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The incredible shrinking vaccine-autism hypothesis shrinks some more

Just when I thought I was out… they pull me back in.

Michael Corleone in The Godfather, Part 3

I hadn’t planned on doing two vaccine posts with such a short interval between them, but all too often, as the they say in the weakest of the Godfather movies, I get pulled back in again. So, after noting last week that 2009 was shaping up–fortunately–to be a very bad year for antivaccinationists, I should have expected a counterattack from the antivaccine fringe. Indeed, the only thing that surprised me after the twin blows of the revelations about scientific fraud on the part of the originator of the claim that the MMR vaccine causes autism, Andrew Wakefield, and the resounding defeat of the first three test cases of the Autism Omnibus proceedings, was that it took longer than I had expected. True, a group had formed, proclaiming that “we support Dr. Andrew Wakefield.” Also true, the antivaccine activists at the Age of Autism have been working overtime to attack the Autism Omnibus as being hopelessly rigged. Indeed, our “old friend” Dr. Jay Gordon has even likened attempts to refute antivaccine pseudoscience to tobacco companies’ P.R. and astroturf campaigns back in the 1950s through 1980s to cast doubt on the strong scientific and epidemiological evidence showing that cigarettes cause lung cancer.

But those contortions of science, epidemiology, law, and logic were merely a warmup for the real counterattack. On February 25, Generation Rescue purchased this full page ad in USA Today:

GenRescue_ad

Unfortunately, the advertisement above was only the beginning. Generation Rescue managed to team up the chief progagandist for the antivaccine movement, David Kirby, along with Robert F. Kennedy, Jr., whom I have discussed before for his total support of the antivaccine movement. The question then becomes: Where would these two team up to spread their message against vaccines? Do you even have to ask?

Their twin articles appear on that repository of all things antivaccine, The Huffington Post, under the title Vaccine Court: Autism Debate Continues. As I will explain, these twin articles represent yet another example of what I have at times referred to as the “incredibly shrinking vaccine-autism hypothesis.”
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Posted in: Science and the Media, Vaccines

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Senator Tom Harkin: “Disappointed” that NCCAM hasn’t “validated” more CAM

Senator Tom Harkin (D-Iowa) owes me a new irony meter.

I’ll explain in a minute, but first you have to know why I even care about what Harkin says or does, given that he’s not my Senator. As you may recall, arguably no single legislator in the U.S. has done more to harm to the cause of promoting science- and evidence-based medicine than Tom Harkin. That’s because it was primarily through Harkin’s efforts that the National Institutes of Health, despite the fact that its scientists were not agitating for it, had the National Center for Complementary and Alternative Medicine (NCCAM) rammed down its throat in 1992, first as the Office of Alternative Medicine (OAM), then in 1998, when NIH Director Harold Varmus tried to place OAM under more scientific NIH control, by elevating OAM to a full and independent Center within the NIH. Thus was NCCAM born.

I’ve complained many times about how NCCAM funds studies that, let’s face it, are of pseudoscience and quackery (homeopathy, anyone?) and even more about how it promotes unscientific medical practices. I’ve argued time and time again that there is no research that is funded by NCCAM that couldn’t be dealt with as well or better by other Centers or Institutes within the NIH. I’ve even argued that NCCAM should be defunded and dismantled, allowing CAM grant applications to be evaluated by the most appropriate center, as has our fearless leader Steve Novella. Most vociferous of all has been my fellow SBM blogger Kimball Atwood, who has made similar arguments at even greater length. I’ve also pointed out Harkin and other CAM-friendly legislators created and managed to increase the funding of NCCAM to the tune of $120+ million a year not for the purpose of rigorous scientific evaluation of CAM practices, but rather to promote CAM and ultimately “integrate” it with scientific medicine. At this they have been enormously successful.

Let me clarify. What I meant is that NCCAM, along with the Bravewell Collaborative, has been very successful in popularizing CAM in medical academia; at “proving” that CAM works, not so much. Evidence that this is so comes from a recent observation that Senator Tom Harkin is very, very unhappy with NCCAM these days and has publicly said so recently, as pointed out by Lindsay Beyerstein, daughter of the late, great skeptical psychologist Barry Beyerstein. On Thursday, Harkin told a Senate panel, Integrative Care: A Pathway to a Healthier Nation, that he was disappointed that NCCAM had disproven too many alternative therapies. (His remarks begin about 17 minutes into the video on the webpage to which I linked.) In addition, Harkin’s statements have also been posted to his Senate blog:
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Posted in: Politics and Regulation, Public Health, Science and Medicine

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Another new blogger for SBM

I’m pleased to announce that I’ve found another blogger for SBM, someone who will represent a viewpoint that I think is very important: That of the physician-in-training. So please welcome Tim Kreider to the stable. Tim is an MD/PhD student at a public university in the northeast US. He never paid much mind to pseudoscience until discovering The Skeptics’ Guide to the Universe and other podcasts that now keep him company during long nights in lab. He practices his skeptical analysis on extracurricular lectures organized by a student interest group for integrative medicine on campus.

As a graduate student, Tim is investigating immune mechanisms in a mouse model of gastrointestinal helminth infection. As a medical student, he has no idea what specialty to pursue and would love advice. He loves to teach math and science and hopes to pursue a career in medical academia.

We’re very happy to have Tim on board. Given that one of my concerns is the infiltration of pseudoscience into the medical school curriculum, I consider it essential to have a medical student on board to give that perspective. Because of his academic load, Tim will be blogging only once a month, although I do hope to tease a little more out of him, as long as it doesn’t jeopardize his education.

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2009: Shaping up to be a really bad year for antivaccinationists

I will begin this post with a bit of an explanation. Between one and two weeks ago, there appeared two momentous news about the manufactroversy regarding vaccines and autism. No doubt, many SBM readers were expecting that I, as the resident maven of this particular bit of pseudoscience, would have been here last week to give you, our readers, the skinny on all of this. Unfortunately, as some know, my wife’s mother died, coincidentally enough, on the 200th anniversary of Darwin’s birthday and a day when one of those two momentous bits of news was released to the public, which is why I used one of my handful of posts written and then held in reserve. I’m back now, though, and I don’t think it’s too late to comment on these bits of news because now that over a week has gone by what I’ve seen has led me to draw some conclusions that I might not have been able to do, had I done my usual bit and been first off the mark (at least among SBM bloggers) discussing the story.

2008: The Best of Years for the Antivaccine Movement

But first, let’s take a look at last year. In 2008, Jenny McCarthy was the new and fresh celebrity face of the movement that believes that autism and all manner of other neurodevelopmental disorders are caused by vaccines and that the government and big pharma are suppressing The Truth. She had emerged in the fall of 2007 after having tried to erase from the Internet her previous involvement in the “Indigo Child” movement in preparation for becoming an “autism advocate” who could write a book that could land her on Oprah’s show. Thanks to her and, perhaps even more so to the star power of her boyfriend Jim Carrey, who is just as wrong about vaccines and medicine as Jenny is, the antivaccine movement came roaring into prominence in a way that it had never managed to pull off before. After all, let’s face it, a former Playboy Playmate of the Year and a famous comedian are far more “interesting” public figures for various media outlets to interview than previous celebrities who spearheaded the vaccine manufactroversy, such as Robert F. Kennedy, Jr. or Don Imus and his wife Deirdre.

Indeed, Jenny’s combination of good looks and utter obnoxiousness led to her showing up all over the media in 2008. For example, on April 1 (appropriately enough), she appeared on Larry King Live! and shouted down physicians who had the temerity to tell her that her Google University knowledge was just plain wrong. The pinnacle of her influence came during the summer, when, having now supplanted J.B. Handley as the public face of the antivaccine group Generation Rescue and transforming GR into “Jenny McCarthy’s autism charity,” she led the “Green Our Vaccines” rally in Washington, DC. True, at most there were several hundred people there, but it got wide news attention, and Jenny was all over the news. She rapidly followed it up by releasing a second book Mother Warriors: A Nation of Parents Healing Autism Against All Odds and appearing on The Oprah Winfrey Show yet again.
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Posted in: Politics and Regulation, Public Health, Science and Medicine, Science and the Media, Vaccines

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Another challenge to surgical dogma

Better late than never with this one.

The dogma that I’m referring to is the remaining practice of using NG tubes in anyone with upper gastrointestinal surgery (liver, stomach, pancreas, duodenum, proximal small intestine) and then placing a jejunostomy tube (a tube, also often called a J-tube, that goes into the jejunum, or the proximal part of the small intestine, through which feedings can be given). The rationale for this was that the peristalsis of the small bowel returns almost immediately; it’s the large bowel and stomach whose return of peristalsis is delayed. Consequently, liquid tube feedings, it was thought, could be given beyond the point of surgery into the small bowel because if there is one surgical dogma that the evidence generally supports and probably always will, it’s always better to use the gut for nutrition than to use total parenteral nutrition (TPN, or feeding by veins). Moreover, there was evidence that such feedings had a protective effect on the lining of the bowel, preventing a phenomenon known as bacterial translocation, in which bacteria could pass through the compromised lining of the bowel after surgical stress. The price, however, was the placement of a tube into the proximal intestine, a procedure that, while safe, was definitely not without complications, some of which (such as bowel perforation) could be serious and require reoperation.

Challenging this dogma is the largest multicenter randomized study yet looking at this question: Which is better, bowel rest (NPO) and J-tube feedings or just letting the patient eat the next day? The study comes out of Norway1 and involved 453 patients. Blinding, much less double blinding, was, as is the case in many surgical trials, not possible because of the very nature of the question being examined, but other than that the design of the study was about as strong as a surgeon could ask for. Basically, patients were randomized to a routine of NPO and J-tube feeding until flatus indicated return of bowel function versus normal food at will beginning on postoperative day one; the experimental design is summarized below:
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Posted in: Clinical Trials, Science and Medicine, Surgical Procedures

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More evidence that CAM/IM advocates see health care reform as an opportunity to claim legitimacy

Four weeks ago (was it really that long?), I wrote one of my usual lengthy essays for this blog in which I analyzed two editorials published by some very famous advocates of “complementary and alternative medicine” (CAM)/”integrative medicine” (IM). They included one in that credulous repository of all things antivaccine The Huffington Post (no, this isn’t about vaccines, but I can’t resist pointing out at every turn the antivaccine slant of that rather famous political blog) and in the Wall Street Journal. The first, published in HuffPo and written by Deepak Chopra, Andrew Weil, and Rustum Roy, was entitled Leaving the Sinking Ship, while the second added Dean Ornish to its team, switched from the highly liberal venue of hte previous article to the conservative WSJ, and was entitled “Alternative” Medicine Is Mainstream: The evidence is mounting that diet and lifestyle are the best cures for our worst afflictions. In doing so, advocates of unscientific and even pseudoscientific faith-based medical treatments seemingly covered the entire span of political thought, from highly liberal to highly conservative, with their message.

That message, as I have argued, along with Wally Sampson, Kimball Atwood, Val Jones, and Peter Lipson, is, to boil it down to its essence, this: The new Obama Administration has promised to make health care reform one of its top priorities, and CAM/IM advocates want to take advantage of this movement for reform as the “foot in the door” behind which they try to muscle their way in to be treated by the government as co-equal with established, science- and evidence-based medicine. How do they plan on doing this? As I have discussed before, they plan on doing this by coopting disease “prevention” strategies as being CAM/IM and using them as a Trojan horse. When the government brings the giant wooden horse into the fortress of government health care, along with the bona fide prevention strategies of diet and exercise a whole lot of woo will jump out of the belly of that horse and open the fortress doors to let in its comrades. Indeed, the same strategy can be seen in how CAM/IM advocates have coopted the Institute of Medicine with a joint conference.

In other words, because CAM/IM advocates have succeeded so well in tying the perfectly acceptable science- and evidence-based modalities of diet and exercise, as well as ghettoizing the respected pharmacology discipline of pharmacognosy by associating it with herbalism and, in essence, bringing it under the CAM umbrella, where it became unfairly and incorrectly tainted with its association with all the other woo that falls under the CAM/IM mantle, they expect that renewing an emphasis on diet and exercise by their definition and on their terms will lead to the opening of the door into the promised land of having their modalities be funded by the government. It’s a very conscious strategy, which is why Chopra et al’s articles so clearly tried to convince readers that diet and exercise are CAM/IM. Unfortunately, that they are able to do this with such success is in part because science- and evidence-based practitioners arguably underemphasize such health prevention strategies.

I learned of another salvo fired off by CAM/IM advocates through my somehow finding myself on the mailing list for The Mary Ann Liebert, Inc. family of medical journals. Unfortunately, one of the journals published by the Liebert group is the Journal of Alternative and Complementary Medicine. This particular e-mail was advertising an editorial written by a chiropractor named Daniel Redwood that spells out in the most detailed manner exactly how CAM/IM advocates plan on hijacking any health care reform that the Obama Administration might come up in order to persuade the government to fund what Wally frequently terms “sectarian medicine” and I simply like to call unscientific. The editorial is freely available to all (unlike the contents of JACM) and entitled Alternative and Complementary Medicine Should Have Role in New Era of Health Care Reform. It’s about as blatant a description of the goals of the CAM/IM movement as I have ever seen.
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Antivaccine hero Andrew Wakefield: Scientific fraud?

Pity poor Andrew Wakefield.

Actually, on second thought, Wakefield deserves no pity at all. After all, he is the man who almost single-handedly launched the scare over the MMR vaccine in Britain when he published his infamous Lancet paper in 1998 in which he claimed to have linked the MMR vaccine to regressive autism and inflammation of the colon, a study that was followed up four years later with a paper that claimed to have found the strain of attenuated measles virus in the MMR in the colons of autistic children by polymerase chain reaction (PCR). It would be one thing if these studies were sound science. If that were the case, then Wakefield’s work would have been very important and would have correctly cast doubt on the safety of the MMR. Unfortunately, they were not, and, indeed, most of the authors of the 1998 Lancet paper later withdrew their names from it.

Over the next decade, aided and abetted by useful idiots in the media, by British newspapers and other media that sensationalized the story, and the antivaccine movement, which hailed Wakefield as a hero, Wakefield managed to drive MMR vaccination rates in the U.K. below the level of herd immunity, from 93% to 75% (and as low as 50% in some parts of London). As a result Wakefield has been frequently sarcastically “thanked” for his leadership role in bringing the measles back to the U.K. to the point where, fourteen years after measles had been declared under control in the U.K., it was in 2008 declared endemic again.

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Since when did an apologist for the antivaccination movement, Dr. Jay Gordon, become an “expert” in vaccine law?

I am an alumnus of the University of Michigan twice over. I completed a B.S. in Chemistry with Honors there in 1984 and then I stayed on to do obtain my M.D. in 1988. I look back very fondly on those eight years spent in Ann Arbor, as several of my longtime friendships were forged or solidified during those years. Consequently, I still care about the place. Indeed, I even once tried to see if I could get a position in the Department of Surgery there a few years back, but unfortunately the “fit” just wasn’t there at the time. That’s why it distresses me when I see my alma mater suffer from a self-inflicted wound, almost as much as the plight of the Michigan Wolverines bothers me, given that never before in my life (at least not since I was old enough to pay attention), have the Wolverines sucked so badly and so hard. Given that level of football futility, though, I consider it even more important that my alma mater not provide any more ammunition to those who would enjoy making fun of it. It doesn’t matter to me that I never went to law school at Michigan; it’s all part of the same campus to me.

This time, the embarrassment comes in the form of an article in the Michigan Law Review by a person who has previously been a subject of posts by both Dr. Novella and me. I’m referring to Dr. Jay Gordon, whom we have both–correctly, I believe–labeled as being, if not fully anti-vaccine, at least a prominent and major apologist for the anti-vaccine movement. Unfortunately, because he is the pediatrician taking care of Jenny McCarthy’s son Evan, he has gained even greater prominence in the antivaccine movement than ever, to the point where he gave a speech last summer to the antivaccine “Green Our Vaccines” march on Washington and where he is regularly called up by TV producers to give a false “balance” whenever a discussion of vaccines and/or autism comes up. He also wrote the foreword to Jenny McCarthy’s latest paean to autism quackery and attack on vaccines as the cause of autism in which he blithely repeated some of the worst distortions of the antivaccine movement. Unfortunately, Dr. Gordon lacks the intestinal fortitude to stop the piteous denials any time he is called out for his parroting of antivaccine pseudsocience and to embrace his inner antivaccinationist. Then, at least, we wouldn’t be treated to the spectacle of his simultaneously claiming he is “pro-safe vaccine, not anti-vaccine” while at the same time saying he “doesn’t give a lot of vaccines” and admitting that parents have actually had to persuade him to vaccinate “reluctantly.”

So what was the topic of the Michigan Law Review article that Dr. Gordon was apparently asked to pen? It’s actually an interesting question from a legal, political and civil rights standpoint, specifically: Whether or not parents should be held legally liable for refusing to vaccinate their children. Not surprisingly, Dr. Gordon took the “no” position. Unfortunately, as we’ve come to expect of Dr. Gordon, he uses a number of highly dubious arguments. However, more interesting to me, having had a nearly four year history sparring online with him off and on, was the seemingly “kinder and gentler” antivaccine stance that he took in this article.

But first, let’s take a look at the debate. The symposium published in First Impressions (the online companion to the Michigan Law Review) was entitled Liability for Exercising Personal Belief Exemptions from Vaccination, and it contained the following articles:

  1. Choices Should Have Consequences: Failure to Vaccinate, Harm to Others, and Civil Liability by Douglas S. Diekema.
  2. Parents Should Not be Legally Liable for Refusing to Vaccinate their Children by Dr. Jay Gordon.
  3. Unintended Consequences: The Primacy of Public Trust in Vaccination by Jason L. Schwartz.
  4. Challenging Personal Belief Immunization Exemptions: Considering Legal Responses by Alexandra Stewart.
  5. Gambling with the Health of Others by Stephen P. Teret and John S. Vernick.
  6. The Problem of Vaccination Noncompliance: Public Health Goals and the Limitations of Tort Law by Daniel B. Rubin and Sophie Kasimow

There were a number of fascinating issues raised here. Although it’s obvious that universal vaccination is a public health policy good, given that the higher percentage of vaccinated children, the greater the herd immunity, there is always the nagging question of how far the state should go to mandate vaccination in a free society; i.e., how much coercion is acceptable to bring about maximal levels of vaccination? In other words, what is the proper balance between the needs of society as a whole and the rights of the individual? The next interesting legal and moral question is whether parents who refuse to vaccinate should be held liable for injuries to other children if their unvaccinated child passes on an infectious disease. Personally, I tend to believe that it is entirely reasonable to require vaccination as a precondition for school or day care and that exemptions should be primarily medical in nature. I grudgingly allow that the freedom of religion guaranteed in the First Amendment probably requires religious exemptions (although I do not understand why religion should be given such a privileged place in society that it can endanger public health), I am far less convinced that philosophical exemptions should be mandated. I realize many may disagree with this position, but I would hope that our disagreements would be based on (1) the best science regarding the benefits and risks of vaccination and (2) honest beliefs regarding the proper balance between public health concerns and individual liberty. Clearly, this is an area of debate. I also tend to believe that if parents refuse to vaccinate their child and that child passes an infectious disease to another child, then those parents should be potentially legally liable. Indeed, Douglas Diekema argues this position very well.

Unfortunately, Dr. Gordon does not meet at least condition #1 above. He does not base his arguments on the best science.
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Just in case anyone’s interested…

…I’m actually on Facebook. So are Val Jones , David Kroll, Peter Lipson, and Steve Novella.

In any case, feel free to check it out and, if you’re interested, leave a note on my wall, that of my co-bloggers, or send us a friend request. Being somewhat new at this whole Facebook thing, I note with some amusement that, in a moment when I was in an unusually perverse mood, I sent Dr. Jay Gordon a friend request, and he actually confirmed it.

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Dismantling NCCAM: A How-To Primer

Two of the earliest posts I wrote for Science-Based Medicine were entitled The infiltration of complementary and alternative medicine (CAM) and “integrative medicine” into academia and The National Center for Complementary and Alternative Medicine (NCCAM): Your tax dollars hard at work. Both were intended as a lament over how not only is pseudoscientific quackery, much of it based on a prescientific understanding of how the human body works and disease occurs, finding its way into some of the most prestigious academic medical centers in the U.S. (for example, Georgetown and Beth Israel) but it’s even finding its way into the heart of the U.S. military.

Worse, aiding and abetting this infiltration is the federal government itself in the form of NCCAM. As I discussed in my usual excruciating detail in my original post and as Steve Novella, Kimball Atwood, and I have subsequently discussed many times on this very blog, particularly recently (so much so that I’m thinking of giving NCCAM its very own category here on SBM), NCCAM not only funds studies of dubious “alternative” therapies, such as reiki and homeopathy, that estimates of prior probability alone would argue to be so close to impossible as to be not worth spending millions, much less thousands, of dollars upon, but it also promotes quackery by funding “fellowships” at various institutions to teach “complementary and alterantive medicine” (CAM) sometimes also called “integrative medicine” (IM). Given that it spends over $120 million a year on mostly dubious studies and CAM promotion, we all have called for NCCAM to be defunded and disbanded.

Nearly a year has passed since I wrote those two posts. Ironically enough, at the time I wrote my first post about NCCAM for this blog, I pointed out that at first I had disagreed with my co-blogger Wally Sampson and his call to “defund” the NCCAM in an article published on Quackwatch nearly five years ago. My original reason was that I thought that there was value in studying these therapies to find out once and for all whether these therapies do anything greater than placebo or not. I now admit that I was very naive, and this was how I admitted it:

Two developments over the last several years have led me to sour on NCCAM and move towards an opinion more like Dr. Sampson’s. First, after its doubling from FY 1998-2003, the NIH budget stopped growing. In fact, adjusting for inflation, the NIH budget is now contracting. NCCAM’s yearly budget remains in the range of $121 million a year, for well over $1 billion spent since its inception as the Office of Alternative Medicine in 1993. Its yearly budget contains enough money to fund around 75 to 100 new five year R01 grants, give or take. In tight budgetary times my view is that it is a grossly irresponsible use of taxpayer money not to prioritize funding for projects that have hypotheses behind them that have a reasonable chance of being true. Scarce NIH funds should not be for projects that have as their basis hypotheses that are outlandishly implausible from a scientific standpoint. Second, I’ve seen over the last few years how NCCAM is not only funding research (most of which is of the sort that wouldn’t stand a chance in a study section from other Institutes or Centers)) but it’s funding training programs. Indeed, that was the core complaint against NCCAM: that it facilitates and promotes the infiltration of nonscience- and nonevidence-based treatments falling under the rubric of so-called “complementary and alternative” or “integrative” medicine into academic medicine.

Nothing has changed since I wrote those words–except for one thing. We now have a new President who stated in his inaugural address:

We will restore science to its rightful place, and wield technology’s wonders to raise health care’s quality and lower its cost. We will harness the sun and the winds and the soil to fuel our cars and run our factories. And we will transform our schools and colleges and universities to meet the demands of a new age. All this we can do. And all this we will do.

As Kimball Atwood put it, Yes We Can! We Can Abolish the NCCAM! The big and as yet unasked (and unanswered) question is: How? Neither defunding nor dismantling NCCAM will be easy, and we have to think about how to preserve the functions of NCCAM that might be worth saving.
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