In his new book The Youth Pill: Scientists at the Brink of an Anti-Aging Revolution, David Stipp tries to answer those questions. From the title of the book, I expected hype about resveratrol or some other miracle pill; but instead it is a nuanced, levelheaded, entertaining, informative account of the history and current state of longevity research. It makes that research come alive by telling stories about the people involved, the failures and setbacks, and the agonizingly slow process of teasing out the truth with a series of experiments that often seem to contradict each other.

Anti-aging can mean several things. Extending the average lifespan is not the same as extending the maximum life span. Extending lifespan is not the same as preventing the degenerative changes characteristic of aging.

We don’t even have a handle on why we die, why we deteriorate over time, or how it could benefit “selfish genes” for women to live past menopause. Several contradictory evolutionary explanations have been proposed. Comparisons with other species have not been helpful: every hypothesis has run up against counter-examples. Generally, the lifespan of animals correlates with body size; humans live longer for their size than expected. Some animals appear not to age. Naked mole rats are a fascinating anomaly: these animals that live in colonies underground and look like saber-toothed sausages live a long life for their size and appear not to show the usual changes of aging even though they have high levels of free radical damage and low levels of antioxidants (70 times less glutathione activity than mice).

Scientists hoped to find an aging gene that they could turn off. It’s not that simple. A large number of genes are involved in aging processes, and there are unpredictable interactions between them. Studying centenarians has provided inconsistent clues.

Antioxidants neutralize the free radicals that cause cell damage. They sounded promising, but their effect is modified by many factors, they can harm as well as help, and raising their levels with supplements may even turn off some of the body’s natural defenses.

Telomerase (the enzyme that keeps the ends of chromosomes from fraying as they age) was another false lead. Drugs that slow aging by boosting telomerase may cause cancer, and it turns out that telomere shortening isn’t the chief driver of body-wide aging.

The most promising idea is severe calorie restriction (CR). It prolongs life in several species, but this effect has not yet been verified in humans. And it is inconsistent and may have different effects at different ages and in different individuals. CR lowers body temperature and fertility and has other side effects. It is not an option most people would willingly choose.

Scientists have studied the chemical changes in CR humans and are looking for a pill that will cause those same changes while allowing people to eat unrestricted calories. Two main candidates have surfaced. Resveratrol (a substance found in red wine) seems to work: it allows overfed mice to live longer and stay healthier. It appears to have a number of benefits in lab animals, but human studies have not been done and it appears that very large doses will be required (comparable to the amount you would get by drinking 200 bottles of wine a day). Rapamycin extends the life of mice and prevents various diseases, but it also inhibits protein synthesis in the brain, suppresses immune function, and raises cholesterol. Researchers are trying to find related compounds that offer the benefits without the harms.

There are all too many variables that can interfere with the results of a study. In one experiment, the female mice lived longer with treatment but the males didn’t. They finally figured out that was because the males’ cagemates were killing them! Stipp does an excellent job of presenting the theoretical underpinnings, the experiments, and the difficulties of anti-aging research. The subject is overwhelmingly complicated, but he simplifies it enough to at least help the reader understand how very complicated it is.

There are longevity clinics and anti-aging products on the market offering all kinds of promises that go way beyond the knowledge. Futurist Ray Kurzweil takes handfuls of supplement pills and spends one day a week getting IVs and other treatments at a longevity clinic and he is convinced this regimen will keep him alive until science finds a way to keep him alive forever. The author of The Youth Pill is more conservative. He is enthusiastic about the promising research on pills like resveratrol and rapamycin, but he’s reluctant to start taking them “until enough clinical data are available to let me make a reasonably well-informed decision about optimal dosing.” Me too.

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.

The moral is not that doctors once did foolish things. The moral is that even the best of people let themselves down when they rely on untested theories and that these failures kill people and stain history. Bleeding and mercury have gone out of fashion, untested certainties and overconfidence have not.

Burch’s conversation with his rowing coach epitomizes the problem:

“I want you to keep your heart rate at 85% of max for the next hour and a half.”
“Why?”
“Because it’s the best way to improve your fitness.”
“How do you know?”
“Because I’ve done it before and it worked. Because that’s what the people who win the Olympics do. I know, I’ve trained some of them.”
“But has anyone actually done an experiment?”
“What on earth are you talking about?”

This book is Burch’s answer to his coach’s question. Medicine’s “beautiful idea” is that we should test all hypotheses and beliefs using the kind of tests that are reliable for determining the truth. Instead of going by tradition, authority, theory, common sense, or personal experience, we now have effective tools to find out for sure whether a treatment really works.

The scientific method developed slowly and there were a lot of hiccups on the way. Researchers frequently misunderstood what constituted evidence.

In an early Chinese experiment, two people were asked to run together. One was given ginseng; the other, who didn’t get ginseng, developed shortness of breath. They thought that was sufficient evidence to prove that ginseng prevented shortness of breath.

Galen gave one of his potions to a lot of patients: some recovered, some died. He thought that was evidence that the potion worked, because

All who drink of this treatment recover in a short time, except those whom it does not help, who all die. It is obvious, therefore, that it fails only in incurable cases.

Galen’s fallacious reasoning is easy to spot, but a 20th century doctor committed a similar error. He gave all his patients aspirin and asserted it was 100% effective in preventing heart attacks. Some of them did have heart attacks, but he didn’t count them because on close questioning he found that they had omitted doses or otherwise didn’t strictly follow the aspirin protocol (which was probably equally true of all his patients).

Even after the importance of randomization was recognized, there were errors in applying the principle. In early trials, randomization was by alternate allocation, where the first subject to enroll is put in group A, the second in group B, the third in group A, etc. But doctors tended to bend the rules to put certain patients in the treatment group. True randomization had to be forced on doctors who thought they knew what was best for their patients and who didn’t even realize they were cheating.

Humility is required of those who have theories rather than evidence. If they design experiments simply to confirm their prejudices, they are in danger of designing bad ones or misinterpreting results. The more researchers want to prove that the results were due to their favored treatment, the more exhaustive should be their search for alternative and equally reasonable explanations.

Burch’s book is a history of medicine with many intriguing stories about people, personalities, penicillin, opium, thalidomide, and the other usual subjects of medical history; but it is also an explanation of the scientific method and a commentary on modern medicine’s failure to rigorously and consistently apply that method.

Despite our increasing acceptance of the scientific method, the term evidence-based medicine (EBM) didn’t appear in the medical literature until 1991. Critics of scientific medicine have unfairly claimed that less than 10% of treatments are EBM. Burch points out that evidence doesn’t just consist of randomized controlled trials (RCTs), and that we have good evidence that parachutes save lives without having to do an RCT on parachutes. The 10% figure is way too low: a recent study estimated that 80% of current treatments are based on evidence.

Testing and experiment have failed to protect us from deluded cures and poisonous remedies. They can’t be relied upon unless they are carried out with method and rigor. Understanding previous mistakes helps us to avoid them.

Burch has some harsh things to say about current medical research and the processes of drug approval. Many treatments accepted as EBM are actually based on poor quality studies. 62% of studies change the definition of what they are studying between ethical approval and publication. Some studies are stopped prematurely because of apparently clear benefits or risks to patients: this is usually a mistake that diminishes the quality of data. It might be better to finish the study as planned and harm a few patients today than to harm thousands of patients later because of a false conclusion.

People worry about withholding new drugs from needy patients while they undergo testing. They worry about the ethics of offering placebos to patients when a new drug offers an apparently effective treatment. But history has shown that the new drugs in these trials are just as likely to harm as to help.

A drug’s effects, even if they are moderately large, can almost never be reliably figured out on the basis of personal experience.

Doctors are still reluctant to trust science when it goes against their prejudices. He tells how cardiologists strongly supported the first Coronary Care Units (CCUs). A study was done comparing CCU treatment to home treatment for heart attacks. The researchers told the cardiologists that there were fewer deaths in the CCU but that the difference didn’t reach statistical significance. The cardiologists all thought this trend was a strong enough reason to insist on CCUs. Then the researchers admitted they had lied: the numbers were correct but reversed. The trend had actually favored home care. Based on the same quality of evidence, the cardiologists now did not consider the data a strong enough reason to insist on home care!

Medicine is becoming more scientific and more evidence-based every day, but we can and should do better.

What is needed is a culture, regulatory and intellectual, where every attempt is made to ensure new medical interventions are used solely in randomized trials. Only when their effects have been determined should they become available for use outside a trial setting. Until then there is a moral obligation on doctors to use unknown drugs and treatments only in such a way as to come to an understanding of them, and a moral obligation on patients to demand treatments that are either supported by sound evidence or only given as part of a trial which will uncover some.

This is good advice for mainstream medicine, and it is even more important for alternative medicine, which Burch doesn’t address. Since by definition “alternative” medicine is medicine that has not been proven effective, following these guidelines would eliminate any use of alternative medicine outside of a clinical trial. I know, the money isn’t there and it would be difficult to implement, but the principle is irrefutably sound. (That’s assuming that we want to avoid using placebos and find out what really works; but I don’t think the general public wants that. I suspect they would resist and prefer to cling to untested beliefs.)  

Here’s a sampling of some of Burch’s quotable words of wisdom:

There is a bitter joke in modern medicine: the violence with which someone makes an argument is inversely proportional to the amount of evidence they have backing it up.

Trials can be full of statistics; difficult to understand and laborious to undertake. They have a loveliness to them all the same, and it comes from their power to uncover parts of the reality we live in.

[It is] our nature to prefer credulity to doubt, confidence to skepticism. We share a tendency to simplify and confuse things, to slip into mental habits that let us down.

The idea that even the most reasonable-sounding theories should be subjected to tests probably has more potential to make the world a better place than all the drugs that doctors possess. Economics, politics, social care and education are full of policies that are based on beliefs held as a matter of principle rather than because they are supported by objective tests. Humility, even more than pills, is the healthiest thing that doctors have to offer.

I highly recommend this book. It’s well-written, entertaining, and provides much food for thought. It’s a great way to learn about fascinating incidents in the history of medicine and a great way to learn what constitutes truly science-based medicine and how to avoid the errors of the past, the errors in thinking that we flawed humans are all susceptible to.

Hippocrates’ discovery that disease had natural causes, sanitation, germ theory, anesthesia, X-rays, vaccines, antibiotics, genetics, and treatments for mental disorders are all worthy candidates for the list. But Queijo ludicrously lists the “rediscovery of alternative medicine” as the tenth “great discovery.” He presents no evidence (because there is no evidence) that alternative medicine has “saved millions” or that it has saved anyone. He doesn’t realize that alternative medicine represents a betrayal of exactly the kind of rigorous scientific thinking and testing that led to all the other discoveries. His list of ten breakthroughs is actually a list of 9 breakthroughs and one breakdown.

He tells compelling human-interest stories about the discoveries. The complexities, the mis-steps, the near-misses, and the ups and downs make fascinating reading. He describes farmer Benjamin Jesty leading his wife and children on a two mile trek through the fields in 1774 to steal cowpox pus from a neighbor’s cow and inoculate his family with a sewing needle to protect them (successfully!) from smallpox. He describes the many chance events that had to conspire for Fleming to see the effects of mold on his culture plate and the long, tortuous course between his observation and the therapeutic use of penicillin. He tells how the pea-gardening monk Gregor Mendel’s discovery of genetic principles went unrecognized until decades later after 3 other researchers had unknowingly replicated some of his experiments.

He offers fascinating tidbits of historical information. Anti-vaccine activists are nothing new: he tells how they sabotaged the use of an early typhoid vaccine in the Boer War by such tactics as dumping vaccine shipments overboard from ships. As a result, the British Army suffered more than 58,000 cases of typhoid and 9000 deaths.

He recounts Roentgen’s early comments about his discovery of x-rays:

I still believed I was the victim of deception.

I have discovered something interesting, but I do not know whether or not my observations are correct.

Before he announced his discovery, he studied the characteristics of the rays, investigating whether they could penetrate various materials or be deflected by a prism or a magnetic field. One can only wish that today’s students of “energy medicine” would employ his cautious, self-questioning, and scientifically rigorous approach!

My favorite was a delightful anecdote about Thomas Edison: in the early days after the discovery of x-rays, Edison received two requests in the mail, one from an apparent voyeur asking him to fit a set of opera glasses with x-rays and the other asking him to

Please send me one pound of X-rays and bill as soon as possible.

There are hints of trouble before we get to the chapter on alternative medicine. Queijo claims that one of Hippocrates’ accomplishments was to believe that respect for a higher power was a necessary precondition for good health. What does that even mean? Why would it be important? He offers no evidence that such respect has ever saved lives or had any positive effect on medical practice.

In the chapter on genetics, he starts by describing the ancient superstition that “maternal impressions” could affect the development of the fetus: for instance, after watching a fire, a woman delivered a baby with a flame-shaped birthmark. He demolishes that possibility with a reasoned discussion of genetic principles and DNA. But then he inexplicably cites a modern study by Ian Stevenson, who holds a number of strange beliefs, is convinced he has solid evidence proving reincarnation, and could be classified as a maverick if you wanted to be polite. Stevenson collected a number of case reports and opined that

In rare instances maternal impressions may indeed affect gestating babies and cause birth defects.

Queijo agrees with him, saying

In the brave new world of genes, nucleotides, and SNP’s it’s easy to dismiss such mysteries as playing no role in the inheritance of physical traits — no more than, say, DNA was thought to have for 75 years after its discovery.

He’s wrong: Stevenson did not find any “mysteries” but merely the kind of coincidences that will be inevitably found if you look hard enough for them.

In the chapter on alternative medicine, Queijo loses it entirely. He seems to think that modern medicine has become so fixated on diseases and technology that alternative medicine had to rediscover that diseases occur in people. He criticizes the reductionism of the scientific approach, but offers no evidence that a non-reductionist approach has ever resulted in discoveries or provided better patient outcomes. He sees the struggles between scientific medicine and alternative medicine as politically motivated turf wars rather than as efforts to establish the truth. He claims that by 1998, Americans were seeking alternative care practitioners more often than their own primary care physicians. If this is true, offering that statement without qualification would be misleading to say the least. Anyway, popularity is no guide as to what treatments work.

He accepts homeopathy uncritically and even suggests that it is now supported by science. He likes the idea of homeopathy because it “shares some underlying values seen in ancient traditional medicines” such as vitalistic energy concepts, detailed interviews to inquire into every detail of the patient’s life, stressing the healer-patient relationship, and deriving many of its remedies from natural products.

He says,

Alternative medicine offered something Western medicine had too often abandoned: the view that every patient was an individual, that natural treatments were sometimes better than dramatic surgery and dangerous drugs; and that the essence of medicine begins with a caring relationship between healer and patient.

This is a straw man argument that badly mischaracterizes mainstream medicine, and it fails to show that alternative medicine has any advantage over scientific medicine practiced with judgment and empathy. If every patient is an individual and the whole person should be treated, why do chiropractors fixate on adjusting spines and acupuncturists fixate on improving the flow of qi through meridians?

He even goes as far as to accuse the stethoscope of being a nefarious device that distances practitioners from patients! He calls its invention “a dark omen for the terrible turn Western medicine was about to take.” Now, really!

Much of this book is an eloquent paean to the value of science. Unfortunately, it abandons science in its discussion of alternative medicine. It deteriorates into apologetics for belief-based medicine based on misunderstandings and opinions rather than on any evidence. Alternative medicine represents a breakdown of the process that led to the real breakthroughs.

If you read this book, I recommend skipping chapter 10.

In Finding Frances, by Janice M. Van Dyck, an elderly woman with COPD and heart disease has had a gradual decrease in her quality of life and has been ready to die for some time. She believes in God and an afterlife and is not afraid of dying. When she needs emergency surgery to remove a section of infarcted bowel, she wants to refuse it, but accepts mainly because she is told that otherwise she will be sent home where insurance won’t cover her care and her husband’s savings will be depleted (which isn’t really true). The first surgery leads to complications and she is offered a second operation with a 25% chance of success. She refuses despite the strong urgings of her health care providers and her entire family. She is given hospice care, stops eating, and eventually dies. The book chronicles the course of the death process in hospice, giving a feel for what the experience is like and how it impacts family members.

In The Leisure Seeker, by Michael Zadoorian, Ella and John, a couple in their 80s, set out on one last road trip in their RV, to follow the entire length of old Route 66 and revisit Disneyland. Their doctors and their children try desperately to dissuade them. He has Alzheimer’s and she has cancer and other health problems: between them they have one functional brain and one functional body. She has refused surgery and chemotherapy, uses a walker, and is dependent on pain pills. He has made her promise that she will never put him in a nursing home. After many mishaps, misunderstandings and misadventures, they manage to reach Disneyland. Then she finds a way to end both their lives at the same time so neither will be left alone. She is a feisty, colorful character and the book is hilarious despite its sad subject. Ella tells us what it feels like to become old and decrepit, to be handicapped and live in pain, and to live with a demented loved one who must constantly be watched and doesn’t always remember who you are. And how one can find joy in the small pleasures of life despite all those problems.

I don’t think I would make the same choices in their situation, but I can understand their choices and empathize with them. They didn’t give up hope or turn to false hopes, but they created their own realistic hope — the hope of a “good death.” They rejected dependence on medical care, took control of their lives, and met death on their own terms. I have to respect their autonomy and admire their courage.

As Ella says at the end of The Leisure Seeker after she plans her own and her husband’s death by carbon monoxide poisoning:

This is not always what love means, but this is what it means for us today. It is not your place to say.

A valuable new book elaborates on this concept: Diagnosis, Therapy and Evidence: Conundrums in Modern American Medicine, by medical historian Gerald N. Grob and sociologist Allan V. Horwitz. They point out that 

many claims about the causes of disease, therapeutic practices, and even diagnoses are shaped by beliefs that are unscientific, unproven, or completely wrong.

While we try to be science-based, we are not always as scientific or as logical as we would like to think. We form hypotheses that are compatible with existing data, and then our assumptions guide our thinking and future research and sometimes interfere with our reception of new data. We must recognize those assumptions and constantly re-evaluate them. It’s important that we look the imperfections of science-based medicine squarely in the face if we are going to have any hope of overcoming them.

Of the therapies recommended in a 1927 textbook only 23 were later validated as effective or preventive. The other 211 were subsequently found to be either harmful, useless, of questionable value, or simply symptomatic.

Medical treatment has had a big impact on human health, but there’s more to the story. We developed effective treatments for ulcers, but the incidence of ulcers was already declining before those treatments had any impact. The decline of rheumatic heart disease is probably not due to antibiotics but may be due to decreased virulence of the causal bacteria. We have no idea why the incidence of stomach cancer has decreased in the US, or why it is so high in Japan.

A popular concept today is that cancer is largely a preventable illness linked to diet, environmental carcinogens and behavior. This is rooted largely in belief and hope rather than fact. Smoking is the one notable exception. Genetic factors and the many physiologic changes of aging may contribute more than we would like to think. To some extent, disease is an unavoidable consequence of life: the idea that science can eventually provide perfect health may be a chimera.

In our efforts to prevent heart attacks we are essentially treating risk factors, without a clear understanding of how they relate to pathophysiology. We are treating hypertension, hyperlipidemia and other risk factors rather than directly treating the cause(s) of cardiovascular disease. We offer behavioral prescriptions based on assumptions derived from inadequate epidemiologic evidence, and this kind of thinking can lead us astray. Recommending a low fat diet helped fuel an epidemic of obesity as people replaced the fat in their diet with extra carbohydrates.

Once we have formed a belief we are slow to respond to new evidence that refutes it. The book covers the history of tonsillectomy. Tonsillectomies remained fashionable long after the evidence showed most of them were useless.

The most interesting question they ask is

How do diagnoses come into existence and why do many disappear with the passage of time?

What ever happened to chlorosis and neurasthenia? The same patient presenting with the same symptoms in 1890 and 2010 would get entirely different diagnoses. The ailments that afflict humans don’t change much; our diagnostic categories do.

Autism, CFS and fibromyalgia are all relatively new diagnoses for conditions that undoubtedly existed long before the diagnostic name was coined. “Their pathobiology remains unknown, and there is little agreement on their diagnostic boundaries. Once given a name, however, the numbers given to each diagnosis have expanded exponentially.”

Psychiatric diagnoses are particularly slippery. Where exactly do you draw the line between normal sadness and depression? Disease occurs on a continuum and we try to fit it into discrete boxes. We organize the data differently at different times as influenced by historical circumstances. The Diagnostic and Statistical Manual of Mental Disorders (in its many iterations, now up to DSM-5) changes as it reflects not only new data but cultural, social, and political forces. There is no evidence that the new DSM categories of anxiety have improved the diagnosis, treatment, or understanding of anxiety disorders. The popularity of the diagnosis of post traumatic stress disorder (PTSD) raises issues about the connection between external causes, individual responses, and resulting symptoms. Broadened criteria for PTSD have made it possible for almost everyone to be diagnosed or considered at risk.

We differentiate between science-based medicine and belief-based medicine, but we mustn’t forget that scientists form beliefs too. Our interpretation of the evidence is influenced by our working hypotheses. We must remember to constantly guard against overinterpretation and to concentrate only on what the evidence actually shows. When we use a diagnosis, we must remember that it is not definitive, but only an artificial category we have imposed on nature to help us understand our patients’ symptoms and provide a framework for treatment decisions. When we have an explanation, we must keep re-evaluating the data to make sure another explanation doesn’t fit the data just as well.

Ionannidis showed that most published studies are wrong. Grob and Horwitz show that many of our current diagnoses, treatments, and ideas about disease may be wrong too.

I suggest that we all repeat the mantra: “I could be wrong” and keep asking “Could any other explanation fit the data?”

This compelling story is the beginning of an excellent new biography of William Halsted, the father of modern surgery, Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted, by Gerald Imber, MD.

When Halsted went to medical school, surgeons still operated in street clothes, with bare hands, and major surgical procedures carried a mortality rate of nearly 50 percent. Suppuration of wounds was called laudable pus. Lister had recently introduced carbolic acid dips and sprays (that were irritating and toxic), but hand washing was discouraged because it was thought to force germs into skin crevices.

Halsted was responsible for the first use of sterile gloves in the operating room, although his initial reason for introducing them was to relieve the skin irritation of the scrub nurse who later became his wife. He collected statistics to prove that gloves reduced the infection rate, although he wasn’t always consistent: he once removed his gloves to better palpate a lesion and the patient got infected and died. In addition to the first gallstone removal, he developed the radical mastectomy (radically improving the survival of breast cancer patients), the first successful hernia repair and aneurysm repair, and many techniques that improved the outcomes of surgery. He established an animal lab to teach surgery to students and to try out new procedures. He kept refining his knowledge of anatomy, used meticulous surgical technique and fine silk sutures to minimize tissue damage (thereby reducing the chance of infection), insisted on hand washing and sterile technique, and kept careful records of outcomes to determine which procedures were best.

With his equally renowned colleagues internist William Osler, pathologist William Welch, and gynecologist Howard Kelly, he helped revolutionize the training of doctors by creating the first modern medical school at Johns Hopkins. Previously, medical schools were little more than for-profit trade schools. There was no laboratory or clinical work and students often did not see patients at all. The course lasted 3 years and had no entry requirements. At Johns Hopkins, an undergraduate degree was required for admission, the program lasted 4 years, there was extensive training in science, bedside teaching rounds were instituted, and there was a hierarchy of post-graduate training with interns and residents.

They even admitted women on the same basis as men. I thought it was hilarious how that came about. After building the hospital they had run out of money and were desperately seeking an endowment to establish a medical school. A committee of women offered to raise the money if the board would agree to admit women students. The board didn’t want to admit women, but they thought it would be safe to agree because they were confident the women would never be able to raise the necessary amount. The women promptly raised more than enough and forced the board to honor its promise! Incidentally, Gertrude Stein was an early medical student there, but instead of sticking around to graduate she went to Paris to write poetry and become famous.

The students Halsted trained (including Harvey Cushing, the father of neurosurgery) developed into a new generation of leaders and teachers: science-based surgeons who were responsible for many of the subsequent advances in surgery. They went on to teach another generation, and many of today’s most prominent surgeons and researchers can trace the line of their teachers’ teachers directly back to Halsted.

Yet this man who accomplished so much for science was a drug addict for 40 years. He was given morphine to help him withdraw from cocaine and ended up hooked on both drugs for the rest of his life. He only worked part of each year. He would disappear for months at a time, apparently to binge on cocaine in privacy. He was sometimes observed by colleagues to be suffering drug effects or withdrawal symptoms. Sometimes he would leave in the middle of an operation, saying he had a headache, leaving his residents to finish the procedure.

He was an odd duck in many ways. He was abrasive, abrupt, inconsiderate, forgetful, and apparently unfeeling: his personality quirks constantly antagonized his students and colleagues. His marriage was apparently sexless and his wife was also addicted to morphine.

His story is interesting in more ways than one. It provides insight into a crucial time in history when medicine was transitioning from superstition to science, when scientific surgery and modern medical education were being born. It is also fascinating to realize that this flawed man was able to maintain an incredibly productive scientific career for 4 decades despite his addictions. I can’t help but wonder what would happen to such a man today.

In Time to Care: Personal Medicine in the Age of Technology, Dr. Makous tackles a big subject. He attempts to show how modern medicine got to where it is today, what’s wrong with it, and how to fix it. For me, the best part of the book is the abundance of anecdotes showing how medicine has changed since Dr. Makous graduated from medical school in 1947. He gives many examples of what it was like to treat patients before technology and effective medications were introduced. He describes a patient who died of ventricular fibrillation before defibrillators were invented, the first patient ever to survive endocarditis at his hospital (a survival made possible by penicillin), a polio epidemic before polio had been identified as an infectious disease, the rows of beds in the tuberculosis sanitariums that no longer exist because we have effective treatments for TB. He tells funny stories: the patient who was examined with a fluoroscope and told the doctor he felt much better after that “treatment.” He describes setting up the first cardiac catheterization lab in his area. No one who reads this book can question the value of scientific medicine’s achievements between 1947 and 2010. Today we can do ever so much more to improve our patients’ survival and health. But in the abundance of technological possibilities, the crucial human factor has been neglected.

Individualized care, which involves the use of science-inspired technology, is not personal care. Alone, it is incomplete. It does not provide the necessary reassurance that can only be provided through a trusted physician who focuses upon the totality of the person and not just upon a narrow technological application to a disease. Time and personal commitment are needed to build the mutual understanding and trust that are fundamental to personal care….the continued acceleration of science, technology, and cost has intruded on personal care in our country. This has also occurred during a time in which American individualism and its accompanying sense of entitlement have become more of a cult than ever before. In the absence of personal attention, patients demand more testing, but testing does not satisfy the need for personal interaction.

Makous invokes the Golden Rule: “Over the course of my career, I learned to treat patients as I would like to be treated under similar circumstances.”

Some of his recommendations:

• Unhurried visit
• Undivided attention to patient (not to chart or recording device)
• Sitting down to talk to the patient
• Laying on of hands
• Humor
• And finally, “Most patients will choose a doctor who enjoys their company.”

Makous points out that the “holistic” approach to medicine is nothing new: Hippocrates introduced the concept in the 5th century BC and good clinicians have always used it.

Medicine is an applied science, not an exact science, and often the best the physician can do is make an educated guess. The better the doctor knows the patient and the better he incorporates the personal element of care, the more educated the guess. For instance, knowing whether a patient is typically stoic or a complainer helps us decide how seriously to take his complaints. The “worried well” typically complain about every little thing; the stoic may not realize they are ill until they can’t get out of bed.

He thinks that evidence-based medicine only helps with about 5% of a physician’s work. Surely evidence-based medicine constitutes a larger percentage than that, but perhaps what he means is that when he is trying to make a difficult clinical decision there is only a pertinent, useful clinical study to guide him in about 5% of cases. Study populations may not be representative of the individual in the doctor’s office. Studies isolate one condition: your patient may have many others. “No study has been done that can’t be faulted in its extrapolation to the individual.” Most studies generate as many questions as they answer.

I agree with much of what he says, but then he goes too far:

The assumption is that physicians relying on personal experience have been on the wrong track and their practices need to be changed. In reality, the opposite is true.

No, relying on personal experience is a recipe for self-deception, and those practices need to be tested. There’s a danger in too much “personalization” of medicine: the doctor can be seduced into believing he is wiser than he really is and into rejecting science. If you think every patient is so different that scientific studies don’t apply, then anything goes. You can find an excuse to try any treatment you can think of. This is similar to the pitfalls of CAM’s claims of individualized treatment, as recently described by David Gorski.

Doctors today must please two masters: the patient and the healthcare organization. Care is fragmented, and specialists feel obligated to do more tests. Consultants often assume they are expected to do certain tests rather than to decide for themselves if the tests are really warranted. They are concerned about liability if they fail to do a test. They are reimbursed for doing the test, but are not reimbursed for the time needed to evaluate the patient holistically and determine if the test is really in his best interest. They are content to assume that the referring physician has already done that. But the referring physician may not know enough about the test to decide, and he may be assuming the consultant will decide appropriately. Costs and malpractice litigation rise as a result. Poor Medicare reimbursement means many doctors are refusing to accept new Medicare patients. We need a system to get more compassionate care to geriatric patients, more time with their doctors, not more technology.

Physicians are reimbursed lavishly for doing procedures but not for spending extra time talking to patients. They are not reimbursed adequately for counseling about preventive measures. Makous suggests that detailed advice on obesity and smoking might be better addressed as a public health concern and provided by non-physicians.

This is a thoughtful book by a wise old soul who has “been there, done that.” It is well worth reading for the insight it provides into recent medical history and for its reminder that doctors should treat patients as they themselves would want to be treated.

I read a lot of psychology and skeptical literature, and I thought I knew a lot about false beliefs in psychology, but I wasn’t as savvy as I thought. Some of these myths I knew were myths, and the book reinforced my convictions with new evidence that I hadn’t seen; some I had questioned and I was glad to see my skepticism vindicated; but some myths I had swallowed whole and the book’s carefully presented evidence made me change my mind.

The authors start with a chapter explaining how myths and misconceptions arise.

1. Word of mouth. If we hear something repeated enough times, we tend to believe it.
2. Desire for easy answers and quick fixes.
3. Selective perception and memory. We remember our hits and forget our misses.
4. Inferring causation from correlation.
5. Post hoc, ergo propter hoc reasoning.
6. Exposure to a biased sample. Psychologists overestimate the difficulty of stopping smoking because they only see patients who come to them for help, not the many who stop on their own.
7. Reasoning by representativeness – evaluating the similarity between two things on the basis of superficial resemblance.
8. Misleading film and media portrayals.
9. Exaggeration of a kernel of truth.
10. Terminological confusion. Because of the etymology of the word schizophrenia, many people confuse it with multiple personality disorder.

They discuss our susceptibility to optical illusions and other cognitive illusions, our propensity to see patterns where they don’t exist, the unreliability of intuition, and the fact that common sense frequently misleads us. They characterize science as “uncommon sense” – it requires us to set aside our common sense preconceptions when evaluating evidence.

They cover 50 myths in depth, explaining their origins, why people believe them, and what the published research has to say about the claims. Everything is meticulously documented with sources listed. Here’s a sample of the myths they cover:

• Criminal profiling is helpful in solving cases. In most studies, professional profilers barely do better than untrained persons. Most of what they say can be inferred from “base rate information” about criminals: guessing that a serial killer is a white male will be right more than 2/3 of the time just based on statistics.
• A large proportion of criminals successfully use the insanity defense. The insanity defense is raised in less than 1% of criminal trials and is successful only about 25% of the time.
•  If you’re unsure of your answer when taking a test, it’s best to stick with your initial hunch. Darn! I wonder how many questions I got wrong over the years because I believed that. 60 studies have consistently shown that students are more likely to change a wrong answer to a right one than vice versa, and students who change more answers tend to get higher test scores.
• Students learn best when teaching styles are matched to their learning styles. This turns out to be an urban legend not supported by any acceptable evidence. It could backfire because students need to correct and compensate for their shortcomings, not avoid them. The authors cite a satirical story from The Onion about nasal learners demanding an odor-based curriculum.
• It’s better to express anger to others than to hold it in. The evidence shows that expressing anger only reinforces it and leads to more aggression.
• Men and women communicate in completely different ways. There are differences, but they are very slight, probably not enough to be meaningful, and definitely not enough to suggest that they are from different planets as claimed in the book Men are from Mars, Women are from Venus. Women don’t talk more than men: a study of college students carrying recorders showed that both sexes talked about 16,000 words a day.
• A positive attitude can stave off cancer. Not only does the evidence not support this claim, but there is evidence that women who were highly stressed were less likely to develop breast cancer. And attitudes don’t prolong survival: even the most optimistic cancer patients lived no longer than the most fatalistic ones.
• Memory is like a tape recorder.
• Memories of traumatic experiences are commonly repressed.
• Subliminal advertising is effective.
• Some people are left-brained, others are right-brained.
• Playing Mozart’s music to infants boosts their IQ.
• When dying, people pass through a universal series of psychological stages.
• Hypnosis is useful for retrieving memories.
• The polygraph can detect lies.
• Low self-esteem is a major cause of psychological problems
• Only deeply depressed people commit suicide.
• Abstinence is the only realistic treatment goal for alcoholics.
• Childhood sexual abuse usually leads to adult psychopathology.

They also list a total of 250 other myths in a brief “Fiction/Fact” format with suggested resources for further reading. Some of these facts intrigued me. Dreams occur in non-REM sleep as well as during REM sleep. Transcendental meditation yields no greater effects than rest or relaxation alone. Most women don’t have worse moods in the premenstrual period. Women are no better than men at guessing the feelings of others. Sexual content of ads may make people pay more attention, but they are less likely to remember the product’s brand name. There’s little or no evidence for the G-spot. Men don’t think about sex every 7 seconds – somebody just made that up. Individual efforts produce better quality ideas than group brainstorming sessions.

I hope they will elaborate on some of these in “50 More Myths of Popular Psychology” and “Popular Psychology Myths, Volume 3” and a whole ongoing series. For that matter, it would make a great TV show along the lines of Mythbusters. Although, unfortunately, without explosions.

They end the book with a baker’s dozen of true psychological findings that are difficult to believe, showing that truth is indeed stranger than fiction.

If you read this book, you may be challenged to give up some of your cherished beliefs. Some people find it painful to admit that they were wrong. I find it one of the greatest pleasures of skeptical inquiry and science. When I change my mind about something I don’t chastise myself for the original error; I congratulate myself for having learned better and for having achieved a better grasp on reality.

The proper stance of a skeptic or scientist is to defer judgment pending evidence. In practice, that isn’t always possible. We can’t take the time to thoroughly investigate everything we hear. It is reasonable to provisionally accept something that everyone says is true, that is compatible with common sense, that is plausible, and that is often based on some preliminary evidence. As long as we keep in mind that these claims may be based on inadequate evidence and we remain ready to change our minds when better evidence arrives.

We’re all susceptible to this kind of error. The authors of this book fell for one myth themselves. In a short mention of medical myths they included this one: “eating too many carrots makes our skin turn orange.” Apparently they had read it on more than one list of medical myths. I wrote the lead author to tell him this was not a myth, but a recognized condition called carotenemia. It looks just like jaundice except that the whites of the eyes are spared. I had a patient with that condition, caused by eating LOTS of carrots on a weight-loss diet. She had bright red hair and with her bright yellow skin she looked like something out of a comic book – sort of like an anti-Smurf. It was very impressive. As a good scientist, Dr. Lilienfeld accepted the evidence and promised to amend the statement in subsequent editions.

Apart from carrots, I found nothing to criticize in this book. The authors have done us a great service by compiling all this information in a handy, accessible form, by showing how science trumps common knowledge and common sense, and by teaching us how to question and think about what we hear. I highly recommend it.

He meant that any medicine that has effects has side effects, that the poison is in the dose, and that we must weigh the benefits of any treatment against the risks. Dr. Kirschner has no beef with scientific medicine. He does have a lot of other beefs, mainly with the health insurance industry, the pharmaceutical industry, and alternative medicine.

 He explains the FDA, the standard drug approval process (phase I through III studies), fast-tracking, classification of drugs (Schedule I through V), black box warnings, drug recalls, off-label prescribing, the scientific method, package inserts, expiration dates, drug interactions, side effects, the role of sanitation in disease prevention, informed consent, developing resistance to antibiotics, placebos, immunizations, ethical issues, conflicts of interest, drug advertising, copycat drugs, why drugs cost so much, why “natural” doesn’t mean “harmless,” how dietary supplements can kill, how alternative medicine is not based on scientific evidence, chelation, DSHEA, NCCAM, the infiltration of CAM into medical schools and why we need a new Flexner report, what’s wrong with the American medical system (“What’s broken is the coverage system, not the care delivery system.”), and why “poison, cut and burn” is sometimes the only rational option. He does not like insurance companies, and he explains why. He ends by saying Lincoln’s characterization of our government as “Of the people, by the people, for the people” is now better described as

Of the people, Buy the lawmakers, For the corporations. 

I liked his comments on the natural herb that has caused more human grief than any other in history: tobacco. I liked his assertion that it would be redundant to label family practitioners as “holistic.” I didn’t like his discussion of automated lab tests because he missed the opportunity to explain how ordering panels of tests to screen patients can do more harm than good by finding false positives. 

I particularly liked his essay on “Doing Nothing.” Treatment is not always necessary and sometimes the decision to do nothing is actually doing something. It ties in with what I wrote about “Not Treating – A Neglected Option.”  

He says,

In my opinion, CAM is often neither complementary, alternative, nor medicine.

But his criticism of alternative medicine is weak. He falsely conflates chiropractic with massage. Instead of excoriating the idiocy of therapeutic touch he merely calls it a “treatment that sometime works but is actually doing nothing.” In criticizing CAM his approach is more like that of Caspar Milquetoast than like the respectfully insolent snarkiness of our esteemed colleague Orac.

 The book is derived from his previous writings over the last 60 years, everything from lectures to letters to the editor. It shows. It is fragmented, with short chapters on a variety of unconnected subjects. He has a lot of solid information and clinical wisdom to share, but his material is not well organized and suffers from an awkward, stilted style of writing. Some of the examples he uses are ill-chosen. 

That said, the book might appeal to laymen and it might serve to get some very important points across to the public. The catchy title might persuade people to read it who would not otherwise be exposed to these ideas.

It was a delight to read a new book   about a doctor who was exposed to real flak in Iraq. His story is a wonderful reminder of how effective modern medicine is and it is an eye-opener about the selfless dedication of doctors who put themselves in harm’s way; who accept lower incomes, separation from families, and poor living conditions; who care desperately about their patients; and who magnanimously apply the same skills to treating friend and foe. 

The title is Coppola: A Pediatric Surgeon in Iraq. The author, Chris Coppola, is an Air Force pediatric surgeon who was twice deployed to Balad Air Base, 50 miles north of Baghdad, as a trauma surgeon. In his first night on call, he treats the five worst gunshot injuries he has ever seen – and they are all in the same patient! Despite serious damage to liver, colon, small intestine, pancreas, duodenum, vena cava and spine, the patient, a 22 year old Iraqi policeman, recovers. As the foreword of the book explains, the survival rate for troops injured in the field was 20% in WWI, 40% in WWII, 66% in Viet Nam, and is now an astounding 97% in Iraq. Lessons learned in war are translated to civilian trauma care and we all benefit from the knowledge however much we may deplore the war. 

No subluxations were adjusted, no qi manipulated, no acupuncture points stimulated, no homeopathic or herbal medicines given. Beside numbers like these, alternative medicine looks pretty puny and irrelevant. And the Air Force’s initiative to train doctors in battlefield acupuncture looks frankly delusional. 

Coppola is in Iraq during the first elections. An elderly woman is the victim of an IED (Improvised Explosive Device) detonated near a line of people waiting to vote. As they prepare her for surgery to stabilize her broken bones, she proudly holds up her right index finger with the purple ink stain showing she voted. They also treat a 17 year old girl who was shot in the neck at a polling place and will likely never walk again. They treat a small child with a skull fractured by shrapnel while waiting with his father in a voting line. Children are particularly at risk from IEDs: their heads are proportionately larger and they are closer to the ground. 

They treat an insurgent whose bomb detonated prematurely. He is a would-be murderer, but all Coppola sees is “a dying man who needs our treatment.” 

He has to work through translators. Cultural differences intrude as he tries to explain to a father that his baby “boy” is really a girl with an intersex condition. Such a child would be raised as a girl in the US, but the Iraqi father violently objects to that option because of cultural prejudice against females. 

They treat many Iraqi citizens and are worried when they release them because they are not likely to get adequate follow-up care. The Iraqi medical system has been devastated: doctors have fled, supplies are impossible to get. The Iraqis are not taxed: the government is funded only by oil sales and foreign aid. They do colostomies meant to be temporary but know it is unlikely their patients will ever be able to get the colostomies taken down. They see Iraqis with soiled towels wrapped around their colostomies because they can’t get colostomy bags. When a colleague wonders if they should send a patient to a burn facility, he is told “We are the burn facility in Iraq.” 

The Iraqi children he treats are small for their age and malnourished. Nutritious food is part of the medical treatment. They discover that a Kurdish refugee boy is only taking a few bites of his meals and hoarding the rest to take home to his family. They persuade him to eat by offering him Oreos and enough other donations from their own care packages to fill two large bags to take home. 

Coppola paints a vivid picture of deployed life: eating MREs (Meals Ready to Eat), jogging with 35 pounds of body armor and other protective equipment, suffering through the “hurry up and wait” military hassles, having to wear a gun in the OR during alerts, taking cover from incoming missiles, desperately missing his family. There is a signpost with the distance to various cities around the world, topped by a sign “Hell – 0 miles.” And yet he is more than willing to go back for a second deployment because he knows how badly he is needed. 

He treats casualties from the battle at Abu Ghraib prison, where prisoners and insurgents mounted a coordinated attack on the guards. Iraqis tell him they were not surprised to learn that prisoners had been tortured by Americans. They assumed that torture was being used – torture had always been a part of that prison, and far worse had happened under Saddam Hussein, attested to by the adjacent mass graves. Not that that’s any excuse. 

By his second tour, the patient population had changed. After the troop surge, Al Qaeda was no longer so brave about attacking Americans; now they concentrated on civilian targets, even including schools. Instead of American and Iraqi soldiers, now most of their patients are civilians and 1/3 of them are children. 

One of the most affecting stories in the book is that of Leila, a little girl who was extensively burned by an incendiary bomb thrown into her home. Her father was an Iraqi officer who had been successfully subduing the insurgents in his area and this was an act of revenge. Coppola is doing a complicated skin graft procedure on Leila when an emergency intervenes to commandeer his OR; he has to improvise to save the grafts and free up the OR as soon as possible. He treats her tenderly for a couple of months and is devastated when she eventually dies of a complicating infection. Later an Iraqi adult patient is taken away by guards. Coppola learns that that patient was the one who had thrown the firebomb into Leila’s house – and the American hospital had saved his life. And he later learns that Leila’s father is killed by insurgents. 

Another detainee is ungrateful even after several life-saving operations. He only speaks to repeatedly vow to shoot them all. 

Coppola is in the OR during a Christmas USO show with Robin Williams, Lance Armstrong, Miss USA, Kid Rock, Lewis Black and other celebrities. He is sorry that he missed the concert but says he couldn’t have enjoyed it knowing a child was waiting to be operated on. He says, “Each new injured child I see seems to rip the scab off a wound in my heart that won’t let me rest.” One of the reasons he chose surgery over pediatrics is that he is so distressed when he has to cause pain to an awake child. 

Coppola accepted an Air Force scholarship and advanced training that obligated him to 6 years of pay-back service. He points out that this meant a financial disadvantage. In 3 years in private practice he could have paid off any medical school debts and still have had a greater income than his Air Force salary for 6 years. He joined the Air Force because he wanted to serve his country. He went to Iraq because he had signed a contract and was obligated to go wherever they sent him.  Some of his colleagues supported the war, some did not, but they were all there to save lives. All were volunteers. 

One word kept running through my mind as I read this book. It is a word seldom used these days. The word is “honor.”

Unfortunately, last week the latest celebrity know-nothing to promote health misinformation released a brand new book and has been all over the airwaves, including The Today Show, Larry King Live, and elsewhere promoting it. Yes, I’m talking about Suzanne Somers, formerly known for her testimonial of having “rejected chemotherapy and tamoxifen” for her breast cancer, as well as her promotion of “bioidentical hormones,” various exercise devices such as the Thighmaster and all manner of supplements. Her book is entitled Knockout: Interviews with Doctors Who Are Curing Cancer–And How to Prevent Getting It in the First Place. It is described on the Random House website thusly:

In Knockout, Suzanne Somers interviews doctors who are successfully using the most innovative cancer treatments–treatments that build up the body rather than tear it down. Somers herself has stared cancer in the face, and a decade later she has conquered her fear and has emerged confident with the path she’s chosen.

Now she shares her personal choices and outlines an array of options from doctors across the country:

EFFECTIVE ALTERNATIVE TREATMENTS

• without chemotherapy
• without radiation
• sometimes, even without surgery

INTEGRATIVE PROTOCOLS

• combining standard treatments with therapies that build up the immune system

METHODS FOR MANAGING CANCER

• outlining ways to truly live with the diease

Since prevention is the best course, Somers’ experts provide nutrition, lifestyle, and dietary supplementation options to help protect you from getting the disease in the first place. Whichever path you choose, Knockout is a must-have resource to navigate the life-and-death world of cancer and increase your odds of survival. After reading stunning testimonials from inspirational survivors using alternative treatments, you’ll be left with a feeling of empowerment and something every person who is touched by this disease needs…HOPE.

I first found out about Somers’ book about a month and a half ago and was fortunate enough (I think) that one of my readers who had a review copy of the book sent me a chapter list. The reason I wanted a chapter list was because I was really curious just who these doctors were whom Somers had interviewed. In particular, back then I predicted (and hoped) that one of the doctors would be one whom we’ve met before. It was. Can you guess which one? Think about it. What major study did I blog about in the middle of September? What form of cancer quackery has been covered so ably by Kimball Atwood since the very beginning of this blog? No, no, you don’t have to go back to the archives and search. I’ll tell you:

Dr. Nicholas Gonzalez. He’s the second featured doctor who is “curing cancer,” right there in Somers’ book in Chapter 6!

That’s right, one of these doctors who are “curing cancer” is a quack (in my opinion, of course) whose “protocol,” which includes 150 supplement pills a day topped off by a couple of coffee enemas per day, was recently shown to be worse than useless for pancreatic cancer and, indeed, based on a recent study, far worse than conventional treatment.

From my perspective, it was incredibly bad timing and bad luck on Somers’s part to have one of the subjects she lionized in your book to have his protocol shown to be not just worthless, but likely actively harmful, a mere two months before the release of her book. In case there are any journalists who might be interviewing Somers and are interested in more than a puff piece that lets her promote her book, I list all the posts on Science-Based Medicine that have discussed the rank pseudoscience that is the Gonzalez protocol because, as many of you have figured out, I’m never satisfied with a hammer to smack down a form of woo when going nuclear is so much more fun:

• “Gonzalez Regimen” for Cancer of the Pancreas: Even Worse than We Thought (Part I: Results)
• “Gonzalez Regimen” for Cancer of the Pancreas: Even Worse than We Thought (Part II: Loose Ends)
• Tom Harkin, NCCAM, health care reform, and a cancer treatment that is worse than useless
• Cancer Quackery is Dangerous – The Gonzalez Treatment
• The Ethics of “CAM” Trials: Gonzo (Part I)
• The Ethics of “CAM” Trials: Gonzo (Part II)
• The Ethics of “CAM” Trials: Gonzo (Part III)
• The Ethics of “CAM” Trials: Gonzo (Part IV)
• The Ethics of “CAM” Trials: Gonzo (Part V)
• The Ethics of “CAM” Trials: Gonzo (Part VI)
• The “Gonzalez Trial” for Pancreatic Cancer: Outcome Revealed

Sadly, this bad timing appears to have had no effect whatsoever on the publicity blitz of an actress who every day tries to live down to the character she played on Three’s Company back in the 1970s or on the questions asked of her by interviewers. Somers has been all over the media this week, and I’ve seen nary a challenging question stronger than pointing out that some of the doctors featured in Somers’ book have gotten in trouble with their state medical boards, much less a much deserved question about Nicholas Gonzalez. Instead we’ve thus far been treated to cliched, credulous headlines like Suzanne Somers questions chemo in new book, Somers’ New Target: Conventional Cancer Treatment, or Suzanne Somers works to ‘Knockout’ cancer. The article circulating about her book on the AP wire begins:

Less than a year after the former sitcom actress frustrated mainstream doctors (and cheered some fans) by touting bioidentical hormones on “The Oprah Winfrey Show,” she’s back with a new book. This one’s on an even more emotional topic: Cancer treatment. Specifically, she argues against what she sees as the vast and often pointless use of chemotherapy.

Somers, who has rejected chemo herself, seems to relish the fight.

Let’s get one thing straight here. It is most definitely not, as implied by various articles about Somers, in any way amazing that Somers is still alive after having “rejected chemotherapy.” As I explained at the dawn of this blog, Somers had a stage I tumor with a favorable prognosis. If Somers is going to play the gambit of repeating, “I rejected chemotherapy and tamoxifen and I’m still alive” and attributing her survival to the alternative medicine woo she chose instead, perhaps now is the time to go into more detail than I’ve ever gone into before about her case. Well, not quite. I did go into quite a bit of detail in my talk at the Science-Based Medicine Conference at TAM7 in July. After all, I did the research; so I might as well get some more use out of it and spread it beyond the 150 or so people who heard my talk.

Prelude by flashback: Suzanne Somers’ breast cancer

In preparation for my talk at TAM7, I searched for all the information I could find that was publicly available about Suzanne Somers’ diagnosis of breast cancer back in 2000. For your edification, I’ve also uploaded the slides from my presentation relevant to Suzanne Somers’ breast cancer diagnosis as a PDF file. Suffice it to say, there is a great deal of misunderstanding of breast cancer in Somers’ testimonial. In this case, I don’t actually blame Somers all that much for her misunderstanding, because it is a very common misunderstanding that clearly derives from a misunderstanding of the difference between using chemotherapy for primary treatment of cancer versus adjuvant treatment of cancer. In early stage breast cancer, which can be surgically removed for cure, chemotherapy and radiation therapy are in general used as additional therapies that decrease the risk of recurrence of the cancer after surgery. That’s what adjuvant therapy is, extra therapy that improves a patient’s odds of surviving after a primary treatment. In the case of early stage breast cancer, the primary treatment is surgery.

From what I can find from publicly available information on the Internet (I’ve never read one of Suzanne Somers’ books), at age 54 Somers was diagnosed with a breast cancer that was treated by lumpectomy (excision of the “lump” or tumor) and a sentinel lymph node (SLN) biopsy, the latter of which was negative for tumor cells in the SLN, plus radiation therapy. For those not familiar with the SLN procedure, it is a procedure that developed in the 1990s to determine whether a woman’s breast cancer has spread to the axillary lymph nodes (the lymph nodes under the arm) without actually removing all of the axillary lymph nodes. Before the advent of SLN biopsy, the standard of care was to do an axillary dissection (removal of all the lymph nodes under the arm) on the side of the tumor in order to determine if and how many of the lymph nodes are positive for cancer. This is critical information, because the single most powerful prognostic indicator for potentially curable breast cancer (i.e., breast cancer that has not spread beyond the axillary lymph nodes to the rest of the body, such as bone, liver, or lung) is the presence of metastases in the axillary lymph nodes and, if they are present, how many. Unfortunately, as less invasive means of treating breast cancer were developed, such as lumpectomy, the part of the operation that carried the most morbidity was the axillary dissection. Consequently, as science-based physicians are wont to do, during the 1990s surgeons tried to find a way to get the same information (are the lymph nodes positive or negative) with a less morbid procedure and thus reserve axillary dissection only for patients who do have lymph nodes with breast cancer metastases in them.

Thus, the SLN biopsy was developed as a strategy to decrease the possibility of the most feared complication of axillary dissection, lymphedema, and still get the necessary information regarding lymph node positivity or negativity. Basically, an SLN biopsy is preformed by injecting both a radioactive dye and a blue dye (usually Lymphazurin Blue) into the breast. The dyes are then taken up in the lymphatics and head towards the axilla, where they lodge in one or more lymph nodes. This is (these are) the sentinel lymph node(s). The concept behind the procedure is that the sentinel node is the first lymph node a tumor cell that broke off from the tumor and got into the lymphatics will “see” and lodge in. In other words, the dye mimics the pathway that tumor cells take to metastasize to the axillary lymph nodes. If the sentinel node is negative, it’s an accurate indication that the rest of the lymph nodes are negative, and in general no further surgery is needed. Women are identified as node negative without removing all the axillary lymph nodes. Best of all, the risk of lymphedema from the procedure very, very small, far smaller than it is for axillary dissection (removing all the lymph nodes). Since the purpose of axillary dissection was far more diagnostic (to find out if the lymph nodes are contain tumor and, if so, how many), this is a good thing. On the other hand, if the SLN contains tumor, then axillary dissection is needed. In fact, far fewer women now undergo the procedure than in the past, and it is even coming under question whether a woman with a positive SLN truly needs a full axillary dissection.

Why do I mention this? Because I want readers to understand that Somers underwent, as far as I can tell, standard surgery for a favorable, estrogen receptor-positive stage I cancer. She also underwent radiation, although she has stated in the past and now states in Knockout that, if she had it all to do over again, she would not have opted for radiation. Be that as it may, she has been trumpeting proudly for a number of years that she rejected chemotherapy and tamoxifen and has done quite well. This claim, although true, says nothing about whether he decision to eschew those adjuvant therapies was a good one and even less about whether the woo she pursued after that had anything to do with her survival. As I described so long ago, however, surgical excision is curative for most small breast cancers. Radiation therapy reduces the risk of local recurrences (recurrences in the breast), and chemotherapy and antiestrogen therapy (like Tamoxifen) reduce the risk of systemic recurrences (recurrences elsewhere in the body). In other words, chemotherapy and radiation are “icing on the cake” after surgery. Indeed, there is a website known as AdjuvantOnline.com that allows physicians to calculate the estimated risk of recurrence and the estimated benefit of chemotherapy and, if appropriate, antiestrogen therapy. Given when Somers had her cancer diagnosed (2000) and because I know that she had a stage I tumor, i entered data for her assuming a tumor between 1-2 cm in size, mainly because most tumors under 1 cm would not warrant adjuvant chemotherapy. Here is a blowup of the key slide from my talk where I showed the results I got when I entered the known information about Suzanne Somers’ tumor into AdjuvantOnline:

(Click for a larger image.)

As you can see, based on what we know from publicly available sources, Somers had an 88.6% chance of living 10 years without any chemotherapy or Tamoxifen. Chemotherapy provides a survival advantage of 2.5%; tamoxifen, 2.5%; and combination therapy, 4.1%. In other words, eschewing chemotherapy and tamoxifen increased Suzanne Somers’ odds of dying of her cancer within 10 years by around 4%, not a huge number. As I’ve explained before, although the benefit of chemotherapy and tamoxifen for early stage breast cancer is around 30% on a relative basis, but it’s only around 4% or 5% on an absolute basis. You may think that’s not very much, but, I assure you, the vast majority of women are willing to undergo chemotherapy and hormonal therapy for that extra insurance. Indeed, I would point out that surveys I have seen have revealed that a majority of women would still opt for chemotherapy even if it provided only a 1% absolute survival benefit. Moreover, for more advanced tumors, that relative benefit generally stays around 30% or so, meaning that, as the risk of dying from cancer goes up, the absolute benefit of adjuvant chemotherapy goes up as well. Be that as it may, I’ve laid out this information to point out that testimonials like Somers’ are not particularly impressive if you know something about breast cancer. I also mention it to point out that, even though it’s a bad idea for Somers to be pumping herself full of “bioidentical hormones,” the favorable nature of her tumor means that she can get away with it. Even if it increased her risk of recurrence by 10 or 20%, the odds of survival would still be overwhelmingly in her favor, adjuvant chemotherapy and tamoxifen or not, thanks to her friendly neighborhood surgeon. So when you see a passage like this about Somers, remember what I’ve just told you:

Diagnosed with breast cancer a decade ago, she had a lumpectomy and radiation, but declined chemotherapy, as she did more recently when briefly misdiagnosed with pervasive cancer.

As I said before, Somers’ misunderstanding of the role of adjuvant therapy in breast cancer is somewhat understandable. It is a concept that can be difficult to communicate this to patients under the best of circumstances, and the absolute benefit of chemotherapy in treating a stage I ER(+) cancer is relatively small. Moreover, treatment paradigms change with new scientific evidence. Most women these days with a stage I ER(+) tumor would undergo Oncotype DX® testing, and the results of that testing would guide the decision of whether chemotherapy is recommended or not. Oncotype DX did not exist in 2000, and adjuvant chemotherapy was recommended for the vast majority of women with a stage I breast cancer with a tumor greater than 1 cm in diameter.

Somers’ second testimonial, however, is not as forgivable as the first, which is actually only somewhat forgivable, given how aggressively Somers has used her own testimonial to promote “alternative” medical treatments such as mistletoe extract (which may have some anti-tumor activity but the evidence is very weak–more on that perhaps in a future installment). It reveals such a profound ignorance of what she herself is recommending to women for their “health” that, as a breast cancer surgeon dedicated to providing only the best science-based surgical and medical care to my patients, I must call her out for it.

Knockout: Suzanne Somers’ “whole body cancer” scare

I do not yet have my promotional copy of Knockout, although, I’m assured, it’s on the way. I had debated whether to wait until I had read it to write about the book, but then last week I saw this interview with Ann Curry:

It was also pointed out to me that Chapter 1 of Knockout is available online at the Random House website. It’s entitled A Cancer Story–Mine. I read it and was appalled at the degree of misinformation being discussed right there in the very first chapter of the book, so much so that I started to doubt whether it was such a good idea of me to get a copy of the whole book and do a review on it. Still, I’m made of fairly stern stuff, and Somers is out there promoting the hell out of this book; so I feel that it’s my duty to look critically at the story she begins her book with. Suffice it to say, after I read Chapter 1, I was left shaking my head that anyone would listen to Suzanne Somers about cancer or any other health issue, so deep is the ignorance and so strong the distrust of “Western medicine.” Somers starts out her book by describing a cancer scare. Specifically, she describes an incident in which she was brought to the hospital with what sounds like an anaphylactic reaction of some sort and was misdiagnosed with what she calls “full body cancer.”

Before I go on, let me say right here that I do not mean to denigrate or otherwise downplay the seriousness of what happened to Somers, nor do I mean to cast doubt on the veracity of her story. At the very least, Somers appears to believe what she is saying, and it is quite possible that she was misdiagnosed with widespread metastasis from her breast cancer. I also don’t want to under estimate how much it probably scared her. Imagine yourself having survived breast cancer and then, eight years later, being admitted to a hospital for something else and being told that you had widespread metastases. It’s a horrible thing, if it really happened the way Somers said it happened, and it’s the sort of experience that would terrify anyone.

Color me somewhat skeptical, however.

Certain elements of Somers’ story sound a bit fishy. First off, Somers declines to identify the hospital. Right at the outset, I wondered why that is and can guess at a couple of likely reasons. First, perhaps she’s worried about being sued. Of course, if you’re a celebrity and the truth is on your side you probably don’t have much worry about being sued. In such a case, it’s far more likely that the entity suing would get the worst of it, at least as far as negative publicity. More likely, Somers knows that, whatever hospital she had been admitted to and whatever doctors had cared for her, patient confidentiality and HIPAA law prevent the hospital and doctors from discussing her case–or even admitting that Somers was ever a patient. Indeed, neither the hospital nor any of the health care professionals involved with Somers care can discuss her case without her explicit permission. Their hands are completely tied, and Somers can write and say whatever she wants without fear that anyone will contradict her. That’s why it disturbs me that no one who has interviewed Somers yet has asked her a handful of very obvious–and inconvenient–questions based on the anecdote in Chapter 1, namely:

• At what hospital were you hospitalized and when?
• Who were your doctors?
• Will you release some of your medical records and allow your doctors to speak about your hospitalization?
• If not, why not?

These are questions that need be asked in addition to questions about Somers’ support for Nicholas Gonzalez, whose pancreatic cancer “protocol” was recently shown to be worse than useless, but I have yet to see anyone ask her these questions.

Now, on to Chapter 1:

I wake up. I can’t breathe. I am choking, being strangled to death; it feels like there are two hands around my neck squeezing tighter and tighter. My body is covered head to toe with welts and a horrible rash: the itching and burning is unbearable.

The rash is in my ears, in my nose, in my vagina, on the bottoms of my feet, everywhere — under my arms, my scalp, the back of my neck. Every single inch of my body is covered with welts except my face. I don’t know why. I struggle to the telephone and call one of the doctors I trust. I start to tell him what is happening, and he stops me: “You are in danger. Go to the hospital right now.” I knew it. I could feel that my breath was running out.

Right off the bat, to me Somers’ symptoms sound like an allergic reaction to something or an anaphylactic reaction. It could be something else (more later), but the first thing that comes to mind is an allergic reaction. Indeed, upon hearing this story, I couldn’t help but wonder if one of the many supplements that Somers takes on a routine basis was the cause. Did she start any new supplements recently? Certainly I’d wonder about that. (Again, more on that later; my speculation may well have been correct, just not in the way I thought at first.) Regardless of the initial cause, it certainly sounded as though the E.R. docs at whatever hospital Somers was brought to thought she was having some sort of allergic reaction. Based on that, they treated her appropriately with Benadryl, Albuterol, and steroids. Even someone as medically ignorant as Somers realized the most likely diagnosis:

I say to the doctor, “It seems to me that I’ve either been poisoned or am having some kind of serious allergic reaction to something. I mean, doesn’t that make sense? The rash, the strangling, the asphyxiation. Sounds classic, doesn’t it?”

“We don’t know. A CAT scan will tell us. I really recommend you do this,” the doctor says. “Next time you might not be so lucky — you might not get here in time. You were almost out.”

As I read this part of the story, I was puzzled, and certainly Somers didn’t initially give enough information for me to hazard a particularly educated guess about why her doctor ordered a CT scan. After all, a CT scan is not generally the test of choice for diagnosing the cause of anaphylaxis or respiratory distress, which is what it sure sounds as though Somers was being treated for. On the other hand, maybe doctors saw a mass on chest X-ray (quite likely, as we will soon see). They may also have suspected a pulmonary embolus (PE), for which chest CT has supplanted the older test previously to detect PE, namely the V-Q scan. There may have been other findings on physical examination that suggested that a CT scan might be indicated. (There almost certainly were.) Again, initially, at least, Somers doesn’t give us enough information to judge. She does, however, engage in typical pseudoscientific thinking. While acknowledging that those evil pharmaceuticals had saved her life, still she can’t help but attack them:

I am now dressed in a blue hospital gown, and so far I’ve been reinforced by three rounds of oxygen and albuterol. I’m starting to feel normal again. Drugs have been my lifesaver this time. This is what they are for. Knowing the toxicity of all chemical drugs, I’ve already started thinking about the supplement regime and detox treatments I’ll have when I get out of here, to get all the residue of pharmaceuticals out of me. I’m hopeful this will be the one and only time I have to resort to Western drugs.

Remember, whenever you hear an alt-med maven say “Western medicine” (shades of Bill Maher!), what that alt-med maven is really referring to is science-based medicine. As for supplements, if they have anything in them that does anything physiological, they contain “chemical drugs.” There is no difference between “chemical drugs” found in pharmaceuticals and “chemical drugs” found in supplements, other than that the drugs found in supplements are adulterated with all sorts of stuff. There is no magical difference between the two. They both contain chemicals, and the body responds to chemicals through its biochemistry. Nothing makes supplements magically immune to the laws of physics and chemistry. Moreover, “detox” treatments are completely unnecessary quackery. Somers apparently doesn’t realize it, but her body is more than capable of “detoxing” away those evil “Western” pharmaceuticals through its own amazing abilities. Somers appears to think that “Western” pharmaceuticals somehow leave their taint behind. Maybe she thinks the cells in her body have a “memory” in the same way that homeopaths claim that water has “memory” and that the taint has to be somehow purged, just as a Catholic believes that confession purges sins or certain Muslim sects think that self-flagellation will purge them of their sins. It really is religious thinking more than anything else for Somers to think that she was somehow “contaminated” by “Western” pharmaceuticals and needed to have that “contamination” purged.

But I digress. So what did the CT scan find? This, apparently:

We have very bad news,” he continued. My heart started pounding, like it was jumping out of my chest. “You have a mass in your lung; it looks like the cancer has metastasized to your liver. We don’t know what is wrong with your liver, but it is so enlarged that it is filling your entire abdomen. You have so many tumors in your chest we can’t count them, and they all have masses in them, and you have a blood clot, and you have pneumonia. So we are going to check you into the hospital and start treating the blood clot because that will kill you first.”

We already know that Somers did not, in fact, have cancer. (Otherwise, it would not have been a misdiagnosis.) So what she did have, I’ll get to shortly. In the meantime, let’s take a look at what Somers says about her oncologist:

The oncologist comes into my room. He has the bedside manner of a moose: no compassion, no tenderness, no cautious approach. He sits in the chair with his arms folded defensively.

“You’ve got cancer. I just looked at your CAT scan and it’s everywhere,” he says matter-of-factly.

“Everywhere?” I ask, stunned. “Everywhere?”

“Everywhere,” he states, like he’s telling me he got tickets to the Lakers game. “Your lungs, your liver, tumors around your heart … I’ve never seen so much cancer.”

So the oncologist who saw Somers first was a world-class jerk. It’s quite possible. Not every doctor has a good bedside manner, and some have a horrendous bedside manner. Sadly, some of them are oncologists, even though, if there’s a specialty that really demands a good bedside manner, it’s that of medical oncologist. On the other hand, as physicians we have to remind ourselves all the time that what we think we have said to the patient is not always how the patient has heard it and how we come across to the patient is not always how we have, in fact, come across to the patient. Maybe the oncologist was that uncaring, maybe not. We have no way of knowing because all we have is Suzanne Somers’ report. Maybe it’s also true that the other oncologist who saw her was somewhat less of a jerk but just as quick to jump to a conclusion prematurely:

Then the lung cancer doctor enters the room. Maybe he has better news. But no—he says, “I just looked at your CAT scan, and you have lung cancer that has metastasized.” He is nicer, more thoughtful. “I mean, I’m going to think about this,” he says. “Maybe it’s something else, but this sure doesn’t look good. I’ll be back tomorrow.” Leslie takes out pen and paper and is making notes. She will continue to do this the entire week, writing down everything everyone is saying. Thank God, because when you are stunned and on medication, things get foggy.

Day one is almost over. The most shocking, devastating day of my life, our life! I know the facts: when you have lung cancer and it has metastasized to your liver, heart, abdomen, and all over your body, you have at most two months—maybe only two weeks or less.

As a possible bit of perspective, I’ll point out that not too long ago I had to relearn the lesson of how my perception of what I say to a patient may not always jibe with the patient’s perception of what I said. A while back, I saw a patient with breast cancer in her hospital room, a woman I had operated on the day before. I thought I had calmly laid out the situation, reassured her that her tumor was treatable, and told her that she might not need chemotherapy. About an hour later I got a frantic page from the floor. The patient was in tears, and the family was in an uproar. I don’t know how I had done it, but I had somehow given this patient the impression that her situation was hopeless and that she was going to die. When her family arrived to take her home she was crying. Apparently she had interpreted my telling her that she might not need chemotherapy (mainly because of her age and tumor characteristics) as telling her that it was pointless to treat her more. I relearned a valuable lesson that day, one I (and, I daresay, most doctors, no matter how experienced) need to relearn periodically, namely that patients don’t always interpret what I tell them the way I think they will and that sometimes how I view a conversation with a patient may be very different than how the patient viewed the conversation. Fortunately, I was able to reassure everyone and correct the misconceptions that had been left, but I did not feel too good about my bedside manner that day. In fact, the rest of that day I felt like the most insensitive, idiotic doctor in the world.

Or maybe Suzanne Somers’ oncologist was indeed a flaming jerk. That would be the worst case for “Western medicine” in this story, and it is not nearly as uncommon as I’d like to admit for a physician to have the personality of a paper cup or the bedside manner of bully. Besides, it’s easier to assume that that is how the oncologist in question treated Somers. Even so, in that case, I’d say, “So what?” I’m sorry that Somers’ oncologist treated her badly. There’s no excuse for that. I’d also tell her simply to go and get another oncologist or go back to her regular oncologist, which she ultimately did. One nasty doctor does not invalidate “Western medicine,” nor does the occurrence of a misdiagnosis, even one apparently this spectacular. In any case, it’s quite possible that there was a bit of Somers hearing things one way when her doctors weren’t telling it the way she interpreted them as telling her. The reason I say that is because Somers goes on and on, mainly in interviews but also in the book, about how, over six days, doctors told her she needed chemotherapy. As someone who has dealt with medical oncologists every day for over 10 years, that part of her story just didn’t seem very likely to me. The reason is that, in general, oncologists are very reluctant to administer chemotherapy to a patient in the absence of a definite tissue diagnosis proving that they have cancer, be it metastatic cancer or any cancer.

This would be doubly true in a case like what Somers describes in her book, particularly given that she had one oncologist thinking that she had lung cancer, not a recurrence of her breast cancer. In any case, widespread cancer could be a recurrence of her breast cancer (especially given Somers’ proclivity to pump herself full of “bioidentical hormones” after having been treated for an estrogen receptor-positive cancer), but in a 63-year-old woman, there are lots of other possible malignancies. Chemotherapy would be used for breast cancer might not work very well against, say, colon cancer or ovarian cancer, both of which are other likely possibilities in a woman of Somers’ age. Another reason I seriously question whether doctors were pushing hard for chemotherapy in a mere six days is because, if they truly thought she had such a massively widespread recurrence of her breast cancer, particularly an estrogen receptor-positive breast cancer, all treatment would be palliative. We can’t cure most metastatic solid tumors, and the first rule in treating stage IV disease is usually the classic “First, do no harm.” Thus, oncologists usually tend to do the minimum possible that it takes to relieve symptoms and (hopefully) slow the progression of the tumor. Most likely, if this was indeed metastatic breast cancer, an oncologist would have chosen to treat Somers first with an anti-estrogen drug, probably an aromatase inhibitor (no tamoxifen if she had blood clots causing that much trouble!) and then seen how she did. In the case of a woman who has ER(+) cancer recur as stage IV disease, that is almost always the first option. In such cases, chemotherapy is usually reserved for the case when antiestrogen therapy fails. Indeed, if the cancer was truly as widespread as Somers reports, chemotherapy might not even be used at all if the likelihood of success is tiny; in such cases, hospice would be recommended.

Be that as it may, the very first thing that any competent oncologist would demand before initiating chemotherapy is a tissue diagnosis, either from a needle biopsy or other tissue, to prove that there was cancer and to identify the type of cancer, so that the correct chemotherapy could chosen. Cancer chemotherapy is not like antibiotic therapy. In the case of infectious diseases, it is not uncommon to begin an antibiotic empirically based on the most likely organisms to be causing the infection and then to tailor the therapy to whatever organism(s) can be identified by cultures. Oncologists, on the other hand, are incredibly reluctant to treat metastatic cancer empirically, particularly cancer that appears to have recurred eight years after the original diagnosis of a stage I tumor. Such cancer might very well be a different cancer from a different organ, and the chance of doing harm with chemotherapy for no benefit is too great.

That’s why I thought right away that there’s something very fishy about Somers’ story. It just doesn’t add up very well. What I suspect to have happened is that perhaps the oncologist did have a conversation about a probable need for chemotherapy, and, like my conversation with my postoperative patient, Somers saw the conversation differently from how her doctors did. She probably viewed various “what if” scenarios or “if this is recurrent breast cancer, then you will need this” conversations as “pressuring” her to take chemotherapy. If her oncologist wasn’t particularly warm and fuzzy or patient, she might have been even more likely to interpret his recommendations that way. Or perhaps her oncologists were incompetent enough to pressure her to take chemotherapy without a diagnosis of biopsy-proven cancer. Who knows? Even if the latter is true, it still doesn’t excuse Somers’ horrible ignorance that becomes manifest later in the chapter.

Ultimately, Somers did get a biopsy. She describes it in her interview above, “They cut into my neck and went in and took a piece of my lung, a piece of one of the so-called tumors around my heart turned out it was not cancer at all.”

So what was it?

I’ll admit that my first guess, sarcoidosis, was dead wrong. Given the symptoms of skin lesions, shortness of breath, and, apparently, “tumors around the heart” (which could indicate either pericardial involvement, or, more likely enlargement of the paratracheal nodes), I didn’t think it too unreasonable a first guess. (Besides, in the cases in House, MD, sarcoidosis almost always appears on the differential diagnosis list.) However, never having lived in the southwest, having forgotten my medical school learning about common fungal infections, and being what I self-deprecatingly like to call a dumb surgeon, I didn’t consider what turned out to be the real diagnosis right away, namely valley fever, or, as it’s known by its official name, coccidioidomycosis. Indeed, the description of the most severe disseminated form of coccidioidomycosis matches Somers’ presentation quite well:

The most serious form of the disease, disseminated coccidioidomycosis occurs when the infection spreads (disseminates) beyond the lungs to other parts of the body. Most often these parts include the skin, bones, liver, brain, heart, and the membranes that protect the brain and spinal cord (meninges).

The signs and symptoms of disseminated disease depend on which parts of your body are affected and may include:

• Nodules, ulcers and skin lesions that are more serious than the rash that sometimes occurs with other forms of the disease
• Painful lesions in the skull, spine or other bones
• Painful, swollen joints, especially in the knees or ankles
• Meningitis — an infection of the membranes and fluid surrounding the brain and spinal cord and the most deadly complication of valley fever

Now here’s the kicker. Take a look at these two (out of several) risk factors for the most severe form of coccidioidomycosis:

• Weakened immune system. Anyone with a weakened immune system is at increased risk of serious complications, including disseminated disease. This includes people living with AIDS or those being treated with steroids, chemotherapy or anti-rejection drugs after transplant surgery. People with cancer and Hodgkin’s disease also have an increased risk.
• Age. Older adults are more likely to develop valley fever than younger people are. This may be because their immune systems are less robust or because they have other medical conditions that affect their overall health.

These are risk factors for the serious disseminated coccidioidomycosis. Most people who contract coccidioidomycosis are either asymptomatic or exhibit relatively mild symptoms. Indeed, valley fever often presents as a flu-like illness from which people recover rapidly. Many people, in fact, are unaware that they’ve ever had coccidioidomycosis until there’s either an abnormality on chest X-ray done for another reason or they have a positive skin or blood test. It’s very much like histoplasmosis right here in the Midwest. So why did Somers get such a serious case? It’s a legitimate question, given how she represents her regimen of supplements, bioidentical hormones, and various other woo as a highly effective path to rejuvenation and health that she recommends to her readers. Let’s see. Somers is 63, but apparently in good health. She also takes all sorts of supplements which, or so she claims, “strengthen the immune system.” But her immune system was obviously not strong enough to prevent her from getting disseminated coccidioidomycosis. Why didn’t all those supplements ward off the fungus? For someone who takes handfuls of supplement pills every day and makes millions of dollars selling woo to “boost the immune system,” Somers sure doesn’t appear to have a particularly strong immune system, as it failed miserably to protect her from a severe infection due to an endemic fungus that usually causes only mild disease or any symptoms at all but almost killed her.

Another possibility presents itself. As we know from her previous books and appearances on The Oprah Winfrey Show, Somers takes boatloads of “bioidentical” hormones. She promotes them as a fountain of youth for women. One wonders if any of her various supplements or bioidentical hormones were somehow adulterated with corticosteroids, which suppressed her immune system, one does. Or at least I do.

One need wonder no more. Right there, in Chapter 1 of her book, is a highly plausible, highly likely explanation for why Somers became as ill as she did from coccidioidomycosis:

Day 5. Dr. Oncologist comes into my room. Now, you would think he’d say, “Well, sometimes it’s good to be wrong.” Or “Isn’t it great that you don’t have cancer?” But no. He walks in, doesn’t sit down, just looks at me and says angrily, “Well, you should have told me you were on steroids.”

I am flabbergasted. I don’t know what to say to him; I am so stunned by his lack of compassion that I just stare at him. I am not on steroids. I would never take steroids. But because he is stuck in old thinking and so out of touch with new medicine, he has no clue and doesn’t understand cortisol replacement as part of the menopausal experience.

I don’t know where to begin with him. He’s too arrogant to listen to a “stupid actress,” anyway. So much of his attitude with me has been the unsaid but definite “So you think all your ‘alternatives’ are going to help you now, missy?”

Why steroids would have anything to do with being misdiagnosed with full-body cancer, I can’t guess. But we still don’t know what has gone wrong in my body. We still have to find out what caused me to end up in the ER.

(Emphasis mine.)

It’s incredibly hard at this point not to go even beyond Mark Crislip-grade acid sarcasm at the arrogance of ignorance on display. Here we have a woman who is apparently taking cortisol as part of her “bioidentical hormone” cocktail, and this woman does not know that each and every one of those estrogens she is taking is a steroid hormone. More importantly, Somers apparently does not know that cortisol is a corticosteroid (”cortico,” get it?), the very same kind of steroid that is routinely used by us evil reductionist practitioners of “Western medicine” as an anti-inflammatory and immunsuppressant. When used that way by us evil pharma shills, cortisol is known as hydrocortisone, which is–gasp!–a pharmaceutical concoction! It’s also “bioidentical,” too, proving once more that “bioidentical” does not mean “risk-free.” Indeed, hydrocortisone is often included as one of the drugs in immunusuppressive protocols used to prevent the rejection of organ transplants. Given that Somers has said that she takes enough “bioidentical” estrogens to recreate the hormonal milieu of a woman in her 20s (in other words, far more estrogens than a 63 year old woman would ever have or need), it’s not beyond the pale to wonder whether she similarly takes a significant dose of hydrocortisone (sorry, cortisol) as part of her brew of “bioidenticals,” particularly in light of her having fallen seriously ill due to an organism that usually causes mild disease in immunocompetent hosts. Yes, valley fever can sometimes be a bad disease in immunocompetent hosts, but being immunocompromised for whatever reason is still a significant risk factor for disseminated disease or the reactivation of quiescent disease.

After reading Somers’ story in Chapter 1, I shook my head in disbelief that Random House apparently didn’t have better editors who could have told Somers that she had just written something incredibly contradictory and just plain dumb when she wrote that didn’t take steroids in the context of writing how she castigated her oncologist for “not understanding” the role of cortisol in her menopause treatments. Also, based on Somers’ (or her ghostwriters’) own words in Chapter 1 of her book, I think I have discovered the most likely explanation for Somers’ contracting disseminated coccidioidomycosis. True, it could be that she was just unlucky and getting old, given that age is indeed a risk factor for disseminated disease, but one can’t ignore all the supplements she was taking. One can’t ignore that Somers was apparently taking cortisol as part of the cocktail of “bioidentical hormones” to recapture her youth. It is thus very reasonable to wonder whether the reason that Somers became so ill last year was because she had been chronically dosing herself with cortisol and suppressing her very own immune system. Worse, Somers doesn’t even understand that cortisol is a steroid and an immunosuppressant and therefore can’t accept or admit that this is a possibility. Indeed, that misunderstanding is leading her to view her misdiagnosis as clear evidence supporting her worldview that “Western medicine” is hopelessly flawed, chemotherapy rarely works, and the “alternative” medicine doctors whom she interviews can actually cure cancers that “Western” medicine cannot. Even worse still, Somers is successful enough to be able to parlay her suspicion into a highly lucrative career, and her promotion of dubious, unproven, and even ineffective medical treatments for cancer may well result in cancer patients who might be saved eschewing science-based medicine and endangering their lives. At least, that is what I fear.

A panoply of unproven treatments and what’s to come

As I said before, I plan on looking at Knockout and writing a more formal review once I get my copy to read. That’s why this post is labeled “Part 1.” However, so incensed was I at the rank pseudoscience and dangerous misinformation being promoted relentlessly over the past week by a woman who is apparently utterly ignorant of what a steroid hormone is or that steroids are immunusuppressive that I decided to do this post now, while Somers’ media blitz is still at its height. I concluded that an antidote to Somers’ promotion of nonsense such as the Gonzalez protocol needed to be provided in clear, concrete, unequivocal terms was needed now, that someone needed to express his opinion now that pseudoscience such as the Gonzalez protocol is quackery, particularly given the limp, woo-friendly response of Dr. Otis Brawley, chief medical officer for the American Cancer Society. His article, Somers’ cancer advice is risky, appeared on CNN.com. In it Dr. Brawley practically bent over backwards to be conciliatory, calling Somers a “wonderful actress” (she’s not and never has been), writing that he is “not critical of the concept of alternative and complementary medicine” (I am) and that “open-mindedness to other ideas is how we advance conventional medicine” (apparently his mind is so open that his brains threaten to fall out), even going so far as to invoke the hoary old alt-med examples of aspirin being derived from tree bark or vincristine being derived from a plant as though pharmacognosy were the same thing as herbalism. It’s not. Moreover, I wanted to provide a handy-dandy resource for journalists who may be interviewing Somers or people who may be seeing her at book signings or promotional events, hoping against hope that skeptics will ask her why she doesn’t think a steroid like cortisol wouldn’t predisopose her to disseminated coccidioidomycosis or why she thinks that Dr. Gonzalez is “curing cancer” when a clinical trial was published a mere two months before her book was released that showing clearly that his protocol is worse than useless and that pancreatic cancer patients undergoing conventional therapy live three times longer than those undergoing the Gonzalez protocol.

A guy can hope, can’t he?

In the meantime, here’s a chapter list, which will give you an idea of what you have to look forward to when I get around to reading the book:

The Doctors Who Are Curing Cancer
Chapter 5: Stanislaw Burzynski, M.D.
Chapter 6: Nicholas Gonzalez, M.D.
Chapter 7: Burton Goldberg
Chapter 8: Julie Taguchi, M.D.
Chapter 9: James Forsythe, M.D.

Preventing Cancer Before it Starts
Chapter 10: Russell Blaylock, MD
Chapter 11: Steve Haltiwanger, MD
Chapter 12: David Schmidt
Chapter 13: Jonathan Wright, M.D.
Chapter 14: Steven Sinatra, M.D., F.A.C.C., F.A.C.N.
Chapter 15: Michael Galitzer
Chapter 16: Cristiana Paul, M.S.

Most names I actually don’t know, but some names stand out, such as Dr. Burzynski, whom we haven’t yet discussed much on this blog but should (reviewing this book will give me just that opportunity), and Dr. Blaylock, who is best known for videos like this about H1N1:

I’ll spare you parts 2 and 3 of Dr Blaylock’s video. You get the idea, and if you are masochistic enough top want to view them, you can easily find them on YouTube. Suffice it to say, showing up on Alex Jones’ Prison Planet TV is not exactly a way to burnish one’s scientific credentials. Jones’ websites, Infowars and Prison Planet, are repositories of conspiracy craziness on par with David Icke’s lizard people, including 9/11 Truthers, “New World Order” conspiracy theorists (including, of course, the Illuminati and the Rothschilds), and a heaping helping of anti-vaccine and alt-med conspiracy mongering. In fact, Dr. Blaylock isn’t too far from David Icke’s rant about how the swine flu vaccine is a plot by the Illuminati.

Such are Suzanne Somers’ “doctors who are curing cancer.”

The bottom line is that, whatever her intentions, whether they be to help people or make money or both, Somers is unwittingly promoting dangerous cancer “cures” that are anything but cures. They are treatments that are anything but science-based, as well. Just as Jenny McCarthy, Jim Carrey, and Bill Maher are promoting anti-vaccine pseudoscience to the nation and Oprah Winfrey is providing an unmatchable soapbox for all manner of promoters of woo, Somers is taking advantage of her position to bash conventional medicine and promote non-science-based medicine, most likely raking in the cash hand over fist.

People may well die as a result.

I’ll never forget the day when I argued for protecting parents against misleading and false information about the treatment of autism. I was working at a large consumer health organization whose mission was to “empower patients with accurate information” so that they could take control of their health. My opposition was himself a physician who requested that our organization publish an article that advised parents of children with autism to seek out DAN! practitioners and chelation therapy.

I prepared my remarks with the utmost care and delivered them to a committee of our lay executives. I cited examples of children who had died during chelation treatments, explained exactly why there was no evidence that chelation therapy could improve the symptoms of autism and in fact was based on the false premise that “heavy metals” in vaccines were implicated in the etiology of the disease. I concluded that it would be irresponsible for the company to publish such misleading advice/information for parents, and would in fact be counter to our entire mission.

My physician opponent suggested that it was our company’s duty to inform parents of all their options, that we should not be judgmental about treatments, and that I was part of a paternalistic medical establishment that tried to silence creative thinking.

The committee ended up siding with my opponent. I was flabbergasted and asked one of the committee members what on earth they were thinking. She simply shrugged and said that my opponent was more likable than I was.

This experience marked the beginning of my journey towards fighting fire with fire – understanding that being right is not the same as being influential, and that “winning” an argument (where lives are on the line) requires a different skill set than I learned in my scientific training.

Book Review

And so it was with great interest that I picked up Randy Olson’s book, Don’t Be Such A Scientist: Talking Substance In An Age Of Style. I was pleased to see that other scientists had experienced the same revelation – that we need to be more communication-savvy to become more societally-influential.

Olson’s book outline is simple: four “don’ts” and one “do.” Don’t be so cerebral, literal-minded, poor at telling stories, or unlikeable. Do be the voice of science. He begins his book with a captivating story: a marine biologist goes to Hollywood and is shredded by an acting teacher for being incapable of raw emotion. Most scientists will get a good chuckle out of this narrative and will relate to Olson’s culture shock.

As the book winds along, the reader is introduced to a series of the author’s former girlfriends. He reminisces:

She would listen to me talk and talk and talk to the old folks and finally, by the end of the day, she would have had enough. So her favorite thing to do in the evening was, when I was done talking, to look deeply, romantically, lovingly into my eyes and say in a soft and seductive Germanic voice… “You bore me.”… p.82

Another girlfriend developed an affectionate nickname for me, “Chief Longwind,” which she would abbreviate when I’d get going on something and just say, “That’s enough for tonight, Chief.” p.83

Unfortunately, as these ladies noted, Olson’s strong suit is not compelling dialog – a tragic irony for a book written to inspire more effective science communication. Nonetheless, since scientists are rarely deterred by boredom, I think that there are some conceptual gems worth unearthing.

These are my top 5 take-home messages:

1. Communicate in a human way – be humorous, tell stories, don’t feel as if you have to present all the details. The goal is to get people curious enough to ask more questions.

2. Broad audiences prefer style over substance – learn to be bilingual (to speak with academics versus a general audience).

3. Marketing is critical for influence. The creators of Napoleon Dynamite spent a few hundred thousand dollars on production and $10 million on advertising/marketing. The movie grossed $50 million. Scientists who wish to be influential (or get their message across broadly) must bow the knee to the marketing gods.

4. Some people are naturally good communicators, others are not. Find the good ones and make them  spokespeople. “The strongest voice is that of a single individual.” p. 166

5. Likability trumps everything. People make snap judgments about whether or not they like you, and your message’s impact is dependent upon your likability factor. Likability is related to humor, emotion, and passion. p. 148

And so, Don’t Be Such A Scientist offers some great food for thought – and I suppose if it hadn’t been written by a scientist it might also have been a more engaging read! But who am I to say, I’m still trying to bend my mind around the idea that Americans don’t care about facts.

•  Autonomy
•  Beneficence
•  Non-maleficence
•  Justice

Autonomy means the patient has the right to consent to treatment or to reject it. Autonomy has to be balanced against the good of society. What if a patient’s rejection of treatment or quarantine allows an epidemic to spread? Beneficence means we should do what is best for the patient. Non-maleficence means “First do no harm.” Justice applies to conundrums like how to provide kidney dialysis and organ transplants equitably in a society that can’t afford to treat everyone with expensive high-tech treatments or where the rich can afford better treatment than the poor.

Medical ethicist Ronald Munson has written a fascinating book entitled The Woman Who Decided to Die: Challenges and Choices at the Edges of Medicine. His clinical vignettes vividly illustrate the difficult decisions that must be made when science-based medicine runs up against the harsh practical reality of ethical dilemmas.

The woman who decided to die had leukemia and chose not to try a treatment that had a 20% chance of success. She had two small children and wanted to die sooner rather than later so her husband could re-marry and her children would be less traumatized.

A young woman doesn’t want to enroll in a clinical trial because she thinks the experimental drug is her last chance and she won’t risk being put on a placebo. She can’t legally get the experimental drug outside a controlled trial – should she be able to?

A teenage boy who is unhappy and who is being bullied resorts to cutting himself repeatedly to relieve his emotional distress. What should his doctor do?

How can you determine whether a patient really represents a danger to himself or others, and does that justify involuntary commitment?

A convicted murderer will die if he doesn’t get a liver transplant. Should his crime influence his eligibility for transplant?

Should people have the right to sell a kidney? Allowing such sales would save lives by making kidneys more available for transplants. But poor people might be coerced to sell a kidney to keep their family from starving.

A patient has no hope of recovery and is being kept alive by artificial measures including a feeding tube. Is it ethical to stop feeding him?

If a patient is enduring terrible suffering and has no chance of improvement, is it ethical to euthanize him at his request? Or at the request of his spouse if he is unable to communicate?

How can we determine someone is dead when he is on life support?

The case that disturbed me the most was that of Meg, a young woman who was diagnosed with breast cancer in 1995. Chemotherapy failed, and she was offered a bone marrow transplant – actually a procedure in which some of her own cells would be harvested from her blood and saved, she would be given high-dose chemotherapy that wiped out her bone marrow, and then her own cells would be re-infused (high dose chemo with stem-cell rescue). She was told the evidence: a few small studies showed that the treatment offered a small benefit, but none of the studies randomly assigned women to get either standard chemo or high-dose chemo plus stem cell rescue. The oncologists who recommended it were making a judgment call in the absence of genuine scientific evidence. She saw it as her only chance, had the procedure, endured weeks of suffering in the hospital and was dead 8 months later.

Stem-cell transplants had been so widely and uncritically accepted that oncologists tended to think of them as a conventional therapy that would soon be validated by clinical trials. The treatment seemed so reasonable on theoretical grounds that waiting for the scientific evidence seemed only a formality. The lesson for medicine here is that it must remain vigilant and not allow a treatment, no matter how prima facie reasonable it appears, to gain the status of a standard therapy without clinical testing. Patients tend to think that any novel therapy is better than a relatively ineffective standard one, and when physicians seem enthusiastic about it, for desperate patients that’s equivalent to an endorsement.

The data from 4 well-conducted studies were released in 1999. They showed no benefit from the procedure, and oncologists stopped offering it. That knowledge came too late for Meg.

Modern scientific medicine has learned to prolong life, but sometimes those extra years of life involve constant suffering, great financial expense, and poor quality of life. We CAN provide many interventions, but SHOULD we always use them?

Munson provides a sympathetic, thought-provoking discussion of issues many of us will eventually face for ourselves, our patients, or our family members. There are no easy answers.

Dr. Sears is a genius. No, not in an Albert Einstein or Pablo Picasso kind of way. He’s more of an Oprah or a Madonna kind of genius. He’s a genius because he has written a book that capitalizes on the vaccine-fearing, anti-establishment mood of the zeitgeist. The book tells parents what they desperately want to hear, and that has made it an overnight success.

Dr. Robert Sears is perhaps one of the best-known pediatricians in the country. The youngest son of Dr. Bill Sears, the prolific parent book writer and creator of AskDrSears.com, Dr. Bob has become the bane of many a pediatrician’s existence. He has contributed to his family dynasty by co-authoring several books, adding content to the family website, and making myriad TV appearances to offer his sage advice. But Dr. Bob is best known for his best-selling The Vaccine Book: Making the Right Decision for your Child. This book, or at least notes from it, now accompanies many confused and concerned parents to the pediatrician’s office. Parents who have been misled by the onslaught of vaccine misinformation and fear-mongering feel comforted and supported by the advice of Dr. Sears, who assures parents that there is a safer, more sensible way to vaccinate. He wants parents to make their own “informed” decisions about whether or how to proceed with vaccinating their children, making sure to let them know that if they do choose to vaccinate, he knows the safest way to do it. And for $13.99 (paperback), he’ll share it with them.

In the final chapter of his book (entitled “What should you do now?”), after reinforcing the common vaccine myths of the day, Dr. Sears presents his readers with “Dr. Bob’s Alternative Vaccine Schedule.” He places this side-by-side with the schedule recommended by the American Academy of Pediatrics and the CDC’s Advisory Committee on Immunization Practices. He then explains why his schedule is a safer choice for parents who chose to vaccinate their children. Without a doubt, the alternative vaccine schedule is among the more damaging aspects of this book. It’s the part that gets brought along to the pediatrician’s office and presented as the the plan going forward for many parents today. But the book is also dangerous in the way in which it validates the pervasive myths that are currently scaring parents into making ill-informed decisions for their children. Dr. Sears discusses these now common parental concerns, but instead of countering them with sound science, he lets them stand on their own as valid. He points out that most doctors are ill-equipped to discuss vaccines with parents, being poorly trained in the science of vaccine risks and benefits. He then claims to be a newly self-taught vaccine expert, a laughable conceit given the degree to which he misunderstands the science he purports to have read, and in the way he downplays the true dangers of the vaccine-preventable diseases he discusses in his book. He then provides parents with what he views as rational alternatives to the recommended vaccination schedule, a schedule designed by the country’s true authorities on vaccinology, childhood infectious disease, and epidemiology.

So what does Dr. Sears have to say, exactly, about the risks of vaccines, and just how out of touch is he with medical science and epidemiology?

VALIDATING THE UNTRUTHS

Public versus individual health

It is not uncommon for people to be confused about how public health measures relate to personal or individual health. With regard to vaccines, some feel that recommendations made “for the good of the public ” may not necessarily be for the good of the individual. Some feel that while they may understand the rationale for vaccinating on a societal level, they are unwilling or afraid to place the burden of potential vaccine risks on their child. Dr. Sears falls for this line of thinking, and leads parents to believe that certain vaccines protect the community but not the individual child. He gives polio as an example, stating that the risk of polio is zero, and that therefore the vaccine does not protect the individual child from disease. This, of course, is untrue. While new cases of polio no longer arise in the United States (thanks to the success of the polio vaccine) they still do in other areas of the world. As is true for many infectious diseases, imported cases and potential outbreaks are a quick airplane flight away. The more unvaccinated children we have, the more likely an imported case will lead to larger outbreaks of disease. So yes, vaccinating protects the individual child as well as the community at large. Ironically, polio would likely have been eradicated from the earth by 2002 had it not been for the propagation of a vaccine myth. In the impoverished Indian state of Uttar Pradesh (which, in the year 2000, accounted for 68% of all polio cases in the world), a myth that the polio vaccination campaign was really a government conspiracy to sterilize children prevented that campaign from accomplishing its true mission of ridding the world of this horrible disease.

Of course herd immunity, an epidemiological concept, is of vital importance to public health. We know that Dr. Sears understands at least this much, because he advises parents who fear giving their children the MMR vaccine not to tell their neighbors, lest too many parents develop similar fears. He warns that an increasing number of unvaccinated children will result in a resurgence of the disease. He couldn’t be more correct. Enlarging pockets of unimmunized and underimmunized children around the country have already resulted in outbreaks of disease. These vaccine-preventable outbreaks are just harbingers of worse outbreaks yet to come, should this trend continue.

Throughout his book Dr. Sears highlights common parental concerns about vaccines. He follows these not with fact-based discussions, but with subtle (and often not so subtle) words of reinforcement. For example, Dr. Sears often downplays the potential danger of vaccine preventable diseases, or the risk of infection for the unimmunized child. Although the book is rife with such misinformation, I will limit my discussion to just a few examples to give a sense of the distortions involved.

DTaP

In his chapter on the DTaP vaccine (against diphtheria, tetanus, and pertussis), in the “Reasons some people choose not to get this vaccine” section, Dr. Sears states:

In truth, tetanus is not an infant disease…Also, diphtheria is virtually non-existent in the United States. So, one could create a logical argument that a baby could skip the tetanus and diphtheria shots for a few years and be just fine.

Infants with tetanus

Perhaps Dr. Sears is unaware that tetanus is indeed a disease of infants, and potentially of anyone. And to make the case that because diphtheria (or any infectious disease) is not endemic to the United States it is therefore not a threat to unimmunized children, betrays Dr. Sears’ naivete when it comes to basic principles of epidemiology and infectious disease. Epidemiology and history has shown us that when vaccination rates drop sufficiently, outbreaks of seemingly vanquished diseases return with a vengeance. Diphtheria is no exception. In the newly independent states of the former Soviet Union, declining childhood and adult vaccination rates against diphtheria have played a major role in a massive epidemic of that deadly disease. And as we see more and more pockets of unvaccinated children around this country, we are beginning to see the reemergence of horrific vaccine preventable diseases. Recent outbreaks of invasive Hib disease and of measles should remind us how important it is to maintain our herd immunity against these scourges of the not-so-distant past. Of course, Dr. Sears never challenges the unsupported concerns about vaccine risks. He simply restates these concerns, and then adds fuel to the fire, supporting the irrational fears that led to this growing trend of underimmunization.

Epidemiological missteps

Dr. Sears’ understanding of epidemiology and vaccine adverse event surveillance is startlingly poor. He purports to break new ground by doing the first ever statistical vaccine risk-benefit analysis for parents. Unfortunately, his calculations are meaningless as he misunderstands the most basic concepts, like cause-and effect, and fails to grasp the significance of vaccination rates in determining the likelihood of contracting a vaccine-preventable disease. Dr. Sears bases the risk of a child suffering a severe vaccine reaction on his analysis of VAERS data. VAERS (the CDC’s Vaccine Adverse Events Reporting System) is a passive surveillance system that everyone (doctors and patients alike) is encouraged to use anytime a vaccination is followed by an adverse event, whether or not they suspect the vaccine is the actual cause of the event. Being an open, voluntary, passive reporting system, VAERS is susceptible to fraud and abuse, as anyone can submit a report. The purpose of the system is to give a very broad look at possible unforeseen events related to vaccination. It is a screening tool, from which trends can be observed, possibly triggering true validated analyses. Raw VAERS data simply cannot be used to analyze the risk of vaccine reactions, because the data does not tell us anything about causality. Despite this, Dr. Sears and others continue to misuse VAERS data, representing it as a true estimate of vaccine adverse events. To quote the CDC,

The purpose of VAERS is to detect possible signals of adverse events associated with vaccines. Additional scientific investigations are almost always required to properly validate signals from VAERS and establish a cause and effect relationship between a vaccine and an adverse event.

But Dr. Sears uses VAERS data to come to the conclusion that “for about every 100,000 doses [of vaccine], one person suffered a severe reaction.” He fails to mention that VAERS data tells us absolutely nothing about the risk of developing a vaccine reaction, severe or not. He then takes this number and, by assuming every vaccine dose has the same risk attached to it of creating a severe reaction, determines that a child has a 1/100,000 chance of developing a severe reaction for each vaccine dose he receives. By inappropriately and misleadingly using VAERS data, Dr. Sears concludes that,

The risk that any one child will suffer a severe reaction over the entire, twelve-year vaccine schedule is about 1 in 2600.

He then calculates that,

The risk of a child having a severe case of a vaccine-preventable disease is about 1 in 600 each year for all childhood diseases grouped together.

And then asks parents the ultimate question, concluding with an example of his trade-marked, passive-aggressiveness,

Is vaccinating to protect against all these diseases worth the risk of side effects? That’s the million dollar question.

Of course, the answer is so overwhelmingly “yes” that it’s difficult to conjure up the energy to respond to Dr. Sears’ misleading analysis. Not only does he start his statistical sleight-of-hand by inappropriately using VAERS data, he then calculates the risk of acquiring a vaccine preventable disease using current disease incidence rates. What he doesn’t acknowledge is that those rates are predicated on current vaccination rates. The reason a child today is at low risk for contracting these diseases is precisely because our vaccination rates are so high!

Hib

Dr. Sears fails to mention that, while the incidence of severe invasive Hib disease is currently very low, it was actually common in the pre-vaccine era. In the years before the introduction of the vaccine in 1987, approximately 1 in 200 children below the age of 5 acquired invasive Hib disease. He admits that the vaccine is responsible for keeping the disease at bay, but then states,

HIB is a bad bug. Fortunately , it’s also a rare bug, so rare that I haven’t seen a single case in ten years…Since the disease is so rare, HIB isn’t the most critical vaccine.

If parents follow the extremely dangerous, backwards logic of Dr. Sears, we are certain to see the incidence of vaccine-preventable diseases rise, as we are now just beginning to see in the US. Rest assured, it doesn’t take long for a disease to reemerge once vaccination rates drop.

Measles

Dr. Sears’ discussion of measles consists of a series of downplayed statements. He describes the rash as one that “can look similar to rashes…of other diseases, so its not easy for a doctor, much less a parent, to recognize.” And he states that the disease is “transmitted like the common cold”. The clinical presentation of measles is striking and very difficult to mistake for any other illness. As I was taught during my residency, there’s no such thing as a mild case of measles. Every child with the disease is very ill appearing. And, while it is transmitted by respiratory droplets like the common cold, it seems the sole reason for making this statement is, again, to liken it to other, less dangerous viral infections. In answer to his self-posed question “Is measles serious?”, Dr. Sears replies,

Usually not. Most cases, especially in children, pass within a week or so without any trouble. However, approximately 1 in 1000 cases is fatal…Now that measles is rare, many years go by without any fatalities.

He then makes the astoundingly misleading statement,

The possible complications of measles, mumps, or rubella are very similar to the side effect of the vaccines themselves.

Because I can’t fathom he is that ignorant of the facts, I am inclined to believe that Dr. Sears is simply being deceitful. Here are the facts about the complications of measles:

• One in 1000 cases of measles results in encephalitis, with a high rate of permanent neurological complications in those who survive.
• Approximately five percent develop pneumonia.
• The fatality rate is between one and three per 1000 cases.
• Contrary to Dr. Sears’ statement, death is most commonly seen in infants with measles.
• Subacute sclerosing panencephalitis (SSPE) is a rare complication of measles infection that occurs years after the illness in approximately 10 of every 100,000 cases.

Here are the facts about complications of the measles vaccine:

• It causes fever and a mild rash in 5-15% of recipients.
• 0.03% will have a febrile seizure – likely not a result of the vaccine itself, but simply a child’s individual predisposition to febrile seizures.
• One in 10,000 children will have a more serious event following the vaccine, such as a change in alertness, a drop in blood pressure, or a severe allergic reaction.
• Approximately 1 in 25,000 cases is associated with an asymptomatic drop in the blood platelet count, which quickly returns to normal without any consequences.

Dr. Sears uses reactions listed in the vaccine package insert as if they are true vaccine side effects. This is analogous to using VAERS data to draw conclusions about vaccine reactions, since there is no evidence that any of these are causally related. Most side effects listed in package inserts occur at the same rate as background or placebo rates. Nevertheless, Dr. Sears goes out of his way to reinforce parental concerns, even though the facts are right at his fingertips. The section entitled “Reasons some people choose not to get this vaccine”, that occurs at the end of each vaccine discussion, further reinforces parental fears by simply restating parental concerns with no attempt at setting the facts straight. In a box at the end of his discussion of the hepatitis B vaccine, he does attempt to explain the concept that temporality does not imply causality. Ironically, he states in this explanation,

Parents who have watched helplessly as their child develops neurological problems within weeks of being vaccinated will probably always be 100 percent convinced that the vaccine caused the problems. The fact that neurological complications are listed in the product inserts lends credibility to their case.

And so does Dr. Sears with the insidious, misleading messages he uses in his book. He concludes his discussion of causality with this confused statement,

I’m sure the truth of the matter is somewhere between causality and coincidence. Hopefully someday we will know for sure which side effects are truly vaccine related.

Of course we will never “know for sure” if every report of an extremely rare event following a vaccine is causally related or not. We continue to monitor trends and conduct rigorous surveillance, and follow that with sound epidemiological studies when concerns arise. This is why we can say, with good confidence, that these vaccines are extremely safe, and that Dr. Sears’ concerns and equivocations are misleading at best.

TOXIC SHOTS

Throughout his book, Dr. Sears discusses the common fears concerning vaccine dangers, never correcting when these fears are based on myth or misinformation. Rather, he presents them in a “we just don’t know enough” manner (even when we do), or as matters of fact (even when they’re not). Dr. Sears raises the concern in his book that the recommended schedule of childhood vaccines may pose a danger. He suggests that we just don’t know if the chemicals contained in the vaccines (which he lists in alarming fashion) may be too great of a burden for the developing child.

Thimerosal

In the very first page of the book’s preface, Dr. Sears tells his readers that he is “not going to discuss, at length, mercury or thimerosal in vaccines because, thankfully, these have been taken out of virtually all vaccines” (my emphasis). This is followed by more language that makes it clear he believes thimerosal wasa dangerous additive, and that the little remaining thimerosal in the vaccine supply (contained in one form of the influenza vaccine) is still a risk. Of course, we know that the thimerosal in vaccines was unlikely to ever have been a danger to children, but Dr. Sears uses the same old misinterpretations of the science and conspiracy theories to arrive at the conclusion that it was. In fact he point blank states that “vaccine manufacturers knew that we were overdosing babies with mercury, but no one in the medical community realized the possible implications for almost ten years.” This kind of fear mongering is no different than that spewed by the folks at Generation Rescue, and lacks any basis in science. In his section on vaccine ingredients, Dr. Sears (again, either naively or dishonestly) discusses the rise in the rate of autism diagnoses as possibly a result of thimerosal in vaccines. He cites the same tired and poor references (and an article from the LA Times) we’ve heard before from the likes of Jenny McCarthy, and then asks “so who do we believe?”. Again, that question is left hanging.

Aluminum

Of particular concern to Dr. Sears is the potential dangers of aluminum, which has become his new post-thimerosal villain. Although he worries aloud in his book that ”aluminum may end up being another thimerosal”,  Dr. Sears is unaware that such a comparison doesn’t exactly strike fear in the hearts of the scientific community.

Many vaccines contain aluminum as an adjuvant. An adjuvant is a substance that boosts the ability of a vaccine to induce an immune response. It acts locally at the site of injection, as a signal to the immune system, drawing a heightened response to the injected vaccine. Ironically, without adjuvants we would need a larger dose of the vaccine to induce an immune response. I doubt that would go over well in anti-vaccine circles.

Unfortunately, Dr. Sears’ concerns about aluminum are the result of a distorted reading of what is known about aluminum toxicity and the risk of vaccines in children. In discussing “controversial ingredients”, he states

…some studies indicate that when too many aluminum-containing vaccines are given at once, toxic effects can occur.

In fact, no such studies exist. He does correctly state that there is very little known about the pharmacokinetics of intramuscularly injected aluminum as it occurs in vaccine adjuvants, but he goes on to distort what we do know about aluminum toxicity into a rationale to fear our current vaccine supply and schedule. For instance, we know that aluminum has been blamed for producing neurotoxicity in some patients with renal failure on long-term dialysis, and in some extremely premature infants given prolonged courses of aluminum-containing intravenous nutritional solutions. But this is not comparable to the exposure of healthy infants to adjuvant-containing vaccines given intramuscularly on a few, discrete occurrences over a period of months. Similar to the way the safety data for methylmercury is often incorrectly applied to the ethylmercury in thimerosal (and incorrect inferences of toxicity made), Dr. Sears uses safety limits set for something else, and incorrectly applies them to the aluminum in vaccine adjuvants.

Dr. Sears uses the FDA’s maximum permissible level (MPL) of aluminum for large volume bags of intravenous fluids given chronically to premature infants (25 µg/L), and extrapolates it to adjuvant-containing vaccines. He also uses the number 5 µg/kg/day as the amount of aluminum found to cause toxicity in some premature infants receiving intravenous feeding solutions that contain aluminum. What he doesn’t mention is that the 25 µg/L number comes from studies showing that this concentration produces no tissue aluminum loading, and that it was chosen to allow room for other exposures. In fact, it is estimated that the aluminum in these intravenous feeding solutions accounts for only 10-15% of the total parenteral aluminum intake per kg body weight that premature infants receive in a given day while in intensive care. The number was set low to leave room for the other sources of parenteral aluminum these infants receive. Still, Dr. Sears uses this number as his standard against which he compares the aluminum content of vaccines. This is misleading for a number of reasons. First, the 25 µg/L MPL for parenteral feeding bags says nothing about the maximum amount of aluminum that can be safely injected. This is obvious as the number is expressed as a concentration, not as an absolute amount of aluminum. The average premature infant would likely receive 100 ml/kg/day of solution, and therefore roughly 2.5-5 µg per day of aluminum from this source. Again, accounting for only about 10-15% of the parenteral aluminum the infant would receive in a given day. Dr. Sears does acknowledge that the number isn’t a maximum permissible amount of aluminum for injection, but he uses it anyway stating, in essence, that it’s all we’ve got. But it isn’t all we’ve got, as we shall see in a moment.

The fact that these intravenous, aluminum-containing solutions are administered continuously over long periods of time, whereas vaccines are administered in discrete unit doses at intervals spaced out over time, is also not taken into consideration in Dr. Sears’ discussion. But his use of the FDA limits for intravenous feeding solutions is misleading also because it ignores the difference between intravenous and intramuscular or subcutaneous injection of aluminum, as in the case of vaccines. In fact there is evidence, which Dr. Sears must have missed in his exhaustive review of the literature, that the aluminum from vaccines behaves differently than intravenously administered aluminum, and that the body burden of aluminum from vaccines is not so concerning when placed in the context of the background body burden of aluminum.

One piece of evidence that the aluminum in vaccines is handled by the body quite differently than the aluminum in intravenous solutions comes from studies looking at the intramuscular injection of aluminum-containing adjuvants into rabbits. Rather than entering the blood stream directly and accumulating in tissues, as with intravenously injected aluminum, intramuscularly injected aluminum-containing adjuvants are first dissolved by organic acids in the interstitial fluids, and are then rapidly eliminated.

Another reassuring look at aluminum exposure from vaccines comes from an analysis by Keith, et al. from the ATSDR. They looked very closely at the the way in which all sources of aluminum exposure in the infant contribute to the total body burden of aluminum, including inhalation, oral, dermal, and vaccine exposures. They took into consideration uptake, transfer from the blood, release from the injection site, distribution patterns, and retention and elimination rates of aluminum. They used the Priest formula to assess the fate of aluminum once it has entered the body via any route.

• R = 0.354dt^{−0 .32} (where R is the retained fraction, d the uptake dose in mg Al, and t the time in days following uptake. The equation is summed for repetitive intakes such as with multiple vaccinations.)

Comparison of the aluminum body burden from vaccines to that from ingested breast milk, in relation to the oral MRL for aluminum for infants at the 5th and 50th percentiles for weight, is shown in the figure below (taken from the original article). The analysis assumes injections of vaccines according to the following schedule, with the corresponding aluminum content:

• Birth: Hep B (250 µg)
• 2 months: Hep B + DTaP (1100 µg)
• 4 months: DTaP (850 µg)
• 6 months: Hep B + DTaP (1100 µg)
• 12 months: DTaP (850 µg)

While this leaves out the PCV and Hib vaccines, only one brand of Hib vaccine contains aluminum, and the PCV vaccine contains only 125 µg of aluminum. Thus, this analysis accounts for the bulk of the aluminum that comes from the vaccine series.

As can be seen in the figure, aluminum spikes occur on the day of injection, followed by rapid elimination within a few days. Despite slight and brief overlaps between the vaccine and MRL curves at the time of vaccination, the vaccine curves always fall between the dietary intake curves and the MRL curves. The authors conclude that, in the context of the overall body burden of aluminum with which infants are born and which is added to by ongoing oral, inhalational and parenteral sources, vaccines are likely to constitute only a minor, transient part.

While there is good reason to be confident that the aluminum in vaccines is not the dreaded neurotoxin Dr. Sears fears it is, in his book he suggests otherwise. His mantra is that there are now so many vaccines in the routine schedule that we are overloading our children’s bodies with toxic aluminum. This is neither borne out by the science, nor is it likely given what we know about aluminum and the way in which children are exposed via vaccinations.

Other scary sounding vaccine constituents

In addition to the hot-button concerns discussed above, Dr. Sears highlights a number of other vaccine constituents that “might be of concern to some parents.” In typical style, he doesn’t explain why these concerns are unfounded, but instead makes sure they are listed in alarming fashion so that parents can make there own “informed” decision about whether or not to be concerned. Again, many parents appreciate this approach as one that is non-condescending. What it really is, however, is deceptively lacking in scientific honesty.

• Animal and human tissues – Dr. Sears lists items like “cow fetus serum” in  the What ingredients are in the vaccine sections of each vaccine he discusses. Because the reader doesn’t realize the absolute lack of importance to this fact, he is merely raising the specter of danger without truly informing. He mentions the issue of potential contamination with prions and the risk of transmitting mad cow disease, even though such a risk does not exist. Dr. Sears discusses the contamination of an early polio vaccine in the 1950’s with SV40, a monkey virus, as an example of the potential dangers of using animal and human cell cultures in vaccine manufacturing, although this actually posed no risk at the time. Here’s the gratuitous, completely uninformative way Dr. Sears concludes his section on Animal and Human Tissues, seemingly meant to shock and invoke fear, all under the guise of just giving the facts:

For review, here is a list of the various animal or human tissues used to make vaccines:

Human blood proteins (albumin)

Human lung cells

Human fetal lung cells

Human cell lines

Cow serum (the liquid part of blood)

Cow heart-muscle extract

Cow tissue extract

Monkey kidney cells

Guinea pig embryo cells

Chicken embryos

Chicken kidney cells

Chicken eggs

I’m certain this list is frightening to some parents, but it needn’t be. Unfortunately, Dr. Sears does nothing to honestly inform his readers.

• Formaldehyde- Dr. Sears discusses what he considers to be the toxic properties of formaldehyde – that it’s carcinogenic and causes kidney and genetic damage. He follows this with:

I could not find information on injected formaldehyde. Fortunately, the amount in each vaccine is minuscule.

Perhaps he could also have mentioned that formaldehyde is naturally present in the bodies of infants, at a level far greater than that contained in the vaccines they receive, and that formaldehyde does not appear to be carcinogenic to humans, or that animals injected with extremely large quantities of formaldehyde also fail to develop cancers.

• MSG – The controversial nature of MSG is reviewed, and readers are reminded that “large quantities” can cause nervous system damage “similar to Alzheimer’s disease.” Again, he follows this with the fact that vaccines contain only trace amounts of MSG.

• 2-Phenoxyphenol – The book informs us that this chemical causes reproductive defects, is an irritant, and can be found in nasty things like solvents. Again, Dr. Sears ends by stating that it’s found in “minuscule” amounts in vaccines.

• Sodium deoxycholate – Another toxic substance, harmful to the eyes and lungs, found in minuscule amounts in vaccines.

• Polysorbate 80 and 20, EDTA, Sodium borate, Octoxynol- For some reason these chemicals get a complete pass. Dr. Sears simply states that, in the tiny amounts found in vaccines, they are “considered harmless”. I’m not sure why these toxins are considered harmless in these trace amounts, while the others are not given this quick vote of confidence. Nor am I sure which authorities he is referring to who have made these declarations of harmlessness. Perhaps Dr. Sears is unaware that sodium borate is a chemical used in metal solder, as a laboratory buffer, has been banned as a food additive in Indonesia, and may cause liver cancer. And I’m surprised he didn’t mention that polysorbate 80 can increase the risk of blood clots, stroke, and heart attack. Perhaps he didn’t want to sound too alarmist.

DR. BOB’S SELECTIVE AND ALTERNATIVE VACCINE SCHEDULES

The final product of The Vaccine Book is the two schedules Dr. Sears proposes for different types of concerned parents. The Selective Schedule is offered to parents who “otherwise would have declined all vaccines”. For this schedule, Dr. Sears chooses vaccines he feels are the most important, because the diseases they protect against are either the most dangerous and/or the most common, and have the least severe potential side effects. The Alternative Schedule (the one I see most commonly) is intended for parents who want to vaccinate, but who have concerns about vaccine safety, a group he correctly describes as “growing in recent years as the media and the internet bring theoretical problems with vaccines to light.” This book, of course, is part of the mass-appeal stream of misinformation contributing to that growing trend.

The Alternative schedule, as explained by Dr. Bob, accomplishes the following:

1. It spreads out vaccines to give only one aluminum-containing vaccine at a time. This is done so “infants can process the aluminum without it reaching toxic levels”. Really? Can Dr. Sears cite the references for this scientific sounding rationale?
2. It exposes infants to the chemicals of only two vaccines at a time. Similar to the above anti-scientific rationale, this is done to spread out exposure to “chemicals”, so the infant can process them without risk. In a statement that clearly reveals his lack of scientific understanding, Dr. Sears then states, ” …we don’t know whether this precaution is necessary, but it’s reasonable.” [Reasonable:  1 a: being in accordance with reason <a reasonable theory> b: not extreme or excessive <reasonable requests> c: moderate, fair <a reasonable chance> <a reasonable price> d: inexpensive 2 a: having the faculty of reason b: possessing sound judgment <a reasonable man>] No matter how you read it, reasonable it isn’t.
3. It gives at most 2 vaccines at a time to limit potential side effects. Again, Dr. Sears states we don’t know if more simultaneous vaccinations leads to a greater likelihood of side effects, but concludes that it’s “a reasonable precaution.” We actually do know, contrary to very popular belief, that infants can easily handle all of the recommended vaccines, and then some.
4. It begins with “the most important” vaccines. Dr. Sears would have his readers believe he has come up with a good schedule of vaccination based on giving vaccines that protect against the most serious diseases first. His readers would be better informed if they were told how the AAP/CDC recommended vaccine schedule is designed. How the country’s leading experts on vaccinology, infectious disease, and epidemiology determine which vaccines are most important and when they are best given – balancing when they are most effective at inducing an immune response and when the risk of disease and adverse disease outcome is greatest. Interestingly, the actual order of the real vaccine schedule is the same as Dr. Bob’s.
5. “It delays shots for diseases that are usually fairly mild for infants”. He gives as examples hepatitis A and rubella. The first dose of both the hepatitis A and rubella vaccines are actually recommended at 12-15 months of age. They are not part of the vaccine series given in the first year of life. Further, Dr. Sears’ rationale for delaying rubella vaccine misses the point entirely. Rubella, while usually a mild illness, is not on the vaccine schedule because of the severity of the illness it causes. It is recommended because women infected (usually by children) during the first trimester of pregnancy, have a 50% chance of delivering a baby with severe congenital defects. The vaccine has been successful at nearly eliminated this horrific occurrence.
6. “It delays the shots for diseases that a baby is extremely unlikely to catch during the first few years of life”. He gives as examples hepatitis B and polio. As I discussed earlier, this rationale uses flawed, backwards logic. Babies are at low risk for contracting polio because there is no home grown polio in this country. That is precisely because we vaccinate everyone in infancy. Without a susceptible host, the disease disappears. Unfortunately, because of religious opposition and other myths, the same cannot be said about every area of the world. As a result, we have yet to completely reign in this horrible disease. Although hepatitis B is not common in infancy as long as the infant’s mother is not a carrier (or infected) during pregnancy, it is still a risk. Prior to routine vaccination against hepatitis B, 18,000 children per year were infected. Half of these children did not contract it from their mother at the time of birth. Because the disease can be severe, chronic, and can lead to destruction of the liver or liver cancer, and because it can be spread through casual contact with contaminated objects like toothbrushes, it is recommended that all children get vaccinated as early as possible. Because the vaccine is so safe (it does not cause a hepatitis-like illness as Dr. Sears warns his readers), and it can be transmitted casually (it’s not just a sexually transmitted disease as Dr. Sear states), it is recommended during infancy.
7. “It gives live-virus vaccines one at a time so that a baby’s immune system can deal with each disease separately”. Here Dr. Sears travels further from science than he does perhaps anywhere in his book. First, he refers to a live virus vaccine as a “disease”. This is either a serious mistake, purposeful deceit, or dangerous ignorance on his part. He discusses the potential dangers of giving the MMR vaccine as a combined vaccine, and recommends separating it into M, M, and R components and spreading them out over time. He then states that
   

   “it’s probably okay to give the combination MMR booster at age 5, when a child’s immune system is more mature [my emphasis].”

   First of all, we know the vaccine is effective at invoking a protective immune response when given at the recommended ages (12 months, and 4-6 years). The notion that multiple vaccines can somehow overwhelm an infant’s immune system indicates an absolute lack of understanding of how the immune system responds to vaccines, and is thoroughly refuted by science. I will not go into depth here discussing the enormity of the evidence refuting any causal association between the MMR vaccine and autism, nor discuss the apparent fraud that was perpetrated in the publication of the original paper the made this issue the phenomenon it has become. Others have exhaustively covered that topic. I will say that for Dr. Sears to perpetuate this extremely dangerous myth is deplorable. He has the audacity to pander to the fears of parents by stating,

   Splitting the MMR into separate components is thought by some researchers to decrease the risk of autism and other reactions, although medical science has not proven this to be so.

   I don’t know to whom he is referring when he writes “some researchers”. I do know (as should Dr. Sears) that there is not one shred of scientific support for the notion that a split MMR confers any benefit over the combination vaccine. It certainly can’t decrease the risk of autism, since the MMR does not cause autism. And there is no scientific evidence that it decreases the risk of any side effects. What it does do is increase the number of shots a child receives, increasing the time, expense, and pain involved. More importantly, it increases the amount of time a child is susceptible to disease. But the most damaging aspect of this kind of deceit, is that it further erodes society’s understanding and trust in science. Tagging the statement, “although medical science has not proven this to be so” at the end, does nothing to exculpate him from this offense.

After explaining his alternative schedule, Dr. Sears cavalierly remarks that if he’s wrong about all of this, the worst case scenario is that “you risk really annoying your doctor because you’re trying to think outside the box.” I’ve just discussed the real harm of this schedule. Applying the positive expression “thinking outside the box” in an effort to cast a positive spin on it is disingenuous. Thinking outside the box can be a good thing in science. But, unless we’re talking about quantum theory, not as a way of understanding science itself.

Dr. Sears claims to listen to parental concerns and to be impartial when it comes to whether or not, or how, to vaccinate. He says that, rather than tell them what to do, he prefers to give parents all the information they need to make their own, informed decisions. But instead of accurately discussing the science for concerned parents, correcting the pervasive vaccine myths and misinformation so prevalent in the media, on-line, and in our communities, he distorts, misinterprets, and misleads. Dr. Sears has either a very poor understanding of how to read the scientific literature, and of the scientific method itself, or he is intentionally misleading his readers. Either explanation indicates an unacceptable and egregious abuse of his public and professional responsibilities. Dr. Sears is not as blatantly anti-vaccine as others. In the beginning of the book he informs his readers that it “is not an anti-vaccine book” (his emphasis), and that other books over-emphasize the dangers of vaccines and do too much to scare parents. This is a nice set-up for the book, allowing parents to believe they are getting the straight, unbiased story from a doctor that really wants to inform. While Dr. Sears’ brand of fear-mongering is more subtle than some, it is at least as dangerous. Because of his family name and public persona, Dr. Bob has become one of the country’s most recognized pediatricians. And his plain language “parents know best” philosophy has attracted the admiration and trust of parents looking for authoritative validation of their fears, concerns, and beliefs. Unfortunately, Dr. Sears is good at repeating and reinforcing common parental fears and anti-vaccine myths, but is quite poor at reading the literature and understanding epidemiology. While he doesn’t overtly tell parents not to vaccinate, he certainly stacks the deck this way. In his discussion of each vaccine, his “reasons to vaccinate” section tends to downplay the risks of the disease. He “balances” this with a section called “reasons some parents choose not to vaccinate”. But I view this as simply his attempt to exculpate himself for being, in reality, an anti-vaccine spokesperson. For all intents and purposes, this gives parents every reason to feel confident that their rationale for not vaccinating is supported by sound reasoning. Dr. Sears rehashes and lends credence to the same debunked myths that have led to these parental fears in the first place, all under the guise of providing parents with “both sides” of the issue. Of course what he does is provide bits and pieces of good information alongside inaccurate and incorrect information, and asks parents to make an “informed” opinion.

With his best-selling book (it currently ranks at #414 on Amazon) Dr. Bob, along with a growing platoon of other prominent anti-vaccine spokespeople, is leading parents into a trap that not only threatens their own children’s health, but the health of the entire nation as well. Already, this anti-scientific group-think has increased the number of children who are under or un-vaccinated, and has resulted in preventable death and disease. I hold Dr. Sears and the many vocal prophets of doom (like Jenny McCarthy, Paul Kirby, Robert Kennedy Jr., JB Handley, and Andrew Wakefield) personally responsible for the increasing prevalence of parental vaccine refusal and the ensuing return of vaccine preventable disease.

Note: To watch a less subtle Dr. Sears discuss his views on vaccines, click on this link.

Psychiatrist Morgan Levy has written a book entitled Placebo Medicine. It’s available free online. In it, he makes an intriguing case for incorporating the best alternative medicine placebo treatments into mainstream medicine.

In a light, entertaining style, he covers the placebo effect, suggestibility, and the foibles of the human thought processes that allow us to believe a treatment works when it doesn’t.

“Thinking like a human” is not a logical way to think but it is not a stupid way to think either. You could say that our thinking is intelligently illogical. Millions of years of evolution did not result in humans that think like a computer. It is precisely because we think in an intelligently illogical way that our predecessors were able to survive… [by acting on quick assumptions rather than waiting for comprehensive, definitive data]… We have evolved to survive, not to play chess.

He offers evidence from scientific studies indicating that belief in a treatment and the power of suggestion can have actual physiologic consequences such as production of endorphins or changes on brain imaging studies. He spices his narrative with colorful stories, including anecdotes from his own sex life and an impassioned plea (tongue in cheek?) for everyone to drink coffee for its proven benefits.

He gives examples (10 each) of three groups of treatments that elicit the placebo effect:

• Herbs and spices, (Bach’s flower remedies, Gingko, Echinacea, etc.)
• Misused therapies (chelation, colonic irrigation, fish oil, etc.)
• Totally fake treatments (acupuncture, homeopathy, ear candles, etc.)

He explains that some of these treatments do have real therapeutic effects, but they are being marketed for claims that are not the same as those real effects, or the real effects are too mild to support the claims.

“Placebo” is commonly thought of as a synonym for “ineffective” but it actually describes a therapeutic phenomenon that is very real and can be quite effective.
The mechanism of action involves the way we think about therapy rather than any actual effect of the therapy.

What if we told a patient:

I’m sending you to a Placebo Medicine specialist who will administer magnetic therapy. This therapy will have no real physiologic effect. However, if you carefully follow the direction of the magno-therapist and fully buy into what he or she is saying, then your brain will produce endorphins that will relieve the pain in your elbow.

This might work even better if we used Levy’s suggested term “Non-Pharmacological Intervention” or NPI instead of using the word “placebo.”

We could select patients by testing with suggestibility and psychosomatic instruments. We could tell the patient that he is fortunate because “Considering your scores on these scales you have a high probability of responding well to NPI treatments.”

What if scientific medicine were to co-opt the CAM movement? We could take these treatments out of the hands of the less ethical practitioners and outright scam artists and place it in the hands of those who are more likely to be altruistic. The truly altruistic practitioners could work within official guidelines. The charlatans would no longer be able to paint conventional medicine as the enemy. Family doctors would get to use placebos again. It would be a win-win situation.

If an acupuncturist is willing to use sham acupuncture and they don’t mind the patient being fully informed and they don’t cost too much, then I would gladly make referrals… I think that I could select an appropriate patient, perhaps one of my more somatic individuals, and educate them about the placebo effect. I would tell them how it can facilitate the brain to produce naturally occurring endorphins. I would refer patients for chronic idiopathic pain or for nausea and I would encourage them to fully buy into the story that the acupuncturist tells. I would say that the more they are able to do this the better it will work. Finally, I would follow the patient up afterwards.

I’m not entirely convinced, but I wonder if Dr. Levy might just be on to something. What do you think?

It is a very positive book. Sloan has attended over 3000 deliveries but he has not lost his sense of wonder. He tells us what life is like in the womb – how much the fetus can see and hear – and smell! He explains the labor process. He explains how a fetus has to rapidly adapt to life outside the womb with a number of physiologic changes. He reflects the joy of bringing a new life into a family, and the experience of becoming a father. He delves into the history of childbirth, with fascinating anecdotes about “salting” newborns, Queen Victoria’s influence on obstetric analgesia, and the attempt to keep forceps a proprietary secret of one family.

He shows the many contributions science has made to childbirth, some of the mistakes it made along the way, and how it corrected those mistakes.

He covers the history of medical interventions in childbirth both from a scientific and a sympathetic human viewpoint. Twilight sleep, epidurals, fetal monitors, C-sections, birthing positions, attendance by doulas, etc. He makes a strong case for having someone, anyone, stay with the mother throughout the process; there is evidence that this improves outcome. He covers the pros and cons of various types of analgesia and suggests that nitrous oxide could be used more often. He discusses the reasons for the rising C-section rate and carefully considers the risks and benefits of surgical deliveries, including physiology-based arguments I had not heard before. He covers the alarming new trend of elective primary C-sections by mothers who just don’t want to go through childbirth. He discusses circumcision from a neutral standpoint – he doesn’t recommend it, but he does it at parents’ request and he recognizes that there are medical benefits although they are far from compelling.

He explains the newborn reflexes like “stepping” and the Moro reflex in terms of evolution: primate babies needed to grab onto Mom and pull themselves to a nipple; and he says if left undisturbed on its mother’s abdomen, a human baby’s neonatal reflexes allow it to little by little inch itself up to the breast and find the nipple over the course of half an hour. I didn’t know that. I find it fascinating. I’d love to see a video of the process.

The book is full of interesting facts and anecdotes. A human birth takes 30 times as long as a gorilla birth: he discusses the anatomical changes in humans that prolong the process, and possible evolutionary explanations for them. He discusses cord care. The umbilical cord stump can take a long time to fall off – Dr. Sloan’s personal record was “88 parent-torturing days”! He tells about an embarrassing incident from his medical school days when he thought something looked funny about the fetal head but failed to recognize it was a breech presentation. He tells about Apgar Guy – a father who harassed him, wanting him to alter the medical record to show that his baby’s Apgar was really a 10 rather than a 9, as if that would somehow improve his child’s prospects. He tells about the expectant father who ran all the way to the hospital, slipped on the floor, knocked himself out, and woke up to find out his wife was at another hospital.

A fascinating book by a science-based doctor, a wise clinician, and a loving father. An example of what the scientific approach to medicine is all about, showing that it need not be cold and impersonal.

Some critics (such as Richard Dawkins) have expressed reservations about Dr. Collins’ faith, wondering if it might cloud his scientific judgment. Since Collins is rumored to be the most likely candidate for directorship of the NIH, and because I wanted to know if Dawkins et al. had any reason for concern, I decided to read The Language Of God.

First of all, Christians are a rather heterogeneous group – with a range of viewpoints on evolution, science, and the interpretation of Biblical texts. On one extreme there are Christians (often referred to as “young earth creationists” or simply “creationists”) who believe in an absolutely literal interpretation of the Genesis story, and see evolution as antithetical to true faith. Dr. Collins suggests that as many as 45% of Christians may actually be in this camp.

On the other end of the spectrum are Christians who embrace evolution, accept and promote scientific thinking, and understand the Bible to be a blend of poetry, allegory, and historical literature. While they see the Genesis account of creation as poetic, the Gospel accounts of Jesus’ life and teachings are considered to be more literal.

The good news is that Collins’ views are very representative of the scientific end of the Christian spectrum. In fact, he spends several chapters attempting to help creationists embrace evolution. He takes great pains to explain how irrational it is to deny the evidence we have (both from a genetic, and an archeological/basic science perspective) for evolution. He argues that evolution is not an enemy of faith, but rather an enlightening look at how God’s creative process works.

Collins also takes on “Intelligent Design (ID),” exposing it as a PR play, not a true scientific theory. He suggests that ID is an “argument from personal incredulity” expressed in the language of mathematics, biochemistry, and genetics. Furthermore, Collins explains that ID proponents have confused the unknown with the unknowable – there is no current “irreducible complexity” that cannot be explained by evolutionary theory. We don’t need a “God of the gaps” to explain what we’ve yet to learn.

One of the more interesting parts of the book is Dr. Collins’ mathematical review of the incredibly low odds of the right blend of atoms/elements and the correct rate of expansion of the universe to occur by chance. He argues that certain atomic particles needed to be present in unequal and varying amounts at the earliest moment of the Big Bang to produce – eventually – the right conditions for life as we know it. He uses this analogy: it’s possible that a poker player could randomly obtain a straight flush in 50 consecutive hands. However, a more plausible explanation is that he’s cheating. In the same way, the universe could have come into being by coincidence, but it’s more likely that it was a coordinated event.

Collins’ argument for the existence of God is compelling to me. His explanation of why he chose to become a Christian is a little less so. Collins often resorts to lengthy quotes of C.S. Lewis in lieu of his own theological rationale – but I suppose we can forgive him for this. He is first and foremost a scientist, not a theologian, and his book simply reflects that fact. [Those interested in a more compelling theological rationale for Christianity might try Timothy Keller's, The Reason For God: Belief In An Age Of Skepticism.]

In summary, Collins claims to believe in “theistic evolution.” He says that few people have heard of it because it harmonizes science and religion – and “harmony is boring” and doesn’t have a PR agenda. Nonetheless, he finds it internally consistent and intellectually satisfying. The material world is best understood through scientific inquiry, the spiritual world cannot be tested or understood by science. Matters of conscience, morality, and a yearning for answers to questions that may not be resolved empirically (What happens to us after death? What existed before the Big Bang? Is there a soul?) are matters best left for religion.

After reading The Language Of God, I feel confident that Collins is a reasonable person. He embraces science more successfully than many people of faith, and I didn’t notice anything about his beliefs that would make me question his ability to lead the NIH in true, scientific inquiry. In fact, The Language Of God may embolden other Christians to join the Science-Based Medicine movement by offering them a rational way to allow faith and science to co-exist. I hope that  scientists who hold atheist or agnostic religious views will embrace this small group of evolutionary theists as religious moderates who fully support scientific orthodoxy.

I was away in Nature – with a real capital N,  and decided to insert an allegory this week instead of a medical subject. The genesis here was a sweeping of the mind and brushing away of cobwebs and detritus called worries and other preoccupations.  The application to this here blog is – methodology. The experience is one of discovery, and of loss, and of bearing the burden of inaction.   

Some thirty or more years ago a family member became enamored of a new book, The Teachings of don Juan by an unknown author, Carlos Castaneda. But mention the name now and one gets one of two responses: Who is that?  Or, Oh, he is that literary fraud.  But in the late 1960s – 1970s, two social movements had captured imaginations of youth, academics, and much of the intellectual world. They made fantasy seem plausible, and fraud seem believable – psychedelics and postmodernism.

Advocates of psychedelics, most of whom experienced drug-induced alterations,  promoted revolutionary psychological ideas such as drug-induced multiple realities.  The other, postmodernism, was and is the intellectual and philosophical movement originating in academia that similarly views of reality(ies) as possibly multiple.  (The relation, if any, to alternate universes and relativity theories in physics I have to leave to philosophers.) But the ‘60s and ‘70s were decades of several revolutions in social and personal thought – paradigm changes – that brought fairy tales, delusions, and irrationality onto realms of plausibility, from which we are still reeling, and trying to deal with. 

Carlos Castaneda wrote eight books (or was it nine?) on the same subject. He related meeting Yaqui Indian seer and healer don Juan Matus at an Arizona bus station and following him through mountains of Mexican Sonora and a series of hallucinatory drug-induced episodes and lessons of life. Later books introduced different main characters (la Catalina, don Gennaro.) At least three books made the NY Times best seller list, and all netted him millions of dollars.  His books sold well even well after his exposure as a fraud and plagiarist.  The psychedelic and postmodern mental states apparently became dominant enough and entrenched enough in modern folklore that believers could not yield their comfort with fantasy.

Then, after mentioning the name Castaneda, state the name Richard de Mille, and chances are neither one questioned will know who that is. Richard de Mille (1924-2009 died April 9. I found this out after starting this post. Richard (most people were on first name basis with him, as was I) was author of two key books on Castaneda, both written in the 1970s: Castaneda’s Journey, the Power and the Allegory, and The don Juan Papers.

Through Richard de Milles’s diligence and intellectual power, Carlos Castaneda was exposed as a fraud, and his eight books describing psychedelic rituals and perceptions of Yaqui Indians of Sonora were proved to be mislabeled creative fiction. Castaneda did not deny the charge and never brought legal charges against de Mille. (After the first $1 million, who cares, might even have been good for business?)

I read Castaneda’s The Teachings on a ski trip in 1970 or so.  Fascinating.  Given the 1960s psychedelic experiences, don Juan Matus, the Yaqui teacher, who leaped vast distances and moved immovable objects or whose spirit could transform into an animal, kneaded and molded younger minds into trying to concurrently rationalize, imagine, and dream single experiences in differing forms. Castaneda described standard interpretations of reality as “ordinary reality” and a others as a “special reality.”  Another of his book titles was “A Separate Reality.”

The process of reading and following Castaneda’s odyssey required toying with mind-bending ideas.  One such was human perception itself being faulty in that it disallowed more than one form of reality at a time.   If this does not make sense to the 21^st century mind, it didn’t make sense to this 20^th century mind then, either, although not for lack of trying. .

I read the first Castaneda books, and was left in a limbo between, possibility and improbability and the author’s delusional thinking or drug-induced hallucinations. The confusion was aided by the appendix of the first book, The Teachings of don Juan: A Yaqui Way of Knowledge, which was the ostensibly real summary of Castaneda’s field work with don Juan for which he was awarded his PhD in anthropology at UCLA. The method used was ethnomethodology, in which the investigator is not a distant observer of a society’s social behavior, but an active participant in it. The investigation becomes experiential.  And, in the process, scientific method becomes something other than science. But that was the new standard of the time.  

Complementing such neo-ideation, was/is the takeover of academic departments and faculty by postmodernism, the neo-philosophy that formalizes varying perceptions and formulations of reality, going so far in some views to proclaim that language creates reality. It was and is an academic world where almost anything is possible, and there are no ground rules for determining the borders.

Castaneda’s PhD thesis had a ring of fantasy. Castaneda could not produce his original field notes – essential in supporting a PhD thesis – claiming that they were destroyed in a flooded basement of his Westwood residence. (Floods in Westwood?) 

I began heated discussions about the writings because I became more and more skeptical and found what I thought were some errors of timing and of psychedelic plant use (no, I never smoked, inhaled, ingested, etc.)  But just because of an error or two I could not dismiss the rest of it – a PhD, after all.  

At about that time I was introduced to skeptical thinking through a local community college symposium at which several CSICOP members from Buffalo, NY spoke – and by an ensuing subscription to Skeptical Inquirer.  It was in an early SI issue that I read a review of de Mille’s book or books, which I promptly bought and spent weeks devouring.

The first book, Castaneda’s Journey, is itself an allegory as the title states.  Written as a partial imitation of Castaneda, de Mille introduces an imagined – or maybe not – meeting of himself and Castaneda, and an ensuing series of real-or-not meetings and dialogues in which de Mille is the student-seeker, and Carlos the mysterious shadow appearing-disappearing Teacher.  This short work is itself a masterwork of layered, allegorical story-telling.  This book is still in print, and I highly recommend it. Like good music or fine wine, enjoy the literary pleasure.

But Richard’s other major works were as different as phyla. The don Juan Papers traces Castaneda’s academic works in cultural anthropology at UCLA, through comments from his advisers, others who had input into the granting of the degree, and outside observers.  The conclusion of most: the thesis was a work of fiction, perhaps based in some personal experiences, but mostly in works of others, knowledge of other cultural rituals and myths, synthesized into a nearly plausible epic analysis of the occult mysteries of native American tribes.

Perhaps most fascinating for us types is the inability of some academics to discard their beliefs, or to resolve their cognitive dissonance in some rational way…they continued to rationalize the episode of being taken in as good illustrative methodology, containing kernels of truth, and other face-saving imaginings. Academia. Peer review. Not always what we would like them to be. Humans run them.

 The department chairman retains his silence in the matter, as embarrassing as it is. To complement the work is a series of analyses and commentaries by other prominent social anthropologists. It is at times heavy going through anthro-sociology jargon and working concepts. Four hundred pages of it, fortunately and mercifully punctuated at crucial points by de Mille’s interpretation, and identifying of contradictions. Indexed and notated in detail, this is the work of an accomplished academician researcher.

In both works, I marveled at de Mille’s attention to detail, to the lengths of comparing time intervals and dates of the same events in several books. It took a great memory and talent to see the contradictions, so often obscure and separated in place and context.

I asked Richard to contribute an article on his methods to Scientific Review of Alternative Medicine, which he did.  [De Mille R, How I Learned Not to Believe Carlos Castaneda. Sci Rev Altern Med 1999; 3(2):11-14.] He has a short section devoted to some of this in each book as well.

Richard’s method derived directly from his academic career, about which I had forgotten. He had both MA and PhD in psychology, spent brief times at USC and UC Santa Barbara faculties, and more time as an industrial and career psychologist, and had done considerable research in various related fields. He said to the effect of, “I merely strolled over to the UCSB library and applied what I had learned.”  He became an authority on social anthropology and ethnography – and a professional skeptic researcher along the way.

I later read his autobiographical and biographical portraits of himself and his prominent mother, (My Secret Mother, Lorna Moon.) a script writer in Hollywood, who bore him out of wedlock to Cecil B. de Mille’s brother, William. Sin and secrecy were the behavior modes at the time, not public confessions or live-in arrangements, so Cecil B. raised Richard as his son, not telling him his real father was Cecil’s brother until William’s death, when Richard was in his thirties.  Interestingly (to me) is that for part of his childhood he lived on the same L.A. street as my grandmother. We might have crossed “paths.” Perhaps not.  

The heart of this tale is that Richard de Mille, himself the guiltless player of a real life mirage, was the key who exposed the largest literary and academic fraud in history, using techniques of research, objective methodology, intelligence, and diligence.  Studying his methods I was able to construct techniques for teaching that I used years later, and that many other skeptics have developed as well.

Richard de Mille was a mild, retiring giant intellect with (insert superlative) writing talent. He was generous with time and a most gracious human being. 

The lament:  I wanted to write a re-review of one or both of Richard’s Castaneda books, but did not get around to it. I always wanted to visit him in Santa Barbara where he lived, but delayed in that also. A lesson re-learned all too frequently.     

Skeptical Inquirer is the official magazine of what was formerly called The Committee for the Skeptical Investigation of Claims of the Paranormal (CSICOP). It was formed in 1976 and in its early days it concentrated on things like Bigfoot, UFOs and psychics. It has morphed into the Committee for Skeptical Inquiry and the magazine is now described on its cover as “The Magazine for Science and Reason.” It has gone way beyond paranormal claims to address everything from intelligent design to AIDS denial. In the 3 decades of its existence it has performed an invaluable service by investigating alleged phenomena and testing claims scientifically, providing natural explanations for weird observations, refuting pseudoscientific arguments, and teaching people how science works and how to think critically.

We now have many skeptical magazines, including Michael Shermer’s Skeptic in the US and similarly named publications in the UK, Australia and elsewhere. But Skeptical Inquirer was the first. It was the trailblazer and set the standard.

The word “skeptic” has negative connotations for some. But it is really a positive, inquisitive, reality-based approach to all aspects of life. A skeptic is a person who asks for evidence before accepting a belief and who asks if there could be another explanation other than the first one that is offered. Scientists are skeptics. Skeptics think scientifically.

As a longtime subscriber to the magazine, none of the articles in the book were new to me, but they were all well worth re-reading and I noticed things I had forgotten or missed the first time around. More importantly, the way the articles were selected and juxtaposed creates a whole that is greater than the parts.

Science is indeed under siege. Its value is questioned by postmodernists. Its findings are rejected by people who put belief and testimonials above the results of scientific studies. Jenny McCarthy tells women to ignore the scientific evidence on vaccinations and trust their Mommy instincts. Evolution is called “only a theory” as “Intelligent Design” tries to infiltrate our schools. Much of the public is scientifically illiterate, and incompetent reporting by the media is only making things worse. Even some scientists fail to truly understand the scientific method.

Science is respected by the public, but “the evidence shows they don’t know much about it and they poorly understand and appreciate the methods science uses to pursue the truth about nature.” As Carl Sagan says in this book, we need to “present science as it is, as something dazzling, as something tremendously exciting, as something eliciting feelings of reverence and awe, as something that our lives depend on.”

This book offers a spirited defense of the scientific approach and applies it to every kind of human endeavor. Science is flexible, self-correcting, a joint enterprise, and a discipline that works the same everywhere regardless of your religion, political beliefs, or culture of origin. It is the one field where people around the world can reach a consensus about reality. It doesn’t claim to offer absolute “truths” but it offers the best (the only) rational tool to asymptotically approach the best approximation of truths about the real world we share. Incidentally, a rare proofreading error misspelled “asymptotically” twice in Carl Sagan’s article as “asymptomatically.” I couldn’t find anything else in the book to criticize, so I thought I’d mention that.

It would be impossible to choose the best out of so many superb essays, but here are some of the highlights: Carl Sagan’s last Q & A on science and skeptical inquiry. A paean to the wonder and awe of real science by Sagan’s wife, Ann Druyan. An article explaining Ray Hyman’s Categorical Directive: “before we try to explain something, we should make sure it actually happened.” John E. Jones, III’s eloquent decision in the Dover “Intelligent Design” case. An article on AIDS denialism by Nicoli Nattrass, who is director of an AIDS research unit in South Africa and can testify to the incalculable harm denialism has caused her compatriots. Common myths about evolution and how to refute them. The anti-vaccination movement (by our own Steven Novella). Ray Hyman investigates a girl who claims to have x-ray vision, Benjamin Radford finds natural explanations and succeeds in reassuring the frightened inhabitants of an allegedly haunted house, and Joe Nickel infiltrates Camp Chesterfield in disguise to show how so-called psychics deliberately lie and trick their customers. The patent office myth (that a director quit because there was nothing more to discover) is put to rest once and for all (but can be predicted to rise again). Philosopher Mario Bunge illuminates the philosophy behind pseudoscience, helping define what it is and helping us understand how to think about it. Bruce Flamm destroys what little is left of the fraudulent Columbia University study about prayer and in vitro fertilization. Other subjects include energy medicine, health claims for magnets, bogus oxygen therapies, and the now defunct PEAR study of psychic power over machines. Marvin Gardner covers vacuum energy. Other articles address global warming, a proposal to reduce the cost of energy, and thoughtful essays on how science can contribute to political decisions and even ethical discussions and is essential to the democratic process. There is even a skeptical look at the reaction to 9/11, – with a rebuttal by Steven Pinker and his later revised rebuttal after he changed his mind! Overblown fears (Halloween candy from a stranger never ever hurt a child), animal rights terrorism, and more. My favorite anecdote from the book is Massimo Polidoro’s account of accompanying magician James Randi on a live TV show as he tried to replicate a psychic’s magic trick of reproducing a drawing that was in a sealed envelope. They used controls that they had not applied to the psychic and that prevented the kind of tricks the psychic used. It looked like Randi had been backed into a corner with no way out, but he calmly improvised new methods of deception on the spot and proceeded to astound everyone. He fully deserves the name of The Amazing Randi as well as the MacArthur Genius Grant he was awarded in 1986.

This collection is a keeper. If you are a subscriber to Skeptical Inquirer, you will want to have this volume on your reference shelf where so many of your favorite gems will be right at your fingertips. If you are not a subscriber, you have a real treat in store.

Disclaimer: two of my own articles were selected for inclusion in this collection, but I am not receiving any royalties. My share of any profits will revert to the organization.