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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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Posted in: Politics and Regulation, Public Health, Science and Medicine

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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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Posted in: Science and the Media, Vaccines

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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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Posted in: Politics and Regulation, Public Health, Vaccines

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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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Posted in: Medical Academia, Politics and Regulation, Public Health, Science and Medicine

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Natural versus “natural” in CAMworld

“When I use a word,” Humpty Dumpty said in rather a scornful tone, “it means just what I choose it to mean — neither more nor less.”

“The question is,” said Alice, “whether you can make words mean so many different things.”

“The question is,” said Humpty Dumpty, “which is to be master— that’s all.”

From: Through the Looking Glass, and
What Alice Found There
by Lewis Carroll

“How can I help seeing what is in front of my eyes? Two and two are four.”

“Sometimes, Winston. Sometimes they are five. Sometimes they are three. Sometimes they are all of them at once. You must try harder. It is not easy to become sane.”

From: Nineteen Eighty-Four by George Orwell

One of the most powerful weapons in the armamentarium of advocates of the unscientific and implausible medical practices that fall under the rubric of “complementary and alternative medicine” (CAM) or, even worse, “integrative medicine” (IM), both of which seek to seamlessly “integrate” pseudoscience with science to the point that people start to be unable to tell which is which in order to “complement” effective medicine with placebo-based medicine, is their skill manupulating language. Wally Sampson has harped on this time and time again on this blog, particularly in his masterful fictional (but all too true-sounding) response to the question, “Why would medical schools associate with quackery?” Kimball Atwood has even turned the–shall we say?–”plasticity” with which CAM/IM advocates manipulate language to their advantage into humorous and all-too-infrequently recurring Friday feature. All of us have complained about how CAM/IM advocates have coopted diet and exercise as being somehow “alternative” and are now using that as the “foot in the door” to introduce pseudoscientific quackery like reiki and homeopathy into not just medical schools but to try to persuade the incoming Obama Administration to fund quackery on equal terms with scientific medicine as part of a “reform” designed to “promote health.”

Much of the success, both previous and current, of CAM/IM advocates depends upon language. Just like Humpty-Dumpty, to ideologues like Deepak Chopra, words mean just what they choose them to mean, and, just like the view forced on Winston Smith at the Ministry of Love, two plus two are sometimes five, no matter how much we know they are four. All it takes is viewing science as “just another narrative,” as postmodernist supporters of CAM/IM would like. Once that happens, there is nothing to stop one from viewing CAM/IM as being a “narrative” just as valid as that of science-based medicine. It’s the way “quackery” has been transformed into “unconventional,” later into “alternative,” and most recently “integrative” medicine. It’s all designed to play on the natural American desire to be “fair” and the media’s desire for “balance,” even though it is not fair to give pseudoscience a patina of scientific respectability that it does not deserve or use “balance” to present quackery as though it has equal standing with scientific medicine.

If there is one word that has been corrupted by the CAM/IM movement more than any other, my vote would go the world “natural.” Of course, it’s not just the CAM/IM movement that has molded this word to mean whatever meaning is required for whatever purpose is desired. For decades, the advertising industry has done the same. However, the CAM/IM movement takes it to a new level, or “kicks it up a notch,” as a certain TV chef likes to say.

I came across a perfect example of this in the form of a man named Tony Isaacs.
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Posted in: Cancer, Clinical Trials, Science and Medicine

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Let President-Elect Obama know that NCCAM should be defunded!

As you may or may not know, Change.gov is being used by Obama’s team to solicit policy ideas. Americans submit ideas, along with supporting rationale, and people “vote up” or vote down” the proposals. “Up” votes increase the score of the proposals, and “down” votes decrease the score. It is described thusly on the Change.gov website:

Share your ideas on any issue facing the new administration, then rate or comment on other ideas. The best rated ideas will rise to the top — and be gathered into a Citizen’s Briefing Book to be delivered to President Obama after he is sworn in.

A couple of days ago, P.Z. Myers let me know about an excellent proposal over at the Citizen’s Briefing Book: Defund the National Center for Complementary and Alternative Medicine:

Here’s a way to increase the available funding to NIH without increasing the NIH budget: halt funding to NCCAM, the National Center for Complementary and Alternative Medicine. This Center was created not by scientists, who never thought it was a good idea, but by Congress, and specifically by just two Congressmen in the 1990′s who believed in particular “alternative” (but scientifically dubious) treatments. Defunding NCCAM would save at least $225 million, possibly more.

Defunding NCCAM would also provide a direct societal benefit. Practitioners of so-called “alternative” medicines constantly refer to NIH’s support as a way of validating their practices and beliefs, most of which are not supported by evidence. The fact is that after >10 years, NCCAM has not yet found a single piece of positive evidence for any of these methods, which include acupuncture, “qi”, homoepathy, magnet therapy, and other treatments.

Any legitimate, promising medical treatment can be funded by one of the existing NIH Institutes. There’s no need for a separate center for “alternative” therapies – but what has happened is that NCCAM has become a last refuge for poorly designed, unscientific studies that couldn’t get funded through the normal peer-reviewed process.

He even cited our co-blogger’s (in)famous article Why the National Center for Complementary and Alternative Medicine (NCCAM) Should Be Defunded. Maybe he should take a gander at my post The National Center for Complementary and Alternative Medicine (NCCAM): Your tax dollars hard at work, as well.
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Chopra and Weil and Roy, oh my! Or: The Wall Street Journal, coopted.

The quest of advocates of unscientific medicine, the so-called “complementary and alternative medicine” (CAM) movement is to convince policy makers, patients, and physicians that it does not deserve the rubric of “alternative,” that it is in fact mainstream. Indeed, that is the very reason why “alternative” medicine morphed into CAM in order to soften the “alternative” label. Increasingly, however, advocates of such highly implausible medical practices appear no longer to like CAM as term for their dubious practicies, because it still uses the word “alternative.” That is, of course, because they recognize that labeling something as “alternative” in relationship to scientific medicine automatically implies inferiority, and CAM advocates are nothing if not full of hubris. Such a term conflicts with their desire to “go mainstream,” and they most definitely do want to go mainstream, but they want to do it on their own terms, without all that pesky mucking about with science, evidence, and rigorous clinical trials. Consequently, they increasingly use a new term, a shiny term, a term free of that pesky “alternative” label. Now they want to “integrate” their unscientific placebo-based practice with real, scientific medicine. Thus was born the term “integrative” medicine (IM, an abbreviation that is the same as that for internal medicine, an identity that I don’t consider coincidence).

One of the biggest complaints we at SBM (or at least I at SBM) have about the attitude of practitioners of scientific medicine towards CAM/IM is that most of them do not see it as a major problem. Dr. Jones characterized this attitude as the “shruggie” attitude, and it’s a perfect term. Equally perfect is her analogy as to why “integrating” pseudoscience with medical science is not a good idea. I myself have lamented the infiltration of pseudoscience and outright quackery into medical academia and the role that the National Center for Complementary and Alternative Medicine (NCCAM) has played in promoting that infiltration. In addition, wealthy patrons of CAM/IM such as Donna Karan and the Bravewell Collaborative have been generous spreading their money around. In this increasingly cash-strapped health care environment, hospitals know on which side their bread is buttered and see the “integration” of woo into their service portfolio as a means of beefing up the bottom line with cash on the barrelhead transactions that require no mucking about with nasty insurance forms. In fact, services such as reiki, homeopathy, acupuncture, and others often require no forms other than credit card receipts for the patient to sign.
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Posted in: Medical Academia, Politics and Regulation, Science and Medicine, Science and the Media

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Christine Maggiore and Eliza Jane Scovill: Living and dying with HIV/AIDS denialism

Christine Maggiore

On Science-Based Medicine, we strive to apply the light of science and reason on all manner of unscientific belief systems about medicine. For the most part, but by no means exclusively, we have concentrated on so-called “complementary and alternative medicine” (CAM) because there is an active movement to infiltrate faith-based, rather than science-based, modalities into “conventional” medicine. Indeed, such efforts are well-financed, both by public and private organizations, and are alarmingly successful at insinuating postmodernist and pseudoscientific beliefs into academia to form an unholy new monster that has been termed by some as “quackademic medicine.”

However, one pseudoscientific belief system about medicine that we at SBM have perhaps not dealt with as much as we should is the belief that, contrary to the overwhelming scientific consensus built up over 25 years, the Human Immunodeficiency Virus (HIV) does not cause Acquired Immune Deficiency Syndrome (AIDS). True, working with Tara Smith, our fearless leader Steve Novella has published an excellent primer on the phenomenon, but not on this blog. This belief system, which is commonly called HIV/AIDS denial or HIV/AIDS denialism, is championed by virologist Peter Duesberg, along with a panoply of groups, such as Alive & Well AIDS Alternatives and Rethinking AIDS; blogs, such as Science Guardian, HIV/AIDS Skepticism, and AIDS Is Over; podcasts, such as How Positive Are You?; books, such as What If Everything You Thought You Knew About AIDS Was Wrong? by Christine Maggiore; and movies, such as The Other Side of AIDS (which resembles in many ways the anti-evolution movie Expelled! and the pro-quackery movie The Beautiful Truth). The influence of HIV/AIDS denialism is horrific, too, particularly in Africa, where advocates of such nonsense, such as Matthias Rath, have advocated quackery over antiretroviral therapy and had the ear of South African President Thabo Mbeki, who lost power in late 2007.
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Posted in: Health Fraud, Public Health, Science and Medicine, Science and the Media

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