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Longing for a past that never existed

There once was a time when all food was organic and no pesticides were used. Health problems were treated with folk wisdom and natural remedies. There was no obesity, and people got lots of exercise. And in that time gone by, the average life expectancy was … 35!

That’s right. For most of human existence, according to fossil and anthropological data, the average human life expectancy was 35 years. As recently as 1900, American average life expectancy was only 48. Today, advocates of alternative health bemoan the current state of American health, the increasing numbers of obese people, the lack of exercise, the use of medications, the medicalization of childbirth. Yet life expectancy has never been longer, currently 77.7 years in the US.

Advocates of alternative health have a romanticized and completely unrealistic notion of purported benefits of a “natural” lifestyle. Far from being a paradise, it was hell. The difference between an average lifespan of 48 and one of 77.7 can be accounted for by modern medicine and increased agricultural production brought about by industrial farming methods (including pesticides). Nothing fundamental has changed about human beings. They are still prey to the same illnesses and accidents, but now they can be effectively treated. Indeed, some diseases can be completely prevented by vaccination.

So why are advocates of alternative health complaining? They are complaining because they long for an imagined past that literally never existed. In that sense, alternative health represents a form of fundamentalism. Obviously, fundamentalism is about religion and the analogy can only go so far, but there are several important characteristics of religious fundamentalism that are shared by alternative health advocacy. These include:
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Posted in: Science and Medicine

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Science by press release

Last week I wrote about a study that purported to show that antidepressants have no effect in mild to moderate depression. A careful reading of the paper shows that the authors dramatically overstated their findings, particularly in their public statements to the media. The study has another implication beyond the misleading claims about antidepressants. It is an object lesson in an ongoing and disturbing phenomenon in mainstream journalism, the wholesale reprinting of press releases of scientific papers instead of reading and analyzing the papers themselves.

Pick up any newspaper or magazine and you can read about the latest scientific breakthroughs in cancer, Alzheimer’s or heart disease. Just keep in mind that what you are reading is probably a commercial message direct from the authors, not an accurate representation of the paper itself. Medical journalists are supposed to interpret the findings of recent medical publications and present them to the general public in ways that they can understand. They are supposed to provide context for the discovery, explaining what it might mean for disease treatment or cure. Yet, they rarely do. Instead, they simply copy the press release.

Most people are unaware that scientists issue press releases about their work and they are certainly unaware that medical journalists often copy them word for word. Instead of presenting an accurate representation of medical research, medical journalists have become complicit in transmitting inaccurate or deceptive “puff pieces” designed to hype the supposed discovery and hide any deficiencies in the research.

Imagine if a journalist reviewing the newest Ford cross-over vehicle didn’t bother to drive the car, but simply copied the Ford brochure word for word. Could you rely on the journalist’s evaluation? Of course not. Yet that is precisely what medical journalists are doing each and every day.
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Posted in: Science and Medicine, Science and the Media

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Study shows antidepressants useless for mild to moderate depression? Not exactly.

As Harriet Hall has written (http://www.sciencebasedmedicine.org/?p=353), psychiatry bashing is a popular media sport. There seems to be a bias against treatment of psychiatric disabilities, and a common claim is that antidepressants are no better than placebo. The New York Times illustrated both the perpetuation of the myth that antidepressants are ineffective, and the increasing and disturbing tendency of major media organizations to confuse the wholesale acceptance of medical press releases with medical journalism.

In Popular Drugs May Help Only Severe Depression The New York Times credulously publicized the findings of a recent study that claimed to show that antidepressants are ineffective in treating mild and moderate depression. Yes, that’s what the study showed, but the study itself is so limited, so fraught with problems, and the conclusions are so misleading that the article is a terrible disservice.

Before we consider what the study showed, let’s think about what kind of evidence we’d need to conclude that antidepressants don’t work.

First, although there are different types of antidepressants, the term used colloquially refers to antidepressants of a specific type, SSRI’s or selective serotonin reuptake inhibitors. There are other, older types of antidepressants that are rarely used today because of their unpleasant side effects. Hence any study that claims to show that “antidepressants” are ineffective, must look at SSRIs.

Second, there are literally thousands of studies of SSRIs, and it would be helpful to aggregate the results. Aggregating results can be done in a type of paper known as metaanalysis. Metaanlysis adds the results of multiple similar studies to find trends that might not be apparent in individual small studies. But a metaanlysis is subject to several important limitations that must always be considered. The most important limitation is that the authors of the metaanalysis choose the papers to be included. Bias can be introduced by examining only papers that have a desired outcome; that can be accomplished by restricting the inclusion criteria in arbitrary ways.

Let’s look at the study, Antidepressant Drug Effects and Depression Severity. According to the abstract:
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Posted in: Science and Medicine

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Reflexive doubt

Those of us who study, practice and write about medicine cherish the hope that explaining the science behind medicine (or the lack of science behind “alternative” treatments) will promote a better understanding of medicine. Certainly, I would not bother to write about medical topics if I did not believe that promoting science based medicine would lead to increased understanding of medical recommendations and decreased gullibility in regard to “alternative” remedies. Nonetheless, lack of scientific knowledge is not the only reason for the current popularity of “alternative health. Indeed, many advocates and purveyors of “alternative” health are impervious to the scientific evidence. What else might be going on?

Belief in “alternative” medicine is a complex social phenomenon. Like any complex social phenomenon, the explanation cannot be reduced to a simple answer. But I would argue that there is an important philosophical component, developed by and promoted by advocates of “alternative” health. That philosophical component is the rise of reflexive doubt. Simply put, among a significant segment of society, it has become a badge of honor to question authority.

As an obstetrician, I am most familiar with its expression among childbirth activists. They recognize that many people hold the common sense belief that modern obstetrical practice has made birth safer, and have worked ceaseless at undermining this common sense view. Craig Thompson, a professor of marketing, has examines this tactic in his paper What Happens to Health Risk Perceptions When Consumers Really Do Question Authority?:
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Posted in: Science and Medicine

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Big Placebo says Medicine never cures anything

Kudos to Lindsay Beyerstein of Majikthise for coining a new appellation “Big Placebo.” Big Placebo is the alternative health counterpart to Big Pharma. Both are special interest groups designed to promote their products, whether they are worthy of promotion or not. There is one big difference between them: Big Pharma makes products that usually work (though not always, and sometimes not safely). Big Placebo hawks books and products that never work.

Big Placebo is unsatisfied with the $40 billion it takes in every year on treatments that don’t even work. They’re aiming for a much larger piece of the healthcare pie and to do so they are criticizing modern medicine.

To hear Big Placebo tell it, virtually all illness can be prevented and anyone who gets sick deserves it because of poor lifestyle choices. If only that were so. Unfortunately, most illness and disease is caused by factors beyond people’s control, including infectious agents, genetic defects and inherited predispositions.
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Is breech vaginal delivery safe?

Between 3-4% of babies begin labor in the breech (bottom first) position, increasing the risk of neonatal morbidity and mortality. Pre-emptive C-section has become the preferred method of delivery for breech babies, but now some are questioning this recommendation. The controversy is fueled by differing appraisals of the danger and by differing assessments of the whether any risk of neonatal death can be justified in the age of the safe Cesarean.

The best conducted and most important study comparing breech vaginal delivery with elective C-section is the Term Breech Trial (TBT) conducted by Mary Hannah and colleagues. It is the only randomized control trial of its kind.

… [W]e found that the fetuses of women allocated planned caesarean section were significantly less likely to die or to experience poor outcomes in the immediate neonatal period than the fetuses of women allocated planned vaginal birth. Although some of the deaths in the planned vaginal birth group were related to difficulty with vaginal breech delivery, others were clearly associated with problems during labour. Thus the avoidance of labour and vaginal breech delivery could have contributed to better outcomes with planned caesarean section…

A more recent trial, the PREMODA (PREsentation et MODe d’Accouchement: presentation and mode of delivery) study produced different findings and as a result, some obstetricians have been calling for a re-evaluation of the standard recommendation for C-section delivery of a breech baby. (more…)

Posted in: Obstetrics & gynecology, Science and Medicine

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The case for neonatal circumcision

Imagine if we could save lives from a dread and often fatal disease simply by performing a minor surgical procedure. People would hail this simple victory and rush to adopt it… Not exactly. The disease is HIV and the simple surgical procedure is circumcision and anti-circ activists oppose it under almost any circumstances.

In this month’s edition of the Archives of Pediatrics and Adolescent Medicine, Tobian, Gray and Quinn present a compelling case for neonatal circumcision. The paper is entitled Male Circumcision for the Prevention of Acquisition and Transmission of Sexually Transmitted Infections. The authors report:

The American Academy of Pediatrics (AAP) male circumcision policy states that while there are potential medical benefits of newborn male circumcision, the data are insufficient to recommend routine neonatal circumcision. Since 2005, however, 3 randomized trials have evaluated male circumcision for prevention of sexually transmitted infections. The trials found that circumcision decreases human immunodeficiency virus acquisition by 53% to 60%, herpes simplex virus type 2 acquisition by 28% to 34%, and human papillomavirus prevalence by 32% to 35% in men. Among female partners of circumcised men, bacterial vaginosis was reduced by 40%, and Trichomonas vaginalis infection was reduced by 48%. Genital ulcer disease was also reduced among males and their female partners. These findings are also supported by observational studies conducted in the United States. The AAP policy has a major impact on neonatal circumcision in the United States. This review evaluates the recent data that support revision of the AAP policy to fully reflect the evidence of long-term health benefits of male circumcision.

The AAP had long recommended male circumcision for prevention of urinary tract infections in young boys, but backed down in 1999, partly in response to pressure from anti-circumcision activists. According to circumcision.org:

Based on a review of medical and psychological literature and our own research and experience, we conclude that circumcision causes serious, generally unrecognized harm and is not advisable.

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Oppose “Big Floss”; practice alternative dentistry

We survived almost all of human history without it. Yet in the last 100 years people have allowed themselves to be hoodwinked by a huge corporate conspiracy into believing that we “need” their products. They cite studies and claim we don’t understand science; they ignore ancient folk wisdom and have no respect for our intuition. They peddle their products without regard to the dramatic increase in chronic diseases and weakened immune systems of recent decades. I’m speaking, of course, of “Big Floss.”

It’s time to take our mouths back from corporate domination. It’s time for alternative dentistry.
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Posted in: Humor, Science and Medicine

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“Toxins”: the new evil humours

They say that everything old is new again and that is certainly true in the world of “alternative” health. One of the axiomatic premises of contemporary “alternative” health puts its believers behind the times … by approximately 500 years.

A fundamental premise held by believers in “alternative” health is that we are swimming in a world of “toxins” and those “toxins” are causing disease. Like most premises in “alternative” health it has no basis in scientific fact; makes intuitive sense only if you are ignorant of medicine, science and statistics; and speaks to primitive fears and impulses.

The preoccupation with “toxins” is a direct lineal descendant of the obsession with evil humours and miasmas as causes of disease. It is hardly surprising that prior to the invention of the microscope the real causes of disease went undiscovered. The idea that disease is caused by tiny organisms that invade the body is not amenable to discovery in the absence of scientific instruments and scientific reasoning. And it goes without saying that the same people who were unaware that bacteria and viruses cause disease could not possibly imagine chromosomal defects, inborn errors of metabolism or genetic predispositions to disease.

Instead, people imagined that diseases were caused by excess evil humours, substances that were named, but never seen or identified in any way accessible to the senses. It was recognized that some diseases were contagious, and in that case, people invoked the idea of “miasmas” that somehow transmitted disease.
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Are the benefits of breastfeeding oversold?

As a mother, I am a passionate advocate of breastfeeding and I breastfed my four children. As a clinician, though, I need to be mindful not to counsel patients based on my personal preferences, but rather based on the scientific evidence. While breastfeeding has indisputable advantages, the medical advantages are quite small. Many current efforts to promote breastfeeding, while well meaning, overstate the benefits of breastfeeding and distorts the risks of not breastfeeding, particularly in regard to longterm benefits.

As Joan Wolf explains in an article entitled Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign:

… Medical journals are replete with contradictory conclusions about the impact of breast-feeding: for every study linking it to better health, another finds it to be irrelevant, weakly significant, or inextricably tied to other unmeasured or unmeasurable factors. While many of these investigations describe a correlation between breast-feeding and more desirable outcomes, the notion that breast-feeding itself contributes to better health is far less certain, and this is a crucial distinction that breast-feeding proponents have consistently elided. If current research is a weak justification for public health recommendations, it is all the more so for a risk-based message that generates and then profits from the anxieties of soon-to-be and new mothers…

Wolf describes the problems with many studies of breastfeeding, particularly those that focus on long term outcomes:

In breast-feeding studies, potential confounding makes it difficult to isolate the protective powers of breast milk itself or to rule out the possibility that something associated with breast-feeding is responsible for the benefits attributed to breast milk. As the number of years between breastfeeding and the measured health outcome grows, so too does the list of possibly influential factors, which means that the challenge is magnifiedwhen trying to evaluate long-term benefits of breastfeeding… Breast-feeding, in other words, cannot be distinguished from the decision to breast-feed, which, irrespective of socioeconomic status or education,could represent an orientation toward parenting that is itself likely to have a positive impact on children’s health. In instances such as this, in which the exposure (breast-feeding) and confounder (behavior) are likely to be very highly correlated, confounding is especially difficult to detect. When behavior associated with breast-feeding has the potential to explain much of the statistical advantage attributed to breast milk, the scientific claim that breast-feeding confers health benefits … needs to be reexamined.

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