Science-Based Medicine

It’s the toxins.

Toujours les toxines.

How many times have I read or heard from believers in “alternative” medicine that some disease or other is caused by “toxins”? I honestly can’t remember, but in alt-world, no matter what the disease or condition under discussion is, there’s a good chance that sooner or later it will be linked to “toxins.” It doesn’t matter if it’s cancer, autism, heart disease, diabetes, hypertension, or that general malaise that comes over people who, as British comedians Mitchell and Webb put it, have more money than sense; somehow, some way, someone will invoke “toxins.”

I was reminded of this obsession among believers in unscientific medicine last Friday when I came across an article by Guy Trebay in the New York Times entitled The Age of Purification. The article appeared, appropriately enough, in the Fashion section and was festooned with photos of cupping, surely one of the silliest of the many “detoxification” modalities that alternative medicine practitioners use to claim to draw the “toxins” out of their clients through the application of, well, cups or various other containers in which the air had been heated in order to generate negative pressure when sealed to the skin and presumably thus bring them to a greater level of purification and health. Indeed, the only “detoxification” rituals sillier than cupping that I can think of off the top of my head are detoxifying footpads and “detox foot baths.”

Oh, wait. Scratch that. I forgot about ear candling, which must surely be the undisputed silliest “detox” treatment of all time—until someone thinks of an even sillier one. Or not. There are just so many silly “detox” procedures that it’s hard to select a “winner.”

Be that as it may, Trebay mixes sarcasm with exposition throughout his article in a rather amusing way that’s worth quoting:

My friend, like everyone else around, seemed to believe that mysterious, amorphous sludge had lodged in the anatomical crannies of half the local adult population. Unseen toxins were lurking, like Communists during the Red Scare.

The “toxins” required elimination, somehow, and thus at lunches, at cocktails, at dinner parties, normal conversations turned abruptly from the day’s news to progress reports on juice fasts, energy alignments, radical purging. From painful sessions with traditional healers to toxin-leaching treatments designed, it might seem, to clean out not just body but wallet, a surprising number of New Yorkers (not all of them well-to-do neurotics) are caught up in a new New Age, the Age of Purification.

How had it happened, I wondered, that so many otherwise sensible, urban people found themselves in the grip of a dreadful feeling that systems are down? “I just bought five pounds of carrots, ginger and kale and put it all in my Breville juicer and pounded that all day,” said a corporate adviser of my acquaintance, far from a credulous woo-woo type.

Of course, as we have noted so many times before, hard-nosed skepticism in one area of one’s life does not necessarily translate to other areas. Many are the people who would never ever fall prey to scams in business, for example, but happily fork over money for scams such as “detox footpads”—or fall for anti-vaccine quackery, like J.B. Handley. Whatever the case, why this fascination with “detoxification” in alternative medicine? Why do so many of its treatments, be they dietary, chelation therapy, purges, colon cleanses, or whatever, claim to eliminate “toxins”? Why is it that, if you Google “alternative medicine” and “detoxification,” you find so many references, some of which claim external toxins need to be eliminated, some of which claim that internal toxins need to be purged, and still more of which blame various “parasites” for all manner of health distress? In this post, I’ll try to explain, but first a little history—self-history that is.
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I saw a patient recently for parasites.

I get a sinking feeling when I see that diagnosis on the schedule, as it rarely means a real parasite.  The great Pacific NW is mostly parasite free, so either it is a traveler or someone with delusions of parasitism.

The latter comes in two forms: the classic form and Morgellons. Neither are likely to lead to a meaningful patient-doctor interaction, since it usually means conflict between my assessment of the problem and the patients assessment of the problem.  There is rarely a middle ground upon which to meet. The most memorable case of delusions of parasitism I have seen was a patient who  I saw in clinic who, while we talked, ate a raw garlic clove about every minute.

“Why the garlic?” I asked.

“To keep the parasites at bay,” he told me.

I asked him to describe the parasite.  He told me they floated in the air, fell on his skin, and then burrowed in.  Then he later plucked them out of his nose.

At this point he took out a large bottle that rattled as he shook it.

“I keep them in here,” he said as he screwed off the lid and dumped about 3 cups with of dried boogers on the exam table.

To my credit I neither screamed nor vomited, although for a year I could not eat garlic.  It was during this time I was attacked by a vampire, and joined the ranks of the undead. Continue Reading »

The White Man’s burden, a bit of racism from the 19th century:

The term “the white man’s burden” has been interpreted as racist, or taken as a metaphor for a condescending view of non-Western national culture and economic traditions, identified as a sense of European ascendancy which has been called “cultural imperialism.” An alternative interpretation is the philanthropic view, common in Kipling’s formative years, that the rich have a moral duty and obligation to help “the poor” “better” themselves whether the poor want the help or not. The term “the white man’s burden” has been interpreted as racist, or taken as a metaphor for a condescending view of non-Western national culture and economic traditions, identified as a sense of European ascendancy which has been called “cultural imperialism.” An alternative interpretation is the philanthropic view, common in Kipling’s formative years, that the rich have a moral duty and obligation to help “the poor” “better” themselves whether the poor want the help or not.

I will let the commentators debate the meaning of the poem. There are places in the world so devastated by poverty, disease and political corruption that it may be beyond the capacity of the local populations to overcome. They need outside help. Certainly, the impulse to help those less fortunate than yourselves is a noble tradition. Haiti, Central America and Uganda are parts of the world that need assistance in overcoming an incredible number of problems to reach even a basic level of material support for its population.
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Naturopathy has been a recurrent topic on this blog. The reasons should be obvious. Although homeopathy is the one woo to rule them all in the U.K. and much of Europe, here in the U.S. homeopathy is not nearly as big a deal. Arguably, some flavor of naturopathy is the second most prevalent “alternative medical system” here, after chiropractic of course, and perhaps duking it out with traditional Chinese medicine, although naturopathy does embrace TCM as part of the armamentarium of dubious medical systems that it uses. In any case, some sixteen states and five Canadian provinces license naturopaths in some form, and in some states naturopaths are fighting for–and in some cases winning–the power to prescribe certain real pharmaceutical medications and order real medical tests. For instance, in California, naturopaths can order laboratory tests and X-rays, which reminds me of a conversation I had with a mammographer from California at TAM last summer. He told me a tale of the dilemma he had when naturopaths and other “alt-med” practitioners ordered tests at his facilities. Specifically, the dilemma came about because he doubted that the naturopath knew what to do with the results. Meanwhile, in Oregon, naturopaths can prescribe certain types of pharmaceutical drugs (as opposed to the usual supplements, herbs, or homeopathic remedies they normally prescribe). Meanwhile, moves are under way to expand the prescribing privileges of naturopaths in Canada, as Ontario (which is, remember, just across the Detroit River, less than two and a half miles as the crow flies from my cancer center—a truly frightening thought to me).

Unfortunately, naturopathy is a hodge-podge of mostly unscientific treatment modalities based on vitalism and other prescientific notions of disease. As a result, typical naturopaths are more than happy in essence to “pick one from column A and one from column B” when it comes to pseudoscience, mixing and matching treatments including traditional Chinese medicine, homeopathy, herbalism, Ayurvedic medicine, applied kinesiology, anthroposophical medicine, reflexology, craniosacral therapy, Bowen Technique, and pretty much any other form of unscientific or prescientific medicine that you can imagine. Despite their affinity for non-science-based medical systems, naturopaths crave the imprimatur of science. As a result, they desperately try to represent what they do as being science-based, and they’ve even set up research institutes, much like the departments, divisions, and institutes devoted to “complementary and alternative medicine” (CAM) that have cropped up on the campuses of legitimate medical schools and academic medical centers like so many weeds poking through the cracks in the edifice of science-based medicine. Naturopaths also really, really don’t like it when they encounter criticism that their “discipline” is not science-based. Indeed, the president of the American Association of Naturopathic Physicians, Carl Hangee-Bauer, ND, LAc (he’s an acupuncturist, too!), wrote a revealing post on the official AANP blog entitled Science and Naturopathic Medicine.

Science. You keep using that word. I do not think it means what you think it means.

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Review

This is the second post in a series* prompted by an essay by statistician Stephen Simon, who argued that Evidence-Based Medicine (EBM) is not lacking in the ways that we at Science-Based Medicine have argued. David Gorski responded here, and Prof. Simon responded to Dr. Gorski here. Between that response and the comments following Dr. Gorski’s post it became clear to me that a new round of discussion would be worth the effort.

Part I of this series provided ample evidence for EBM’s “scientific blind spot”: the EBM Levels of Evidence scheme and EBM’s most conspicuous exponents consistently fail to consider all of the evidence relevant to efficacy claims, choosing instead to rely almost exclusively on randomized, controlled trials (RCTs). The several quoted Cochrane abstracts, regarding homeopathy and Laetrile, suggest that in the EBM lexicon, “evidence” and “RCTs” are almost synonymous. Yet basic science or preliminary clinical studies provide evidence sufficient to refute some health claims (e.g., homeopathy and Laetrile), particularly those emanating from the social movement known by the euphemism “CAM.”

It’s remarkable to consider just how unremarkable that last sentence ought to be. EBM’s founders understood the proper role of the rigorous clinical trial: to be the final arbiter of any claim that had already demonstrated promise by all other criteria—basic science, animal studies, legitimate case series, small controlled trials, “expert opinion,” whatever (but not inexpert opinion). EBM’s founders knew that such pieces of evidence, promising though they may be, are insufficient because they “routinely lead to false positive conclusions about efficacy.” They must have assumed, even if they felt no need to articulate it, that claims lacking such promise were not part of the discussion. Nevertheless, the obvious point was somehow lost in the subsequent formalization of EBM methods, and seems to have been entirely forgotten just when it ought to have resurfaced: during the conception of the Center for Evidence-Based Medicine’s Introduction to Evidence-Based Complementary Medicine.

Thus, in 2000, the American Heart Journal (AHJ) could publish an unchallenged editorial arguing that Na₂EDTA chelation “therapy” could not be ruled out as efficacious for atherosclerotic cardiovascular disease because it hadn’t yet been subjected to any large RCTs—never mind that there had been several small ones, and abundant additional evidence from basic science, case studies, and legal documents, all demonstrating that the treatment is both useless and dangerous. The well-powered RCT had somehow been transformed, for practical purposes, from the final arbiter of efficacy to the only arbiter. If preliminary evidence was no longer to have practical consequences, why bother with it at all? This was surely an example of what Prof. Simon calls “Poorly Implemented Evidence Based Medicine,” but one that was also implemented by the very EBM experts who ought to have recognized the fallacy.

There will be more evidence for these assertions as we proceed, but the main thrust of Part II is to begin to respond to this statement from Prof. Simon: “There is some societal value in testing therapies that are in wide use, even though there is no scientifically valid reason to believe that those therapies work.”

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If you go to the website of the National Center for Complementary and Alternative Medicine (NCCAM), you’ll find that one of its self-identified roles is to “provide information about CAM.” NCCAM Director Josephine Briggs is proud to assert that the website fulfills this expectation. As many readers will recall, three of your bloggers visited the NCCAM last April, after having received an invitation from Dr. Briggs. We differed from her in our opinion of the website: one of our suggestions was that the NCCAM could do a better job providing American citizens with useful and accurate information about “CAM.”

We cited, among several examples, the website offering little response to the dangerous problem of widespread misinformation about childhood immunizations. As Dr. Novella subsequently reported, it seemed that we’d scored a point on that one:

…Dr. Briggs did agree that anti-vaccine sentiments are common in the world of CAM and that the NCCAM can do more to combat this. Information countering anti-vaccine propaganda would be a welcome addition to the NCCAM site.

In anticipation of SBM’s Vaccine Awareness Week, I decided to find out whether such a welcome addition has come to fruition. The short answer: nope.

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A couple of weeks ago, in a review of the Mayo Clinic Book of Home Remedies, Harriet Hall expressed relief that she hadn’t found any “questionable recommendations for complementary & alternative medicine (CAM) treatments” in that book:

Since “quackademic” medicine is infiltrating our best institutions and organizations, I wasn’t sure I could trust even the prestigious Mayo Clinic.

The Home Remedies book may be free of woo, but Dr. Hall was right to wonder if she could trust the Mayo Clinic. About a year ago I was asked to comment on an article in the American Journal of Hematology (AJH), in which investigators from the Mayo Clinic reported that among a cohort of lymphoma patients who were “CAM” users,

There was a general lack of knowledge about forms of CAM, and about potential risks associated with specific types of CAM…

This suggests the need to improve access to evidence-based information regarding CAM to all patients with lymphoma.

No surprise, that, but I couldn’t help calling attention to the paradox of one hand of the Mayo Clinic having issued that report even as the other was contributing to such ignorance:

The Mayo Clinic Book of Alternative Medicine details dozens of natural therapies that have worked safely for many patients in treating 20 top health issues. You may be surprised that Mayo Clinic now urges you and your doctor to consider yoga, garlic, acupuncture, dietary supplements and other natural therapies. Yet the record is clear. Many of these alternative therapies can help you achieve reduced arthritis pain, healthier coronary arteries, improved diabetes management, better memory function and more.

Nor could such a paradox be explained by the right hand not having known what the left was doing: Brent Bauer, MD, the Director of the Mayo Clinic Complementary and Integrative Medicine Program, is both the medical editor of the Book of Alternative Medicine (MCBAM) and a co-author of the article in the AJH.

As chance would have it, I had picked up a copy of the latest (2011) edition of the MCBAM only a couple of days before Dr. Hall’s post. Does it live up to its promises? Do its “straight answers from the world’s leading medical experts” respond to “the need to improve access to evidence-based information regarding CAM?” Let’s find out. In some cases I’ll state the implied questions and provide the straight answers.

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One of the main topics that we’ve covered here on this blog over the last couple of years is the relatively rapid, seemingly relentless infiltration of pseudoscience into what should be bastions of science-based medicine (SBM), namely medical schools and academic medical centers promoted by academics who should, but apparently don’t, know better. From the very beginning, we’ve written numerous posts about this infiltration and how it has been facilitated by a variety of factors, including changes in the culture of medical academia and our own culture in general, not to mention a dedicated cadre of ideologues such as the Bravewell Collaboration, whose purpose is to blur the lines between science and pseudoscience and promote the “integration” of quackery into science-based medicine. Certainly promoters of what Dr. Robert W. Donnell termed “quackademic medicine” wouldn’t put it that way, but I would. Indeed, promoters of quackademic medicine scored a major victory last month, when a credulous piece of tripe about acupuncture passing as a review article managed to find its way into the New England Journal Medicine, a misstep that was promptly skewered by Mark Crislip, Steve Novella, and myself. It’s rare for more than two of us to write about the same topic, but it was earned by a mistake as dire as the editors of the NEJM allowing rank pseudoscience to sully its normally science-based pages.

Today, I want to riff a bit on one aspect of this phenomenon. As a cancer surgeon, I’ve dedicated myself to treating patients with cancer and then subspecialized even further, dedicating myself to the surgical treatment of breast cancer. Consequently, the interface of so-called “complementary and alternative medicine” (CAM) in the treatment of cancer both interests and appalls me. The reason for my horror at the application of CAM to cancer patients, as you might expect, is that cancer is a disease that is highly feared and can be highly deadly, depending upon the specific kind of cancer. Cancer patients deserve nothing less than the best science-based evidence that we have to offer, free of pseudoscience. Yet in even the most highly respected cancer centers, such as M.D. Anderson Cancer Center and Memorial Sloan-Kettering Cancer Center, there are departments or divisions of what is increasingly called “integrative oncology.” The claim behind “integrative oncology” is that it is “integrating the best of science-based and ‘alternative’ medicine,” but in reality all too often it is “integrating” quackery with science-based medicine. I have yet to hear an explanation of how “integrating” pseudoscience or nonscience into science-based oncology benefits cancer patients, but, then, that’s probably just the nasty old reductionist in me. Let’s find out.
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The longer I’m in this whole science-based medicine thing, not to mention the whole skepticism thing, the more I realize that no form of science is immune to woo. To move away from medicine just for a moment, even though I lament just how many people do not accept evolution, for example, I can somewhat understand it. Although the basics of the science and evidence support the theory of evolution as the central organizing principle of all biology, much of the evidence is not readily apparent to those who don’t make it a calling to study biology, evolution, and speciation. It’s not like, for example, gravity, which everyone experiences and of which everyone has a “gut level” understanding. So, not unexpectedly, when the theory of evolution conflicts with a person’s religious beliefs, for most people it’s very easy to discount the massive quantities of evidence that undergird the theory of evolution. It’s not so easy to discount the evidence for gravity.

In many ways, medicine is similar to evolution, but the situation is possibly even worse. The reason is that much of the evidence in medicine is conflicting and not readily apparent to the average person. There’s more than that, though, in that there are a number of confounding factors that make it very easy to come to the wrong conclusion in medicine, particularly when looking at single cases. Placebo effects and regression to the mean, for example, can make it appear to individual patients that, for example, water (i.e., what the quackery that is homeopathy is) or placebo interventions (i.e., acupuncture) cures or improves various medical conditions. Add to that confirmation bias, the normal human cognitive quirk whereby all of us — and I do mean all of us — tend to remember information that reinforces our preexisting beliefs and to forget information that would tend to refute those beliefs — and, at the level of a single person or even practitioner, it’s very, very easy to be misled in medicine into thinking that quackery works. On the other hand, at the single patient/practitioner level, one can also see evidence of the efficacy of modern medicine; for example, when a person catches pneumonia, is treated with antibiotics, and recovers quickly. Regardless of whether they’re being used to demonstrate quackery or scientific medicine, because personal experience and the evidence that people observe at the level of the people they know can be very deceptive in medicine, science-based medicine, with its basic science underpinnings and clinical trial evidence, is necessary to try to tease out what actually works and what doesn’t.

Medicine does, however, have its version of a theory of evolution, at least in terms of how well-supported and integrated into the very fabric of medicine it is. That theory is the germ theory of disease, which, just as evolution is the organizing principle of biology, functions as the organizing principle of infectious disease in medicine. When I first became interested in skepticism and medical pseudoscience and quackery, I couldn’t envision how anyone could deny the germ theory of disease. It just didn’t compute to me, given how copious the evidence in favor of this particular theory is. It turns out that I was wrong about that, too.

On Friday there was a video released that provides a very clear, succinct explanation of germ theory denialism:

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On Friday, one of my partners in crime here at Science-Based Medicine, Dr. Kimball Atwood, wrote an excellent Open Letter to Dr. Josephine Briggs. Dr. Briggs, as most regular readers of SBM know, is the Director of the National Center for Complementary and Alternative Medicine (NCCAM). As most regular readers of SBM also know, we at SBM have been quite critical of NCCAM for its funding of studies of dubious scientific value, including one that I mentioned quite early on in the history of this blog, in which an R21 grant was awarded to investigators at the University of Arizona for a project entitled Dilution and succussion in homeopathic remedy dose-response patterns. The purpose of this project was to compare the effectiveness of a homeopathic remedy at different dilutions. It even compared remedies that are succussed (vigorously shaken) at each dilution step against remedies that were merely stirred. Although this is merely the most egregious example I could find at the time, two years ago I did catalog many more examples, as well as the “educational” grants disbursed through NCCAM in order to teach (and, by doing so, promote) CAM.

Given NCCAM’s long history of promoting pseudoscience, we were all quite surprised when early this year we received an e-mail from Dr. Briggs herself inviting us to NCCAM to meet with her. Unfortunately, due to our work obligations, Steve Novella, Kimball Atwood, and I were not able to coordinate our schedules to travel to Bethesda and enter the heart of darkness itself until early April. Our conversation with Dr. Briggs and her staff was cordial and mutually respectful, as Steve Novella described, and we assured her that we understood that studies such as the one I mentioned above were funded before her tenure. At the same time we were a bit disappointed that Dr. Briggs appeared far too eager to dismiss such problems as being before her time. Still, we understood and approved of Dr. Briggs’ stated goal of making NCCAM more scientifically rigorous, even though we did point out that there is nothing done at NCCAM that couldn’t be done as well in the NIH’s structure before NCCAM existed.

Unfortunately, not too long before or after Dr. Briggs met with us, she also met with a group of homeopaths, leading us to worry that perhaps in her quest to appear “open-minded,” Dr. Briggs was being so open-minded that her brain was in acute danger of falling out, particularly after we saw her infamous “science must be neutral” director’s newsletter a month later, which Dr. Kimball skewered as part of his open letter and I recently used as an example of misinterpreting what scientific “neutrality” means during my talk at the SBM Workshop at TAM8 a couple of weeks ago. In fact, I now wonder if I missed a little gray matter oozing out of Dr. Briggs’ ears during the meeting even though I sat right next to her.

Unfortunately, Dr. Atwood’s open letter gives me even more reason to despair, because in it he pointed out that Dr. Briggs will be speaking at the 25th Anniversary Convention of the American Association of Naturopathic Physicians (AANP) from August 11-15 in Portland, OR. (One wonders if Mark Crislip would be willing to make an appearance there for a Very Special Episode of his Quackcast and thereby continue to expand his Internet empire. I realize that doing so would really be “taking one for the team,” but think of the blogging and podcast material!) Kimball’s explanation why this is disturbing is excellent and detailed, as usual, but one thing he didn’t do as much of as I would have is to go into a bit more detail of what sorts of dubious medical modalities and even outright quackery Dr. Briggs will be associating herself with by speaking at this particular convention. He probably didn’t feel the need, given that he referenced his two comprehensive deconstructions of the quackery that is naturopathy, but I’m not as well-versed in naturopathy as he is, and, I suspect, neither are you. Dr. Atwood didn’t need to delve into the woo that will be presented at the AANP. I do. That’s why I thought a bit of a survey of what will be presented at the conference was in order.
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