previous twelve months. Their diets were classified as high, medium or low risk meat diets based on the amount of red meat and white meat adjusted for energy, and they were split into two groups using median consumption as cutpoints. The study was prospective: it assessed diet first and then followed subjects for 10 years and recorded deaths and causes of death.

It concluded that red and processed meat intakes were associated with modest increases in total mortality, cancer mortality and CVD mortality.

In general, those in the highest quintile of red meat intake tended to consume a slightly lower amount of white meat, but a higher amount of processed meat than those in the lowest quintile. Subjects who consumed more red meat tended to be married, more likely to be of non-Hispanic white ethnicity, more likely to be a current smoker, have a higher body mass index, and a higher daily intake of energy, total fat and saturated fat; whereas they tended to have a lower education level, were less physically active and consumed less fruits, vegetables, fiber and vitamin supplements.

They found an increased risk associated with accidental deaths with higher consumption of red meat in men but not in women. It’s hard to know how to interpret that. They found an inverse association for white meat intake: it appeared protective against total mortality, but there was a small increase in risk for CVD mortality in men.

The overall hazard ratios for men ranged from 1.06 to 1.31 for red meat (increasing steadily by quintile of meat intake), .90 to.92 for white meat, and 1.01 to 1.16 for processed meats. The effect of red meat was greater than the effect of processed meats, which was opposite to the findings of the review in Circulation.

They tried to correct for confounders. In the process, they found an increased risk with white meat consumption among never-smokers and commented that the reason was not readily apparent. I suspect that the reason was that if you look at a large enough number of subgroups you can always find an occasional chance correlation that is meaningless.

Their data also showed that increased red meat consumption was correlated to smoking, lack of exercise, higher total calorie intake, higher body weight, higher total fat and saturated fat intake, lower intake of fruits, vegetables and fiber, and lower use of vitamin supplements. Could it be this constellation of factors, rather than red meat itself, that leads to higher mortality?

They estimated that

For overall mortality … 11% of deaths in men and 16% of deaths in women could be prevented if people decreased their red meat consumption to the level of intake in the first quintile.

I don’t think this can be determined from the data. They haven’t reliably ruled out all possible confounding factors and they don’t have any direct evidence that taking people with a high red meat intake and reducing their intake improves their longevity.

What about Vegetarians?

A recent study comparing vegetarians to non-vegetarians found that

…in comparison with regular meat eaters, mortality from ischemic heart disease was 20% lower in occasional meat eaters, 34% lower in people who ate fish but not meat, 34% lower in lactoovovegetarians, and 26% lower in vegans. There were no significant differences between vegetarians and nonvegetarians in mortality from cerebrovascular disease, stomach cancer, colorectal cancer, lung cancer, breast cancer, prostate cancer, or all other causes combined.

Meta-analysis of several prospective studies showed no significant differences in the mortality caused by colorectal, stomach, lung, prostate or breast cancers and stroke between vegetarians and “health-conscious” nonvegetarians.

In vegetarians, a decrease of ischemic heart disease mortality was observed probably due to lower total serum cholesterol levels, lower prevalence of obesity and higher consumption of antioxidants. Very probably, an ample consumption of fruits and vegetables and not the exclusion of meat make vegetarians healthful.

Conclusion

Epidemiologic studies based on self-reporting and recall are not the most reliable form of evidence. What are we to make of all the confusing data? The evidence is far from conclusive, but it suggests that it would be wise to limit our consumption of red meat. The evidence is not strong enough to support recommendations that we give up red meat entirely or become vegetarians.

Aristotle said “Moderation in all things.” Mom said “Eat your vegetables.” They were both right.

I’ve blogged a lot about anti-vaccine hero Andrew Wakefield over the years. The story has become long and convoluted, and to tell it takes a lot of verbiage, even by my standards (or those of Kimball Atwood). However, I’ve found a good resource that tells the tale of Andrew Wakefield and his misdeeds in a highly accessible form:

The question at the very end of the story is about as appropriate as it gets. Unfortunately, the answer to the question is: Yes.

In the world of the anti-vaccine underground, there is one time of the year that looms large. Over the last few years, this time has generally come right around the end of May, usually coinciding with the Memorial Day weekend and the unofficial beginning of the summer vacation season here in the U.S. I’m referring, of course, to Autism One, which blights one of my favorite cities in the world, Chicago, every year about this time. True, of late Autism One has been metastasizing, most recently to blight the city of Toronto and the very grounds of the University of Toronto itself. As you may recall, last fall, when Autism One descended upon Toronto, I described it as “a conference of believers in two things: (1) that vaccines cause autism and (2) that ‘biomedical’ and CAM/IM therapies can treat and even reverse autism,” and it’s true, but Autism One is more than that. It’s a combination of a networking meeting for the anti-vaccine set, a revival meeting for the cult of anti-vaccinationism and autism “biomedical” therapy, and a trade show for “biomed” treatments for autism, all dressed up to appear to be a legitimate scientific conference.

Of all the fake scientific conferences out there, Autism One in Chicago, which begins today, far eclipses all the others, including even Barbara Loe Fisher’s National Vaccine Information Center (NVIC) conference. Closely aligned with the anti-vaccine propaganda group Generation Rescue and its outlet in the blogosphere Age of Autism (both of which, not surprisingly, have been promoting the conference incessantly), Autism One is the granddaddy of fake academic autism conferences, where anyone who’s anyone in the anti-vaccine underground goes to see and be seen, with a keynote address by anti-vaccine celebrity spokesmodel Jenny McCarthy herself this year and each of the last two years. This year Autism One has expanded from three or four days to a full week, and it has taken on a note of political activism that was generally lacking in previous conferences. Consequently, in contrast to previous years, where Autism One pretty much stayed localized to a hotel near O’Hare, far from the center of the city, this time around it’s still at a hotel near O’Hare, but its organizers plan an anti-vaccine protest rally right in Grant Park on Wednesday afternoon. In doing so, this year Autism One’s organizers appear to be cementing the relationship between the autism “biomed” movement, the anti-vaccine movement, and the “health freedom” movement.

A cavalcade of anti-vaccine quackery

First and foremost, Autism One is about two things: “biomedical” quackery to treat autistic children (who are, according to many of the dubious practitioners there, autistic because of “vaccine injury”) and promoting the scientifically discredited idea that vaccines cause autism. In fact, this year, Autism One appears to have taken on the flavor of being in part one big “coming out” party for Andrew Wakefield, who somehow also managed to score an interview with Matt Lauer on Monday. Remember, this is the man whose dubious, incompetent, trial lawyer-funded, and probably fraudulent research back in 1998, aided and abetted by the credulous and sensationalistic U.K. press, not only sparked a hysterical fear of the measles-mumps-rubella (MMR) vaccine resulting in depressed vaccination rates and the resurgence of the measles in the U.K but is arguably the man most responsible for the very existence of the “autism biomed” movement itself. His shoddy and likely fraudulent research was the inspiration that launched a thousand — nay, thousands! — of “biomed” practitioners (a.k.a. quacks) to prey on autistic children. That’s why I thought it would be a useful exercise to take a look at the list of abstracts (just like a real scientific conference!) and make a few observations.

The first thing I noticed when I looked at the schedule is rather telling. I simply searched for the word “vaccine” and immediately noticed that for an autism conference there sure are a lot of references to vaccines! But what is Autism One telling parents about vaccines? What do you think? Let’s find out.

First up on the list is a speaker named Vicky Debold, who is giving a talk entitled What Parents Need to Know About Vaccine Adjuvants. Ms. Debold is described as:

…affiliate faculty member at George Mason University, Health Administration and Policy Department. She previously worked as a health policy analyst for the US Congress at the Physician Payment Review Commission, the Michigan Health and Safety Coalition, and the Michigan State Commission on Patient Safety. Additionally, she has served as an assistant professor at the University of Michigan and as an associate professor and director of the Health Systems Management Program at the University of Detroit, Mercy. Her doctoral degree is from the University of Michigan (1999) – from both the School of Public Health (Health Services Organization and Policy) and the School of Nursing (Health Systems Administration). She was a University of Michigan Regent’s Fellow and completed a post-doctoral fellowship in health services research at the Michigan Peer Review Organization. Dr. Debold’s son, her only child, experienced serious, long-term health problems following receipt of seven live virus and killed bacterial vaccines at his 15-month well-baby appointment. That event sparked her interest in vaccine safety and chronic childhood illness. In addition to serving as a director and committee member for autism non-profit organizations and as the volunteer director of patient safety and a board member of the National Vaccine Information Center, she is the appointed consumer representative to the Food and Drug Administration’s Vaccine and Related Biological Products Advisory Committee (VRBPAC).

Oh, dear. Not my alma mater! Not the University of Michigan! Isn’t it bad enough that Ann Coulter also graduated from the University of Michigan? In any case, of note Debold is a board member of the anti-vaccine organization NVIC. From her abstract, it looks as though Debold is trying to put a reasonable face on the anti-vaccine movement — at least on the surface. Her abstract sounds pretty reasonable until you hit this:

In addition to producing antibodies, vaccine adjuvants can stimulate the immune system to produce abnormal responses in some individuals leading to autoimmunity and chronic diseases such as rheumatoid arthritis and lupus.

I don’t have high hopes for the scientific accuracy of this talk.

Next up is Dr. Mayer Eisenstein. Dr. Eisenstein, as you may recall, has been mentioned several times on this blog, most recently just last week when it was pointed out that he is part of the team that writes anti-vaccine propaganda for the website Medical Voices Vaccine Information Center, the very same website that’s been dodging responding to Mark Crislip’s excellent takedown of one bit of MVVIC’s anti-vaccine propaganda. Dr. Eisenstein, as you may recall, is the founder of the crunchy “alternative” HomeFirst practice in the Chicagoland area. He is noted for claiming that there is no asthma, allergies, ADHD, ADD or Autism in its unvaccinated children based on zero published peer-reviewed evidence. In fact, Eisenstein himself has said:

Eisenstein stresses his observations are not scientific. “The trouble is this is just anecdotal in a sense, because what if every autistic child goes somewhere else and (their family) never calls us or they moved out of state?”

Yet his claim that he has 35,000 unvaccinated children in his practice and has never seen a case of asthma, allergies, ADHD, ADD, or autism in them is taken as Gospel truth in anti-vaccine circles. This time around, at Autism One, Dr. Eisenstein will be speaking on So You Have Decided Not to Vaccinate – How Do You Qualify for a Valid Legal Vaccine Waiver?, and the abstract reads:

Since vaccine mandates are state determined, vaccine laws may vary from state to state. Before submitting any medical, philosophical or religious exemption documentation, I recommend reviewing your state law to determine which of the waivers are applicable in your state. All 50 states in the U.S. allow for medical exemption to childhood vaccines. With the exception of West Virginia and Mississippi, all states also allow for a religious exemption to childhood vaccines. Currently, 17 states have philosophical exemptions to vaccines.

I will address the following questions: Can I give some of the vaccines and not others? Are there medical contraindications to vaccines? Can the state review and deny your physician’s letter objecting to vaccines? Are the chicken pox and rubella vaccines grown on the cells of aborted fetuses? Is mercury still in vaccines? How do I find a sympathetic doctor?

Of note, Dr. Eisenstein was recently in the news for having been an advocate of Mark and David Geier’s chemical castration protocol for autism, as well as a record of harm and death in his practice. And what do vaccines have to do with autism? In the real world, as far as science has been able to ascertain, nothing. In the fantasy world of Autism One, everything. Meanwhile, no form of quackery is off-limits at Autism One. In fact, there will even be homeopaths speaking there about how to use that quackiest of quackeries, homeopathy, to treat autism and “vaccine injury.” For example, two homeopaths named Cindy L. Griffin, DSH-P, DIHom, BME and Lindyl Lanham, DSH-P, BS Spec Ed, both from the Homeopathy Center of Houston, are collaborating to give two talks, one entitled An alternative approach for vaccine injury, which features homeopathy prominently as one of those “alternative” approaches, and another entitled The Houston Homeopathy Method of Sequential Homeopathy: A Drug-Free Alternative to Biomedical Treatment for Children with Autism.

Apparently even the magical thinking that is homeopathy is not too magical for the organizers of Autism One. And if that’s not enough, there’s a naturopath named Darin Ingels, ND (Not a Doctor) presenting on The Role of Allergy Desensitization in Autism, which makes Dr. Lipson’s post last week most timely, as well as another Not a Doctor, Jennifer Johnson, discussing Lymphatic Therapy – the Missing Piece. Get a load of the abstract:

Jennifer Johnson, ND, will speak on lymphatic therapy and how it is the missing link for autism recovery. She will include how lymphatic decongestive therapy prepares the body to be at its optimum level of detoxification prior to laser energetic detox. Also she will include how lymphatic decongestive therapy works in conjunction with the Zyto as well as how it complements IVIG treatment and chelation. This will be done with a slide-show presentation. This will be followed by a demonstration of the electro-lymphatic drainage machine and there will be time for questions and answers.

“Laser energetic detox”? “Lymphatic decongestive therapy”? IVIG treatment and chelation? Truly, no form of autism pseudoscience is too bizarre for Autism One, be it homeopathy or the woo-iest of woo from naturopaths!

Of particular interest to regular readers of this blog is this talk by Laura Hewitson entitled Primate Models for Testing Vaccine Safety. Having had her (and Andrew Wakefield’s) paper on this study withdrawn before officially appearing in the journal NeuroToxicology in the wake of the judgment of the British General Medical Council having found Wakefield to have committed research misconduct. Regular readers may recall that I deconstructed this study, in which Wakefield and Hewitson subjected infant Macacque monkeys to hepatitis B vaccination spiked with extra thimerosal, twice, once on the basis of a couple of abstracts presented at IMFAR and then once based on the actual manuscript describing the study results. Suffice it to say that this study was, in my not-so-humble opinion, bad science, unethical, and a waste of valuable and sensitive primates, who were all killed at the end of the study to examine their brain and organs, as well as to perform whole genome expression profiling on tissues harvested from the GI tract of the dead monkeys. Dr. Hewitson also failed to disclose on her initial abstracts that her husband worked for Thoughtful House and that she and her husband are the parents of a complainant in the Autism Omnibus petition to the Vaccine Court seeking redress based on “vaccine injury” having caused autism in the children involved. As a result of her association with Wakefield, which led to her descent into pseudoscience, Dr. Hewitson saw her once-promising academic career at the University of Pittsburgh tank and ended up joining Wakefield at Thoughtful House. Now that Wakefield has been fired from Thoughtful House, Hewitson remains there. She who once was the learner has now become the master, at least at Thoughful House, while Wakefield is on the outside looking in. Meanwhile, if your research is discredited scientifically, you can always present it at Autism One, as long as it appears to support the belief that vaccines cause autism.

Speaking of Andrew Wakefield, as I said before, Autism One appears to be his “coming out” party after the disrepute he fell into in the wake of the GMC’s ruling, the retraction of his infamous 1998 Lancet paper, and the withdrawal of his NeuroToxicology paper in which he abused baby monkeys by using them for bad science. First of all, he has a new book out entitled Callous Disregard: Autism and Vaccines—The Truth Behind a Tragedy. The title of a book is a play on this passage from the GMC’s ruling on Wakefield’s research misconduct: “You showed a callous disregard for the distress and pain that you knew or ought to have known the children involved might suffer.” Wakefield no doubt thinks that he’s being cheeky and sarcastic by appropriating those words for the title of his book, but the term “callous disregard” fits Wakefield like a glove. Of course, the book is getting rave reviews from the anti-vaccine crowd, but I have yet to see a review from a skeptic. I’m half tempted to see whether I could score a review copy, but after my attempt to read Suzanne Somers’ paean to cancer quackery last fall I’m not sure that would be such a good idea. You’ll notice that there was no part 2 to that series. My brain had a hard time handling all the misinformation there; it caused too much pain.

So what’s Wakfield up to at Autism One? First, he’ll be appearing on a panel with the editors of the anti-vaccine crank blog Age of Autism, where they will tag team a discussion of “AOA’s mission in the coming year and discuss with Andy how to continue to tell the truth about autism.” I can hardly wait. No doubt it will provide me and my fellow SBM bloggers with copious blogging material for the coming year. Then later he’ll be a keynote speaker, where he will discuss in a talk entitled Autism and the vagrant in the brainstem:

This talk examines the possibility that brainstem injury plays a central role in autism. In light of recent observations of brainstem injury in a primate model of vaccine-associated effects on early neurodevelopment, and an analysis of the scientific literature, it is proposed that, as an epicentric event, damage to the dorsal vagal complex (DVC) of the brainstem may be necessary and sufficient to initiate the central and systemic features of autism, including the many that fall outside the behavioral definition of this condition. Mechanisms by which primary systemic inflammation can cause brainstem damage are presented with reference to the published literature. The talk discusses the anatomical predilection of the DVC for injury resulting form a variety of mechanisms including disruption to the blood supply in the developing brain, environmental toxicity and, via retrograde vagal pathways, intestinal inflammation. Ways of examining this theory are discussed.

So now it’s “brainstem injury” due to vaccines, is it? I thought it was gut injury due to measles virus from MMR. Truly, Wakefield is a man with many dubious ideas.

Perhaps the most intriguing event where Andrew Wakefield will appear occurs on Wednesday. It is at this event where Autism One does us skeptics all a great service by demonstrating even more strongly than Jenny McCarthy’s “Green Our Vaccines” rally two years ago that it is about being “anti-vaccine,” not “pro-safe vaccine.”

The anti-vaccine movement “autism biomed” movement meets the “health freedom” movement

One of the biggest examples of either self-delusion or lying that emanates from the anti-vaccine movement is the oh-so-pious and indignant denials that inevitably follow from its members and leaders whenever someone like me has the temerity to point out that they are, in fact, anti-vaccine. The disingenuously angry denials usually take a form something like this, “I’m not anti-vaccine; I’m pro-safe vaccine.” Another variant is for anti-vaccine activists to claim that they aren’t anti-vaccine at all; they’re just “concerned” that children are getting “too many” vaccines “too soon.” What belies these claims, which can be seemingly reasonable on the surface to the uninitiated, is what happens if you try to pin down someone making them on just what, exactly, it would take to convince them that vaccines are safe as administered. A good way to approach this is to try to ask them to tell you specifically exactly what it would take to convince them to vaccinate their next child. What evidence would convince them? What you’ll almost inevitably find, if you push them, is that the answer to that question is: Nothing! Nothing will convince them. Ever!

On cue, seemingly trying very hard to support my oft-stated belief that “pro-safe vaccine” really equals “anti-vaccine,” and the “autism biomed” movement is in reality all about the vaccines, Autism One comes along to back me up. The reason I say that is that on Wednesday, May 26, associated with the Autism One quackfest, there will be a rally in Grant Park, an “American rally for personal rights.” Perusing the website, you’ll rapidly find out that the manifesto of the rally is about vaccines:

We believe in the rights to life, liberty, and personal security for ourselves and our children.

We demand the universal human rights standard of informed consent for all medical interventions. Compulsory vaccination cannot be legally and morally justified.

We affirm the sanctity of personal space, the right to be left alone, and the freedom to make personal health care decisions guided by the professionals of our choosing.

We invite all people, families and organizations committed to protecting these fundamental rights to stand with us in downtown Chicago on May 26, 2010 at our inaugural rally, and to work with us after the event to support grassroots advocacy, education, and leadership in defense of our personal – individual, parental, legal, moral, religious, civil, and human – rights.

Is it a coincidence that this rally is occurring smack dab in the middle of Autism One? Of course not! Is it a coincidence that, at the same time Andy Wakefield is “coming out” after his humiliation in January and February, as well as the impending loss of his medical license in the U.K. and that part of that coming out (not to mention promotion of his book) involves being the keynote speaker for an anti-vaccine rally? Get a load of the promotional video:

If you wanted yet more evidence that the “pro-safe vaccine” movement is really the anti-vaccine movement, here it is. But, wait!, I hear. It’s an entirely legitimate issue about how much power the government should have to require that children be vaccinated and under what circumstances. So it is. It’s a valid political and philosophical question, but a scientific question, not so much, given that the science is firmly behind the safety and efficacy of vaccines. Moreover, the whole “personal rights” bit is a smokescreen to hide the true nature of the rally: Anti-vaccine to the core. In reality, this “personal freedom” angle is very much the intellectual offspring (I think I just choked on the word “intellectual” in this context) of the “health freedom” movement. As I’ve said more times than I can remember, “health freedom” in reality is nothing more than the freedom of quacks to ply their trade on their marks without any pesky interference from laws, regulation, or the government. “Vaccine freedom” is little different at its core. It’s also profoundly deceptive for at least two reasons. First, by “informed consent,” American Personal Rights does not mean to give real, informed consent, with a science-based discussion of the benefits versus the risks of vaccines, which is overwhelmingly in favor of vaccinating being safer than not vaccinating. What such groups mean is an “informed consent” where parents are “informed” of all sorts of scientifically unsupported claims, such as the claim that vaccines cause autism, that they’re loaded with “toxins,” that the don’t work, that they’re dangerous, all coupled with a vastly exaggerated estimation of the rate at which true vaccine complications occur, which is very, very low. Second, except for two states, parents already have the freedom to decline vaccines. The only real enforcement point of our vaccination policy is admittance to public schools, virtually all of which require children to be up to date on their vaccines before they can attend. Even with that leverage, in nearly every state, there are mechanisms within the law to claim exemptions from vaccination requirements based on religion or even personal philosophy (17 states, as Dr. Eisenstein himself points out), the latter of which can be something as simple as saying that the parent has some sort of “philosophical objection” to vaccinating their children. In other words, this is a rally for a right that parents in nearly every state already have.

So why bother? Perhaps some of the literature on the website can tell us. First, let’s take a look at the organizations that are participating in the rally. The participants include a veritable who’s who of anti-vaccine cranks, including Age of Autism, Ginger Taylor, Dr. Sherri Tenpenny, Generation Rescue, the Holistic Moms Network, Medical Voices, Mike Adams, TACA, the Australian Vaccination Network, and many others.

For more evidence, let’s take a look at the suggested slogans for rally signs. I’ve selected a few out of the 100 or so slogans there. There’s lots of “freedom” rhetoric, but there are also quite a few signs that can only be described as pure anti-vaccine:

• 1% US Kids Autistic But Fully Vaccinated
• Adults Die From Vaccine Reactions, Too
• CDC Trades Infectious Disease For CHRONIC – Allergies, Autism, ADHD, Asthma, Diabetes…
• Doctors! Shame On You
• Doctors! You Took An Oath
• Greedy Pharma Calling The Shots
• H1N1 Was a TARP For Pharma
• I Refuse Forced Vaccines
• I Trust My Nurse. Why Don’t You?
• If My Child Is Harmed, You Won’t Pay
• I’m More Afraid Of The Vaccine Than The Flu
• My Child Was Murdered By Vaccines
• No Vaccine Liability! Total Immunity If Vaccine Kills You
• Schools Are Overrun With Vax-Injured Children
• Stop Experimenting On Our Kids
• The Ouch Isn’t What Hurts
• The Right To Be Left Alone
• Too Many Shots
• Too Many Sick Kids
• Why Does Our Government Want Us Vaccinated So Bad?

And my favorite: “There Are No Safe Vaccines.”

Finally, this particular rally has its very own soundtrack.

The American Rally for Personal Rights is pleased to announce that rally speaker Michael Belkin, will for the very first time ever, be performing songs from his upcoming CD at our rally. In 1998, Michael’s daughter died only hours after receiving a required vaccine, sparked by this intensely personal encounter with the negative effects of government mandated vaccines he began a journey of public service which has included providing testimony before Congress, attending vaccine related regulatory sessions and appearing in countless media reports as a vaccine safety advocate.

His journey has found a new path in The Refusers, a musical tribute to the victims (past, present and future) of the government’s misguided mandatory vaccination policy. Inspired by his previous career as a LA session player and recording artist, Michael has brought infectious elements of funk, gospel, rock, and even a touch of punk to this project. Combining this with his pointed lyrics discussing vaccine issues and government-mandated intrusion into our personal lives, The Refusers embodies, in the great American tradition of protest music, a sound that will be heard around the world. With lyrics like “they can keep their flu vaccine” and “a vaccine needle stole my baby away,” this record will have you on your feet shouting “keep your mandates out of my body”!

You think I’m joking? I only wish I were joking, but I’m not, and neither, apparently, is the American Rally for Personal Rights” or The Refusers. There are three songs listed there:

1. Get Your Mandates Out of My Body
2. Vaccine Gestapo
3. We Don’t Want Their Flu Vaccine

You can actually download these songs here. If you want an example of how anti-vaccine (not to mention inane) these songs are, here are the lyrics to one of them, “Vaccine Gestapo”:

They have swastikas on their shoulders
They’re such patriotic soldiers
They’re like a militia in Montana
They’re a government agency in Atlanta

Vaccine gestapo! Vaccine gestapo!
Vaccine gestapo! Vaccine gestapo!

They’re a medical military priesthood
Just like Adolf they preach the greater good
Consciencious objectors are just little snot
Why don’t you quit complaining and go get your shots

Vaccine gestapo! Vaccine gestapo!
Vaccine gestapo! Vaccine gestapo!

Can we see your papers
Have you had all your shots?
your papers please, your papers please
Have you had all your shots?

They’re got a one track mind of domination
They say vaccines are your obligation
If a bad reaction turns you into a vegetable,
They’ll sneer and tell you you’re expendable

Vaccine gestapo! Vaccine gestapo!
Vaccine gestapo! Vaccine gestapo!
Vaccine gestapo!

Let’s just put it this way: The Clash’s immortal classic “The Guns of Brixton” or “Police on My Back,” this ain’t.

I didn’t know whether to laugh or cry after I listened to this song. I also kept holding out hope that The Refusers were some sort of mischievous, clever parody of anti-vaccine nonsense. They aren’t. They’re dead serious. As hard as it is to believe, these lyrics are absolutely real and appear to be intended completely sincerely. Truly, the anti-vaccine movement has degenerated to the point where it is impossible to distinguish real from parody. Maybe I’ll claim another law (well, a corollary, anyway) and hereby name it the Gorski Corollary of Poe’s Law:

Without a winking smiley or other blatant display of humor, it is utterly impossible to parody antivaccinationists in such a way that someone won’t mistake for the genuine article.

Songs like this are impossible to parody. What was that again about Andrew Wakefield and J.B. Handley swearing to high heaven that they aren’t anti-vaccine?

Autism One: An anti-vaccine quackfest fused with the “health freedom” movement

It has been said that it’s impossible to reason a person out of a viewpoint that he has not reasoned himself into. The anti-vaccine world view is just such a viewpoint. There is no convincing (or even good) scientific evidence that vaccines cause autism or any of the other conditions attributed to them by the anti-vaccine fringe, and there is good scientific evidence that vaccines are effective at preventing the diseases for which they are designed and very safe. Serious vaccine injuries are not nonexistent, but they are rare. Again, the risk-benefit ratio for vaccines is overwhelmingly in favor of being vaccinated.

Generation Rescue, Age of Autism, and Autism One, as well as other anti-vaccine organizations, try very, very hard to paint their viewpoint as science-based. It is not. The question of whether vaccines cause autism or all the other conditions attributed to them has been extensively studied over the last decade, and the evidence shows that these vaccines are safe, the efforts of the anti-vaccine movement to discredit the research notwithstanding. The best that groups like Generation Rescue can come up with are incompetently performed non-studies, dubious telephone surveys that don’t show what they think they show, and unethical monkey experiments. When scientists and skeptics point out the utter intellectual and scientific vacuity of these “studies” and attempts to discredit existing science, often they are attacked in misogynistic terms (if they are female) or just smeared (if they are Steve Novella, Paul Offit, or others), sometimes to truly despicable extremes.

Unfortunately, the alignment of the anti-vaccine autism “biomed” movement with the health freedom movement is not unexpected. The two fit together perfectly, because the “health freedom” movement vigorously resists all attempts to regulate quackery and dubious supplements, while the anti-vaccine movement, because of its extreme distrust and loathing of vaccines and anything that smacks of a vaccine mandate, can fit its agenda comfortably with the supplement hawkers wanting to be able to make whatever health claims they like without any pesky interference from the FDA or FTC.

In the end, it’s not about vaccine “injury.” It’s not about autism. It’s not about science. It’s not even about “health freedom,” really, other than as a convenient political justification for wanting to end vaccine mandates that just happens to use libertarian rhetoric that resonates among many Americans. It’s about “bringing the U.S. vaccine program to its knees.” I know this because J.B. Handley himself, the founder of Generation Rescue and major force behind Age of Autism, tells us this is so.

Autism One and The American Rally for Personal Rights are just more of his propaganda tools to try to accomplish that end.

Naturopathy is an unusual chimera.  It is basically a collection of old fashioned medical superstitions presented under a veneer of highly speculative, quasi-scientific assertions.  But given its popularity, it is important, from time to time, to evaluate specific claims made by this particular non-science-based belief system.

A reader informed me that he was advised to seek the advice of a naturopath for treatment of his seasonal allergies.  Since naturopaths claim to be “doctors plus”, I was curious what they would recommend.  Would it be standard allergy treatment with antihistimines and other proven medications along with some sort of vitalistic mumbo-jumbo? It turns out I was half-right.

A visit to a national (US) naturopathic association website is a painful lesson in how naturopathic believers view health and disease.  No unfounded assertion would be complete without a good straw man.  Regarding the difference between real medicine and naturopathy, they say of allergies:

It’s a yearly ordeal for many people, and many others struggle with these symptoms year-round due to molds, dust, and pet dander. Pharmaceutical commercials offer a promise of living clear, but is a life of pills and side effects the only solution?
Far from it, say naturopathic physicians! Allergic symptoms are your immune system’s extreme reaction to substances that are normally found, harmlessly, in your everyday environment. Very often, simple changes of diet, nutritional supplements, and homeopathic remedies can relieve this extreme reaction and the resulting inflammation that triggers most allergy symptoms.

In fact, it’s a bit more complicated than that.  The pathophysiology of environmental allergies is pretty well understood.  Normally harmless antigens are taken in, processed, and presented to the immune system.  Plasma cells then crank out allergen-specific IgE which coats basophils and mast cells.  On re-exposure to the allergen, basophils and mast cells release a soup of mediators of allergic reactions, including substances such as histamine.  After this immediate (and unpleasant) reaction, a later reaction involving other inflammatory mediators kicks in.

The best way to fight allergies is to avoid the offending allergen, but for many of us, this isn’t possible.  Treatments are based on the underlying pathophysiology.  Antihistamines help fight the unpleasant effects of histamine release, including sneezing, itching, and runny nose and eyes.  Unfortunately, they do little to prevent the release of histamine in the first place and some have significant side-effects.  The oldest anti-histamines, such as diphenhydramine (Benadryl) can cause sedation and dry mouth.  Newer antihistamines cause very little sedation and are quite effective.

There are also medications to help prevent degranulation of mast cells, preventing the histamine from being released in the first place.  These “mast cell stabilizers” can be very effective in preventing allergy symptoms, as long as you take it regularly.  Steroids sprayed in the nose can help with many of the symptoms, usually without side effects, and leukotriene inhibitors can also help blunt the immune response and improve symptoms.  These medications are very well-tolerated, safe, effective, and are based on what we know about the pathology of allergies.

The naturopaths offer something else entirely.

Red meat contains a substance called arachadonic acid, which helps to produce the cytokines and leukotrines that cause your immune system to react with allergic inflammation. While you need a small amount of arachadonic acid for your immune system to function, your body can produce this amount naturally. Simply eliminating red meat from your diet can reduce the level of this acid, thus lessening your allergic reactions.

This speculative assertion has no data supporting it.  It is an interesting supposition, but implausible and unproved.  It is unlikely that any dietary modification could reduce a substrate of allergic reactions enough to give relief of allergies.

They also recommend omega-3 fatty acids.  There is very little clinical literature on the topic.  A recent review of the use of omega fatty acids in allergy prevention found that despite some promising in vitro studies, there was no significant clinical benefit.   They also recommend turmeric, papaya, and pineapple, none of which have been shown to be effective treatments for allergies.

There next piece of advice is to toss money away:

For Best Results – Supplement!
A healthy organic diet low in Omega-6 fatty acids and high in vitamin E, Omega-3 fatty acids, and natural anti-inflammatory foods can help to reduce your allergy symptoms. However, your best bet is to supplement your diet with concentrated doses of anti-allergic nutrients such as those listed below:

• Vitamin C (up to 10 grams/day) is a natural anti-histamine;
• Vitamin B5 (up to 800 mg/day);
• Zinc picolinate (up to 150 mg/day); and
• Cod Liver Oil or other cold-water fish oil (look at the label and use a high quality fish oil product containing from 1000 – 2000 mg of the essential fatty acids EPA + DHA per day).

Once again, none of these assertions is backed up by evidence.  Most of it isn’t even promising enough to bother with.  But they really hit it out of the park with their final recommendations.

Homeopathic remedies involve taking an extremely diluted form of selected allergens in liquid or sugar-pill form sublingually (under the tongue). These miniscule doses serve somewhat like a vaccination, stimulating your immune system to an effective rather than extreme response.

Vaccination is to homeopathy as horseback riding is to unicorn wrangling.  First of all, vaccination, while sometimes used as immunotherapy and immunoprophylaxis, is not used to treat type I hypersenstivity, the cause of seasonal allergies.  Immune desensitization is used.  Desensitization uses small but measurable amounts of allergen to induce tolerance and prevent an allergic reaction.  There is nothing homeopathic about it.

They go on to mention liver detoxification, gut flora “balancing”, and chiropractic as useful treatments for allergies.

Naturopaths, it would seem, are not “medicine plus”, but “everything but.”  Since they do not use proven, effective therapies, the throw unproved, implausible therapies at their patients perhaps hoping that when the allergies relent as a natural course of the disease, they might finally claim credit.  That’s what all the best shamans do.

The Institute of Medicine report is a frequent ‘rebuttal’ to science based/real medicine. The argument is usually phrased something to the effect that since medicine can be dangerous, SCAM’s are legitimate. Of course, one does not follow the other. It is the equivalent of saying since you are old, bald and pudgy, I am young, have a full head of hair, and are thin. If every doctor and hospital were to vanish tomorrow like an episode of the Outer Limits, SCAM’s would be just a ineffective.

Despite the flawed logic of the comparison, I have always had an affinity for the estimates that 44,000 to 98,000 were (note the deliberate use of the past tense) killed each year in hospitals. There may be methodological flaws in the estimate but the ballpark figure is probably correct.

In 1999 there were 5000 hospitals in the US. Just one death a quarter would bring the number of deaths to 20,000, and one death a quarter is not that many deaths. Lest I sound hardhearted, everyone dies, 2.5 million a year, and often death occurs in the hospital. Against the background of the mortality of existence, a few ‘extra’ deaths would be lost in the background.

For an individual doctor, it would be indistinguishable against the background death rate in the hospital. What makes it even more difficult to track and recognize excess mortality is that each death may be due to a different breakdown in medical practice.

Amongst my many jobs is Infection Control. For twenty years I have chaired Infection Control for both the Legacy Health, a collection of 5 hospitals in the Portland-Vancouver area, as well as for Portland Adventist Medical Center. As Chair I get the joy of sitting on many other committees such as Quality Council and Pharmacy. I know all the way hospitals could kill and the endless efforts to try and improve and perfect medical practice to avoid these complications.

In 20 years of investigating outbreaks, hospital acquired infections, and deaths, I have yet to see two infection related deaths that are due to same cause. Every infection was reviewed and evaluated as a potential for improvement, and I think we practiced the best medicine we knew of at the time.

With one exception, the universal horse shit compliance with hand washing that was the norm 20 years ago. It always boggled my mind that it was difficult back in the day to get people to wash their hands. The information on efficacy was only 150 years old, after all. But otherwise we practiced state of the art medicine. With the perfect vision of hindsight, I can see that state of the art left much to desired. We didn’t have the studies to guide practice that we have now, and I anticipate that 20 years from now I will be rolling my eyes at how we practiced in 2010. I will sound just like Bones McCoy wandering throughout a 1980’s San Francisco hospital grumping about the butchers of the past and hoping I do not run into T.J. Hooker.

Unlike the hodgepodge of practices that comprise SCAM, medicine changes and mostly for the better. Change is always slow, and always painful, and more difficult to implement than one could ever anticipate, but if you read the medical literature, you have to change.

Hospital based medicine is mind bogglingly complex and difficult, and humans are limited in their ability to always function perfectly. The Institute of Medicine knew what it was doing when they entitled their report “To Err is Human.” And all too often we were not able to pinpoint a breakdown that lead to a complication or death

When I started practice back in the last century, I would have thought that hospital acquired infections were part of the price of taking care of ill and compromised patients. Sure, we can minimize infections, but wound infections, ventilator pneumonias, and line infections are going to happen. You can’t do the things we do to people and NOT get an infection.

Right?

Wrong.

What both administrations at my hospital systems have in common is a commitment to patient safety and over the last decade they have committed considerable time and money to the application of proven procedures to decrease infections and other complications of hospital care.

You cannot know best practice based on individual experience. I like to tell the residents that the three most dangerous words in medicine are “In my experience.” You need large numbers of patients and studies to guide practice. The last 15 years have seen a large number of clinical trials aimed at discovering what is the best practice to prevent everything from line related infections to deep venous thrombosis. Dozens of science based investigations whose goal was to improve patient care in the hospital, and my hospitals aggressively applied them.

The first intervention was the use of alcohol foam instead of hand washing. I have in my mind, and cannot find the reference, that if a nurse would wash her hands appropriately after every contact, he would spend 80% of their shift washing hands. Soap and water, it turned out, was not a practical solution to keeping hands clean. It is too time consuming in a busy work day, despite it’s proven efficacy in preventing infections.

Alcohol foam can be used in a fraction of the time with superior results since it is much easier to foam frequently. And once I discovered it was not to be used orally like cheese whiz, the results were even better.

The foam is now ubiquitous in the hospitals. Even when the use of the foam was 20%, the overall infection rate in the hospitals fell by half when compared to rates with hand washing. Then, over the next decade, the hand hygiene compliance rate has steady increased to around 90% and there was a corresponding steady decrease in infections. It took over a decade of consistent work and a lot of trial and error to get the rates to 90%.

At one hospital the limiting problem was no foam outside the rooms. No one would walk an extra few feet to get to the foam. But at another hospital the fire Marshall said alcohol foam in the halls was a fire hazard and we could not put alcohol in the halls. He was eventually overruled, but what are you going to do in the meantime?

And I could go on for paragraphs about the issue of finding product that minimized the number of HCW’s whose hands where turned raw by the alcohol.

Ninety percent seems to be the best we can consistently achieve with the current program for hand hygiene, and we are puzzling over how to get the rates to 100%. One approach is the “It’s ok to ask” program, where patients are encouraged to ask their provider if they washed their hands. I asked a series of patients if they would ask, and they uniformly said no, they did not want to risk angering their health care provider. I agree. It is important not to piss off the person providing your morphine. Besides, would you fly on an airline if their motto was “It’s ok to ask if the landing gear is down.”

Last year I ran a red light. It was 7 am, I was taking the kids to school and I have to make a right then an immediate left across four lanes of traffic. I make this turn everyday. I am talking to the kids and I look several times, no traffic, and make the turns.

What I did not see was that the light was red nor did I see the cop stopped on my left. I was so intent on the traffic I missed two key features in my environment.

It is the main reason, I suspect, that we cannot get hand hygiene to 100% every time, every where. The hospital has too many opportunities to focus our attention elsewhere that, for the short term, allows us to forget to foam.

Somehow, and I do not know how, I suspect we need to make foaming the default rather than optional; then our rates will get to 100%.

But foam is not the only intervention my hospitals have implemented.

Surgical check lists, best practice bundles (collections of proven interventions gathered together) to prevent ventilatory pneumonias, to prevent intravenous catheter related infections, to prevent urinary tract infections, to prevent deep venous thrombosis. Innumerable checks and balances with pharmacy to prevent medication errors.

Simple things to prevent surgical wound infections but logistically difficult to get to 100%: timing of antibiotics to within an hour of cut time, no shaving the surgical site, not letting the patent get cold post op, and tight glucose control were are associated with decreased wound infections. Next up may be no staples with orthopedic cases as a recent meta-analysis demonstrated fewer infections with sutures. That will be fun, getting surgeons to alter practice.

Over the last year my hospitals have implemented dozens of practice improvements based on the medical literature to improve outcomes and the results have been amazing. Practices that were not effective were abandoned or modified, sometimes going through multiple iterations until were discovered was worked and was practical.

As a result, at Legacy we have prevented over 200 deaths (12.5% reduction in non-risk-adjusted mortality rate, which is now 1.47% for our system that includes a regional trauma center and regional burn center as well as two NICUs, oncology program, and multiple other high-risk programs) and over 570 prevented infections (39.5% reduction in whole-house infection count) above historical data. And that is over the most recent 24 months. At Legacy it is estimated we have also saved 8 million dollars in associated costs.

A few of the hospitals have gone a year without a ventilator associated pneumonia or a catheter related infection. Every year has seen a decrease in the healthcare associated infections and other complications.

That is 100 deaths prevented a year for 5 hospitals. Multiply that for the remaining 4,995 hospitals in the US and the IOM estimates for last century seem reasonable. But not for this century and not for the decades to come.

I used to think that infections were inevitable, but no longer. There is the occasional patient who will get an infection: the badly burned, the multiple trauma. But even the trauma ICU had a marked decrease in all infections with increased infection control compliance. We had a wound infection in a 400 lib patient who literally had dirt tattooed in the palms and soles and a Hemoglobin A1c of 15 who required emergency surgery. I was not surprised that patient developed an post-op infection. We did everything correctly and still had a complication. Sometimes the barriers we have to overcome to prevent infection may be too great, but it does not stop us from trying.

But the experience of Legacy and Adventist demonstrates that aggressive adherence to proven infection control works and that the majority of health care associated infections and deaths need not happen.

I have three epiphanies in my life: my first great meal (at a restaurant called St. Estephe’s), my first great Bordeaux (oddly enough, a St. Estephe’s), and when I realized that most infections in the hospital need not happen.

This has been a real decrease in infections and death, not just playing with numbers to look better. These hospitals look at every healthcare associated infection (HAI) as an improvement opportunity and do not sweep data under the rug.

I also know personally that the numbers are real. I used to derive a significant portion of my income from hospital acquired infections. There are many reasons why my income has declined by 60% over the last decade, not the least of which being large numbers of patients that used to make up my practice (HAI’s, AIDS) have disappeared. The majority of those 570 prevented infections would have been consults. I feel like Phillip Morris making stop smoking ads.

It was not easy making these changes; it took years of committed work. People are like oil tankers and change course slowly. And some are filled with toxic waste. An interesting aspect of instituting the policies and procedures has been who fought against the changes the hardest. Docs. Not all of them, just a small subset. There is a curious subset of MD’s who feel that the data does not apply to them. They do not need to follow infection control procedures, use full barriers when placing a line, or even wash their hands. And I do not get it. I cannot figure out why some docs are so recalcitrant about doing the right thing, the proven thing. Eventually everyone complied, but some people made it more painful than it needed to be.

My hospitals made a serious commitment to providing the best care as determined by the science. It was not simple and required a surprising amount of creativity and time to apply the evidence to the real world. But the nice thing is that when you apply science to problems, you get results. Science works. Quality initiatives work. Next time you point out the deaths caused by modern medicine, leave my hospitals out of it.

It makes me wonder. There are numerous naturopathic, chiropractic, and other alternative schools and clinics involved in patient care. I am sure that they too have numerous quality improvement studies to brag about that have improved patient care and outcomes.

Think of all the practices in medicine that, eventually, have been demonstrated to be worthless, or dangerous, or flawed and that were improved or abandoned for the betterment of patient care.

So let’s start a list, shall we. The following is the top 10 list of alternative medical practices that have been modified or abandoned because of studies that demonstrated they were ineffective or dangerous and the quality initiatives that have improved patient care:

1) Disposable acupuncture needles (thanks to wales)

2)

3)

4)

5)

6)

7)

9)

10)

Sorry. I found nothin’.

Perhaps it is a reflection of the perfection that is alternative medicine. Alternative medicine practices change based on evidence? No need.

Of course, I may well be wrong. As the board president of the Oregon Association of Naturopathic Physicians states, “Both MDs and NDs are trained to work from the evidence-based model of medicine, using best practices and standards of care.” I suppose my inability to find examples is due my inadequate Google and Pubmed skills to find the readily available information. I would have my 13 year old do it for me, but he is on a trip. Even if only 25% of medicine is science based, that is still 25% more than alternative practices.

Please, please, please, someone show me up. Hell, just give me some hand hygiene improvement data and let me know that, if nothing else, there is an understanding of germ theory in the alt med world. Ever since my local paper, the Oregonian, printed a picture of the local Natural Medicine School teaching acupuncture without gloves, I am not so sanguine about that understanding. It still gives me the willies to see that photograph and it looks for all the world that there are two boxes of gloves in the background, so I know they have them. It may be that all the gloves are left handed or right handed and so cannot be worn. Sometimes I pull out a glove for the right hand and it is a lefty glove and then I pull out a glove for the left hand and it is a righty, so I cannot find a pair to wear. It’s a problem.

Medicine slowly improves, too slowly sometimes. I know that 20 years ago we did not have the information to inform our practice that we do now. We did the best we could with what we knew at the time, and we do the best we can now with the information we have today. Still, despite the impressive improvements, it is a bittersweet victory. I can’t help but think what could have been, if only we had known.

For SBM readers in the Toronto area, I’ll be speaking on Friday, May 28, at the Centre for Inquiry on how science advocates can help support better health decisions:

Despite the dramatic improvements in the extent and quality of our lives, largely owing to modern medicine, our current health care system has fostered a backlash, manifested in part by the emergence of non-science-based “alternative” health care practices. This trend has driven a need for dialogue on how best we should balance evidence-based decisions against demands for consumer choice – regardless of the science. In this presentation, Scott Gavura will discuss how health care decision-making differs from other goods and services, and how this impacts on the choices we make, both as individuals, and in aggregate. Through an interactive discussion, he will facilitate a dialogue on the opportunities for science advocates to effect positive change in health at the patient- and population-level.

Science advocates have the evidence to support their positions. How do we translate this evidence to support effective decision making? On May 28, join the conversation.

Get the event details, and you can RSVP on Facebook. The talk is great value-for-money: $5, $4 for students, and free for CFI members.

About a week and a half ago, the ever-ascerbic Mark Crislip applied his dry and devastating wit to a particularly silly bit of anti-vaccine propaganda from an anti-vaccine website, Medical Voices Vaccine Information Center (MVVIC). The anti-vaccine propaganda was entitled 9 Questions That Stump Every Pro-Vaccine Advocate and Their Claims and was written by a naturopath named David Mihalovic. The article was an incredibly — shall we say? — target-rich environment full of logical fallacies (including straw men built to Burning Man dimensions at which Mihalovic aimed a flamethrower of burning ignorance and let loose with napalm-grade flaming nonsense), misinformation, and cherry picking. Dr. Crislip entitled his rejoinder, appropriately enough, Nine Questions, Nine Answers, and his methodical, oh-so-sarcastically complete deconstruction of Mihalovic’s deceptive and disingenuous “nine questions” showed that these questions stump no one who knows what they are talking about when it comes to vaccines. These “nine questions” also reveal an ignorance of vaccines so deep that the strongest bathysphere probably couldn’t withstand the pressure at that depth. After reading Dr. Crislip’s post, truly, I had to bow to the master. I may be capable of some fairly awesome insolence at times, but I’m hard-pressed to keep up with him when he’s on.

Being the ever-benevolent editor that I am and, as such, very proud of Mark’s effort, I decided that common courtesy would suggest that it would be a good idea to send a friendly note to those behind Medical Voices, you know, to let them know that their article had been appreciated for its entertainment value. Well, maybe it wasn’t so friendly. I do recall using the words “nonsense,” “pseudoscience,” “misinformation,” and “despicable” somewhere in the mix. Antivaccine pseudoscience tends to bring that out in me, and it wasn’t a blog post, at least not on SBM. Be that as it may, over a week went by with no response, and I thought that we were being ignored. Oh, well, I thought, no big deal and nothing unexpected. Then, Monday morning, I found this e-mail in my in box from someone named Nick Haas:

Hello Dr. Gorski,

Would you like to debate on vaccines live and publicly over the Internet? You just need a computer and a headset. We could have two medical doctors on each side. We’ll figure out a moderator together.

Nick

A “live” debate. What is it with “live debates”? It seems that cranks always want to challenge those who criticize their misinformation and pseudoscience to “live debates.”

I perused the MVVIC website and quickly figured out who Nick Haas is. He’s listed as the president of something called the International Medical Council on Vaccination, which counts on its board of directors such anti-vaccine luminaries as Sherri Tenpenny, DO; Mayer Eisenstein, MD, JD, MPH; and Harold Buttram, MD, among others. Of note Buttram is the doctor who claims that shaken baby syndrome is a misdiagnosis for vaccine injury. Nick Hass, it turns out has this background:

Nick’s background is in sales and logistics. He is president of Medical Voices Vaccine Information Center. Nick earned his Bachelor of Arts degree from Carthage College in 1998, majoring in both business administration and Spanish. Nick became interested in vaccines when he and his wife became pregnant. He was shocked as he learned about the true risks of vaccines, that their efficacy is grossly overstated, and that vaccines in fact are not responsible for disease eradication. After studying thousands of pages on vaccines and deciding he needed to get involved, Nick founded MVVIC, with all medical doctors on its boards. The organization gladly claims responsibility for sparking the interest of physicians and the public alike, leading them to the truth they did not learn in medical school or from their doctor. Nick and his wife Ana are parents of one unvaccinated son and live in southeast Wisconsin. Nick is not a healthcare provider.

Interestingly (to me at least), there was nothing there about Mr. Haas having a child with autism and viewing the autism as due to “vaccine injury,” which is the usual case for activists of this type. Still, it would appear that Mr. Haas is, like Jenny McCarthy, a graduate of the University of Google who thinks his Google knowledge trumps the science, epidemiology, and the knowledge of scientists who have spent their entire professional lives steeped in immunology and vaccine science. In any case, I had a hearty chuckle after reading the above and forwarded Nick’s message to the rest of the SBM crew, proposing a response. While I waited a day or so, apparently Mr. Haas was growing impatient, because a mere 13 or 14 hours after the first e-mail, I found this in my e-mail in box:

Greetings:

I am CCing all of you to respect your privacy. Each of you has contacted International Medical Council on Vaccination apparently because of the request Dr. David Gorski made that you do so in the comments section of an article published at sciencebasedmedicine.org. One of those who contacted us – and who is included on this e-mail – is Dr. David Gorski himself. While we’ve written off past attacks, we feel we have to respond to the direct challenge made (comment by David Gorski on 07 May 2010 at 8:17 am).

We would like to do much better than provide a refutation of one article on our site. I have sent Dr. Gorski an e-mail (see below) asking that he participate in an open debate via Internet. We would provide the forum and it would be open to the audience without charge, using a mediator both parties agree on.

I am sending this e-mail to all of you so as to provide further incentive for Dr. Gorski to acknowledge that we have responded and to further provide incentive that the sciencebasedmedicine.org crew accept the invitation to a public debate. We also ask that sciencebasedmedicine.org immediately post an acknowledgement of this offer in the comments section of the article. Please feel free to e-mail Dr. Gorski (gorskon@gmail.com) and ask him about his intentions.

Nick Haas

International Medical Council on Vaccination

I particularly like the part about wanting to do “much better” than providing a refutation on the MVVIC website. In actuality, the demand for a “public debate” is a favorite ploy of cranks everywhere. In fact, I’ve seen it used by every variety of crank I’ve ever encountered online, including alternative medicine supporters, anti-vaccinationists, HIV/AIDS denialists, Holocaust deniers, 9/11 Truthers, and believers in ghosts and the paranormal. In particular, I remember a woman named Casey Cohen trying to convince me to take part in a debate with Christine Maggiore a couple of years ago and then declaring victory when I declined.

Deborah Lipstadt, the renowned Holocaust expert who was sued by Holocaust denier David Irving back in 2000 for referring to him as a Holocaust denier in her book, Denying the Holocaust: The Growing Assault on Truth and Memory. Let me make one thing clear before I proceed: in using the example of Holocaust denial, I am not calling Mr. Haas or anyone associated with MVVIC a Nazi or anti-Semite. However, the techniques of dealing with evidence by anti-vaccinationists so resemble the techniques of Holocaust deniers that the comparison is hard to avoid, although difficult to make because of the toxic nature of even mentioning Holocaust denial. (In fact, I’ll also make a prediction: if Mr. Haas or anyone from MVVIC responds to this post, they’ll willfully misinterpret my use of the example of Holocaust denial as an example and complain that I’m calling them Nazis, bigots, or anti-Semites. I almost guarantee it.) In any case, Professor Lipstadt has stated clearly that she does not debate deniers and used the most apt simile I’ve seen about debating denialists, “Debating a denier is like trying to nail a blob of jelly to the wall.”

There are a number of compelling reasons why it is pointless at best and counterproductive at worst to debate a denier, denialist, crank, or whatever you want to call it. For one thing, for a debate to be an intellectually useful exercise, there should be two reasonable points of view being argued, points of view that have a sufficient amount of evidence to support them that it is not unreasonable to hold either view being debated. The evidence doesn’t have to be of equal quantity and quality on each side, of course, but it should at least be somewhere in the same ball park — or on the same planet. This isn’t a rule that is limited to just Holocaust deniers, either. Vaccine denialists (a.k.a. anti-vaxers), evolution denialists (a.k.a. creationists), scientific medicine denialists (a.k.a. alt-med mavens), HIV/AIDS denialists, or 9/11 Truthers, they all fall into this category. All of them desperately crave respectability. As much as they disparage mainstream thought in the disciplines that they attack, be it medicine, vaccines, history, or current events, they desperately crave to be taken seriously by the relevant disciplines. Being seen in the same venue, on the same stage, or on the same media outlet with relevant experts as an apparent equal gives them just what they want.

And some of them are really good at being the jelly that you can’t nail to the wall.

So, with the permission of Steve Novella and Mark Crislip, on Tuesday morning, I responded:

Mr. Haas,

You appear to have misinterpreted my intent. I was not challenging you or your writers to a public debate; I was simply making you aware of an excellent refutation by one of our bloggers of some egregious misinformation that one of your alleged “experts” has published on your website. We do not “debate” anti-vaccinationists. We use our blog to refute their misinformation. That is one reason why Science-Based Medicine exists.

Medical science is not decided by “public debates.” It is decided by evidence, experiments, and clinical trials. Fortunately, the vast preponderance of evidence is against the contentions that vaccines cause autism, that vaccines are somehow more dangerous than the diseases they prevent, that vaccines are loaded with “toxins,” or that they are ineffective, all arguments your “expert” made. Certainly your website does not provide any scientifically compelling evidence to refute what our blogger Dr. Crislip wrote. Even if we at SBM found publicly “debating” anti-vaccinationists to be anything other than a complete waste of our time, I have to be honest here: If your writer Mr. Mihalovic can’t even get some very basic scientific facts correct (or even find easily locatable studies using PubMed, as Dr. Crislip so amusingly showed), a “debate” with him would be even more pointless than usual attempts to debate anti-vaccinationists. (Google ‘Gish Gallop’ for one reason why.)

You or Mr. Mihalovic are, of course, more than welcome to respond in the comments of Dr. Crislip’s post or to try to refute him with evidence on your own website. We do not, however, feel obligated to give his views additional credence by doing an online debate.

David Gorski, MD, PhD
Managing Editor, Science-Based Medicine

Cc: Steve Novella, Mark Crislip

Mr. Haas was not pleased, and later on Tuesday I received this e-mail, again apparently sent to some sort of MVVIC mailing list and cc’d to Steve, Mark, and me:

Greetings: I have BCCed those of you who contacted International Medical Council on Vaccination regarding the Nine Questions article. Sciencebasedmedicine.org has declined giving us the opportunity to defend their attack via an open debate.

We consider ourselves to have done better than their and your request for a response. They have not done as much as acknowledge our reply where they have the article posted. They tell security to not let the other team in the arena and then pronounce themselves the winner to the fans.

This issue is closed; hence, for us. I won’t be replying to anything other than an acceptance on sciencebasedmedicine.org’s part — an acceptance that will never come — to debate the science live, open and fairly.

Thank you for having contacted International Medical Council on Vaccination.

Nick Haas
IMCV

Bottom line: We denied Mr. Haas his preferred forum, and, because he can’t refute what Mark wrote, he and his merry band of anti-vaccine propagandists retreated in a most ignominious fashion. However, being the ever-benevolent editor that I am, I thought I’d be remiss if I didn’t acknowledge Mr. Haas’s reply where Mark’s article was posted, which is exactly what I’m doing now by writing this post. I’m acknowledging his “offer.” I’m also pointing out that his excuse not to respond to Dr. Crislip’s refutation of their propaganda piece is transparently obvious:

When science reared its ugly head, MVVIC bravely turned its tail and fled.

The issue of whether to debate cranks like anti-vaccine propagandists is a question that comes up perennially in skeptical circles. I personally come down on the side that it is a pointless, no-win exercise for skeptics, although some, even those who mostly agree with the contention that it is pointless to debate pseudoscientists, sometimes relent because a lot of pressure is put on them. It’s still a bad idea the vast majority of the time, and most skeptics who have participated in such “debates” (pseudodebates, actually) usually have at least an inkling that it’s a bad idea when they agree to do them. Some skeptics agree, but these are generally the ones so good at debate that they are not troubled overmuch by the Gish Gallop. Truly, though, these are the elite skeptics. Disagreements over tactics aside, as Steve Novella pointed out in our e-mail exchanges, live debates are a terrible forum for science. Written discussions are much better. That is what Mark Crislip did by writing his excellent detailed, question-by-question response to each of Mihalovic’s “nine questions” that supposedly “stump” everyone. That is how the published scientific literature works. Either Mr. Mihalovic, Haas, or any of the members of MVVIC are, of course, free to respond in writing as well, either in the comments of Mark’s original post or on the MVVIC website — or whatever website they desire.

I’ll finish by reiterating and expanding a bit on what I wrote in my e-mail to Mr. Haas: We do not “debate” pseudoscientists, anti-vaccinationists, and purveyors of dubious medical treatments. We use our blog to refute their misinformation and hopefully educate the public. That is one reason why Science-Based Medicine exists. Another reason is (sometimes, at least) to entertain while we educate.

Of course, it’s fun, too, particularly e-mail exchanges with readers like Mr. Haas. Who knows? Maybe he or one of his “experts” will now take a crack at refuting Mark’s post. In the meantime, I’ve encouraged my fellow SBM bloggers to pick an article from the MVVIC website and give it the Mark Crislip treatment.

This is a science and medicine story we have been following for a while – out of personal and scientific interest, and the need to correct confused or misleading new reporting on the topic. Are cell phones linked to an increased risk of brain cancer or other tumors? New data are reassuring.

David Gorski and I have both written on this topic. To give a quick summary, there is no convincing data to link cell phone use and brain cancer. Epidemiological studies have not found an increase in the incidence of brain cancer following the widespread adoption of cell phones in the mid 1990s – as one would expect if there were a causal relationship. Further, large scale studies have not found any consistent correlation between cell phone use and brain cancer.

It is clear from the literature that there is no measurable increased risk from short term cell phone use – less than 10 years. There is no evidence to conclude that there is a risk from long term use (> 10 years) but we do not yet have sufficient long term data to rule out a small risk. Further, the data is somewhat ambiguous when it comes to children – still no convincing evidence of a link, but we cannot confidently rule out a link.

Further, the plausibility of a connection is quite low. While electromagnetic radiation from cell phones is a physical mechanism that can potentially have an effect, it is generally too weak to have any plausible biological effect. This by itself is very reassuring, but still cannot rule out a possible effect from cell phones through some as yet undiscovered biological effect of cell phone radiation.

So the claim for a link between cell phones and brain cancer has low plausibility, good epidemiological evidence for a lack of association for less than 10 years of exposure in adults, and equivocal but generally negative evidence for children and greater than 10 years of exposure in adults. Longer term studies will hopefully address these latter issues more definitively.

With that as background, we have the newly published results of the Interphone study. This is an epidemiological study involving 13 different countries looking for any correlation between cell phone use and two common types of brain tumors – glioma and meningioma. Parts of this data have been previously published, but this is now the first time data from all 13 participants is published – including “2,708 people with glioma, 2,409 with meningioma and 7,658 matched controls.”

The overall findings of the study were negative – no clear association between cell phone use and gliomas or meningiomas. However, there were two interesting subgroup findings. For those with regular use of cell phones there was a 20% decrease in risk of tumors compared to those without any use of cell phones.

As implausible as it is that cell phones cause brain cancer, it is even more implausible that they protect against cancer. So, it’s possible this is just noise in the data. However, epidemiologist Anthony Swerdlow, who was involved in the UK arm of the study, gives another explanation:

“We have evidence that the people who refused to be controls are people who didn’t use phones. This meant that the control group, consisting of people without cancer, was rather skewed, appearing to have more mobile-phone use than would be found in a representative sample from the general population. “The controls were over-represented with phone users.”

These results, therefore, were very likely due to a systematic bias in the data – such are the perils of epidemiology.

The other correlation found was a 40% increase in risk of brain tumor among the top 10% of mobile phone users. This is an interesting result, because it suggests a dose response effect. However, this result is also questionable and may be due to methodology. It turns out that many of the people answering the survey used in the study reported improbable amounts of cell phone use – such as 12 hours per day. It was therefore considered to be an unreliable method of determining cell phone use. Number of calls made per day gave more realistic results, and therefore may be easier for people to understand or remember. When the data is looked at with number of calls made instead of time per day, the correlation with brain tumors disappears.

So at the end of all this, we are pretty much where we started. There is still no evidence to link cell phone use and cancer. This data has a few quirks in it, but in the final analysis is probably negative. So we can be a bit more confident in the lack of correlation – or we can think of it as shrinking a bit further the upper limit of any possible effect from cell phone use.

The study does extend the duration of our data somewhat as well – to about 15 years. But we still lack long term data for exposure greater than 15 years.

Unfortunately, the wrinkles in this study lead to some confusion among the media. While reporting this study it is possible to emphasize the increased risk among the highest cell phone users, while either missing or glossing over the fact that further analysis shows this correlation is probably not real. For example, Science News reports: “Interphone study finds hints of brain cancer risk in heavy cell-phone users.” Many other outlets repeated the headline that the study was “inconclusive.”

Conclusion:

Cell phones are an increasingly common tool of modern society. It is certainly necessary and valid to carefully study their safety and monitor for possible adverse health outcomes from their regular use. I am reassured by the current evidence, however, that there is no large risk from cell phones. There is either no risk or a very small long term risk.

Consider, however, that you are probably at greater risk of premature death from using your cell phone while driving, or from driving at all. So as individuals we always need to balance a small risk against the convenience of new technology. The better data we have and the better we understand that data – the better we will be able to make informed decisions for ourselves.

We know that drinking alcohol during pregnancy can cause birth defects; the government-mandated warnings on alcoholic beverage labels constantly remind us of that fact. But toxicologists remind us that the poison is in the dose: what is the dose of alcohol that causes birth defects? Heavy drinking can cause fetal alcohol syndrome, but there is no evidence that light to moderate drinking can cause it. Alcohol has been implicated in a number of other adverse effects on pregnancy and on the fetus. We simply don’t know if there is a threshold dose below which alcohol intake is safe, so the default position of most medical authorities has been to advise total abstinence during pregnancy. This is not a truly evidence-based recommendation, but rather an invocation of the precautionary principle. Those advising complete abstinence have been accused of paternalism and bias by wine-lovers and other critics, for instance here and here.

The literature on alcohol and pregnancy is extensive and confusing. It addresses many different endpoints, looking at effects on children and on the pregnancy itself. The studies are inconsistent in how they define “moderate” or “light” drinking, and they rely on self-reports that may not be accurate.

It would be impossible to read and accurately summarize such a large body of literature (over 21,000 hits on PubMed!), but here are a few examples that illustrate the scope, diversity, and conflicting results of these studies:

This study found that total abstinence from alcohol during pregnancy was correlated with an increased risk of stillbirth. Alcohol is known to inhibit uterine contractions and has been used IV in hospitals to stop premature labor.

This systematic review found an association of maternal alcohol intake with acute myelogenous leukemia in children.

This study showed a correlation with placental abruption but not with placenta previa.

This study found no association between maternal drinking and autism in general, but it found that binge drinkers (5 or more drinks on a single occasion) were less likely to have autistic children. They reasonably commented that this association was probably non-causal.

This study found a blunted response to pain in alcohol-exposed neonates.

This study found that “children born to mothers who drank up to 1–2 drinks per week or per occasion during pregnancy were not at increased risk of clinically relevant behavioural difficulties or cognitive deficits compared with children of abstinent mothers.”

A study by Willford, Leech, and Day found that prenatal alcohol exposure equivalent to 3-6 drinks a week correlated with lower IQ scores in African-American children but not in whites. As one commentator points out, the same study showed that maternal consumption of cocaine correlated with increased overall IQ scores in white children: this “suggests that perhaps the standards for confounding factors and statistical significance might have been too low.”

I found several websites that mentioned a study of 33,300 California women but I haven’t succeeded in tracking down the study itself. It reportedly showed that even though 47% drank moderately during their pregnancies, none of their babies met the criteria for Fetal Alcohol Syndrome. The authors of this study reportedly concluded “that alcohol at moderate levels is not a significant cause of malformation in our society and that the position that moderate consumption is dangerous, is completely unjustified.”

When studies have conflicting results, we resort to meta-analyses and systematic reviews to try to make sense of the data.

A meta-analysis by Testa, Quigley and Eiden found a detrimental effect on infant mental development at age 12–13 months, but no effect in younger or older infants. And it found a statistically significant improvement in mental development in children of light drinkers at 18-26 months. It’s hard to interpret what this might mean, if it is not a statistical fluke.

A systematic review by Henderson, Gray and Brocklehurst looked for possible effects of light to moderate drinking on outcomes including miscarriage, stillbirth, intrauterine growth restriction, prematurity, birth weight, small for gestational age at birth and birth defects including fetal alcohol syndrome. They

… found no convincing evidence of adverse effects of prenatal alcohol exposure at low–moderate levels of exposure. However, weaknesses in the evidence preclude the conclusion that drinking at these levels during pregnancy is safe.

There are no studies showing harmful effects from 1–3 drinks a week.

Conclusion: The scientific evidence has not identified a threshold below which alcohol consumption during pregnancy is definitely safe, but neither has it shown any convincing evidence of harm at low levels of intake, and it has not ruled out the possibility that low levels might provide a small benefit.

In the absence of better data, we are left to cope with uncertainty. Individuals will have to make decisions based on their philosophy of risk tolerance and their own personal non-scientific reasons. For me, the unconfirmed possibility of a low level of risk was not enough to outweigh the enjoyment of an occasional glass of wine during my pregnancies.