Earlier this year, Australia’s anti-vaccine lobby, the Australian Vaccination Network (AVN), took the NSW Government to the Supreme Court. In dispute was their license to fundraise which had been revoked and a public warning, issued because they refused to put a Quack Miranda on their website.
The public warning was posted after the NSW government investigated their website following two complaints, one from a concerned citizen and one from the parents of a 4 week old girl who had died of pertussis.
The complaints accused the AVN of peddling dangerous health misinformation including that vaccines were linked to autism and that pertussis was “nothing more than a bad cough”.
The AVN had always insisted that the HCCC did not have jurisdiction over them because they were not health care providers or educators in the “traditional sense”. It is true that health legislation in NSW is very much out of date in the Internet age. The rules say you can complain only if you can demonstrate direct harm as a result of taking someone’s dodgy advice. For example you had a stroke because of a chiropractor’s adjustments or a punctured lung from acupuncture. Just having a website full of woo-woo wasn’t really covered.
So the AVN challenged the HCCC on these grounds and, to the surprise of many of us, they won. Those who were present in the court that day recall the Judge urging the HCCC Barrister to present evidence for direct harm. And the worst thing was the HCCC apparently had this information, but for reasons unknown to us, did not present it. Those who were there said the HCCC Barrister dropped the ball big time that day. And they were right.
Within hours the public warning was expunged and shortly after that the authority to fundraise was returned. As if nothing ever happened.
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Science is the Concept by which
we measure our reality
I don’t believe in magic
I don’t believe in I-ching…
I just believe in science…and that reality.
John Lennon. Sort of.
As regular readers of the blog are aware, I am science/reality based. I think the physical and basic sciences provide an excellent understanding of reality at the level of human experience. Physics, chemistry, biology, anatomy, biochemistry, physiology, evolution etc. provide a reliable and reproducible framework within which to understand health and disease. My pesky science may not know everything about reality, but day to day it works well.
“There are more things in heaven and earth, Horatio, Than are dreamt of in your philosophy. – Hamlet (1.5.166-7).”
Perhaps, but all the medical advances in my lifetime have been not yielded new science, just (amazing) variations and extensions of known processes. I sometimes think the blog should have been called reality based medicine, but science is the tool by which we understand reality, and while the tool is constant, our understanding of reality is prone to changing. An understanding of the rules of the universe combined with an awareness of the innumerable ways whereby we can fool ourselves into believing that those rules do not apply to us is part of what makes a science and reality based doctor.
We are often told of the need to keep an open mind, but I like to keep it open to reality. Not that I do not like fantasy and magic, it is a common category for my reading. I just finished Red Country by Joe Abercrombie, and while I love the world he has created, I would not want to apply the rules of that imaginary world to my patients. Well, one exception. As Logen Ninefingers would say, “You have to realistic about these things.” Fictional worlds should be limited to the practice of art, not the practice of medicine.
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There are times when the best-laid blogging plans of mice and men often go awry, and this isn’t always a bad thing. As the day on which so many Americans indulge in mass consumption of tryptophan-laden meat in order to give thanks approached, I had tentatively planned on doing an update on Stanislaw Burzynski, given that he appears to have slithered away from justice yet again. Then what to my wondering eyes should appear in my e-mail in box but news of a study that practically grabbed me by my collars, shook me, and demanded that I blog about it. As if to emphasize the point, suddenly e-mails started appearing by people who had seen stories about the study and, for reasons that I still can’t figure out after all these years, were interested on my take on the study. Yes, I realize that I’m a breast cancer surgeon and therefore considered an expert on the topic of the study, mammography. I also realize that I’ve written about it a few times before. Even so, it never ceases to amaze me, even after all these years, that anyone gives a rodential posterior about what I think. Then I started getting a couple of e-mails from people at work, and I knew that Burzynski had to wait or that he would be relegated to my not-so-secret other blog (I haven’t decided yet).
As is my usual habit, I’ll set the study up by citing how it’s being spun in the press. My local home town paper seems as good a place to begin as any, even though the story was reprinted from USA Today. The title of its coverage was Many women receiving unnecessary breast cancer treatment, study shows, with the article released the day before the study came out in the New England Journal of Medicine:
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There is an obvious survival advantage to the emotion of disgust – we should fear putting unhealthy, tainted, contaminated, or poisonous substances into our bodies. Emotions, however, are a double-edged sword. They are an effective evolutionary mechanism for motivating creatures to engage in certain behavior, but they also tend to be crude and undiscriminating – inadequate to deal with our complex modern society.
A dispassionate consideration of objective scientific evidence is the optimal strategy for deciding on which foods and substances are safe to consume, but it is far easier to scare people about toxins than to reassure them with data. We see this frequently with the anti-vaccine movement, and also with anti-fluoridation attitudes. It is easy to scare people with the idea that there are “chemicals” in our drinking water.
One company, San Diego Pure Water, seems to have made such scaremongering into a marketing strategy. Their website is full of articles and videos claiming that fluoride is the “the greatest fraud that has ever been perpetrated.”
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A correspondent sent me a link to an article about the decision of the Wichita Falls (Texas) Independent School District to recommend that chiropractors be allowed to give sports physicals to junior high and high school students. Current policy limits examiners to physicians, physician assistants, and nurse practitioners. Adding chiropractors to this list would bring the district in line with policies in the rest of Texas, as well as in some other states. And it would “give parents more options.”
I’ve written about the attempts of some chiropractors to assume the role of family doctors and why I think it is a terrible idea. The idea of allowing them to do sports physicals impresses me as somewhat less terrible, but not by very much.
The Reasons for Requiring Sports Physicals
The goals of the Pre-participation Athletic Exam (PAE) include:
- To identify athletes who should not participate because of high risk of injury or death
- To identify those who require further evaluation or treatment so they can participate safely
- To identify conditions that do not affect athletic participation but that should be treated
- To possibly identify those at risk for substance abuse, depression, violence, etc.
- To provide preventive health advice
- To satisfy legal requirements. Continue Reading »
The 2012 election campaign is in full swing, and, for better or worse, health care is one of the major defining issues of the election. How can it not be, given the passage of the Patient Protection and Affordable Care Act (PPACA), also colloquially known as “Obamacare,” was one of the Obama administration’s major accomplishments and arguably the largest remaking of the American health care system since Medicare in 1965? It’s also been singularly unpopular thus far, contributing to the Republican takeover of the House of Representatives in the 2010 elections, as well as the erosion of Democratic control of the Senate. Given that this is a medical blog dedicated to discussing the scientific basis of medicine and not a political or health policy blog, I am not going to go into the reasons for a lot of this. What I am going discuss is a recent eruption of the central problem that led President Obama to make the PPACA one of the central policy initiatives, if not the central policy initiative, of his first term. That problem is the issue of people without health insurance, who number roughly 50 million, with a further estimate that 86.7 million people were uninsured at some point during the two year period from 2007 to 2008, representing about 29% of the total U.S. population under 65.
The question that bubbled to the surface last week in the form of a statement by Republican challenger Mitt Romney, and a tear-inducing op-ed piece published yesterday in the New York Times by Nicholas Kristof entitled A Possibly Fatal Mistake, is what the health impact of not having insurance is for those millions of people. This is a question that can be addressed scientifically and is, despite its politically charged nature, correctly within the purview of science-based medicine. What to do about it, in contrast, is a matter for politics and public policy. So first let’s examine the question.
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It is estimated that 5% of people living in Sub-Saharan Africa are infected with HIV – that’s 22.5 million people. Infection rates vary wildly from country to country, with Swaziland having the highest rate at 25.9%. Gambia is below average, at 2% or 18 thousand people, but still has a serious HIV problem, and now finds themselves at the center of the HIV controversy in Africa.
This epidemic has been magnified by unfortunate realities on the ground. Africa has an insufficient public health and medical infrastructure to deal with the massive challenge such an epidemic presents. This has led the World Health Organization to contemplate partnering with local traditional healers, to make them into an extension of the effort to bring modern medical treatment to the HIV-infected in Africa. This desperate strategy is fraught with problems, not the least of which is that most traditional healers have had no prior contact with science-based medicine.
Former South African president Thabo Mbeki seriously set back his country’s HIV efforts by embracing crank HIV denial. Coupled with his denialism was efforts by Health Minister Manto Tshabalala-Msimang to use traditional medicines to treat HIV/AIDS. This combination resulted in restrictions on the distribution of anti-retoviral drugs in South Africa that is estimated to have cost hundreds of thousands of lives.
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Countering ideologically motivated bad science, pseudoscience, misinformation, and lies is one of the main purposes of this blog. Specifically, we try to combat such misinformation in medicine; elsewhere Steve and I, as well as some of our other “partners in crime” combat other forms of pseudoscience. During the nearly five year existence of this blog, we’ve covered a lot of topics in medicine that tend to be prone to pseudoscience and quackery. Oddly enough, there’s one topic that we haven’t really written much about at all, and that’s genetically modified organisms (GMOs). GMOs, as you know, are proliferating, and it’s quite worth discussing the potential and risks of this new technology, just as it is worthwhile to discuss the potential benefits versus the risks of any new technology that can impact our health, not to mention the health of the planet. Unfortunately, GMOs have become a huge political issue, and, I would argue, they have become just as prone to pseudoscience, misinformation, and bad science as vaccines, with a radical group of anti-GMO activists who are as anti-science as any antivaccinationist or quack.
Leave it to that quackery promoter to rule all quackery promoters, Mike Adams, to give me just the opportunity to show you what I mean. Over the last couple of weeks, Mike has been in a fine lather about GMOs, with multiple posts with titles such as The GMO debate is over; GM crops must be immediately outlawed; Monsanto halted from threatening humanity and The evil of Monsanto and GMOs explained: Bad technology, endless greed and the destruction of humanity. In other words, it’s a series of post with Adams’ typical hyperbole. If you were to believe him, GMOs are the product of a plot by Satan, Monsanto, big pharma, and the government, and he’s not sure which one of these is the most evil of the bunch.
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One issue that keeps coming up time and time again for me is the issue of screening for cancer. Because I’m primarily a breast cancer surgeon in my clinical life, that means mammography, although many of the same issues come up time and time again in discussions of using prostate-specific antigen (PSA) screening for prostate cancer. Over time, my position regarding how to screen and when to screen has vacillated—er, um, evolved, yeah, that’s it—in response to new evidence, although the core, including my conclusion that women should definitely be screened beginning at age 50 and that it’s probably also a good idea to begin at age 40 but less frequently during that decade, has never changed. What does change is how strongly I feel about screening before 50.
My changes in emphasis and conclusions regarding screening mammography derive from my reading of the latest scientific and clinical evidence, but it’s more than just evidence that is in play here. Mammography, perhaps more than screening for any disease, is affected by more than just science. Policies regarding mammographic screening are also based on value judgments, politics, and awareness and advocacy campaigns going back decades. To some extent, this is true of many common diseases (i.e., that whether and how to screen for them are about more than just science), but in breast cancer arguably these issues are more intense. Add to that the seemingly eternal conflict between science and medicine communication, in which a simple message, repeated over and over, is required to get through, versus the messy science that tells us that the benefits of mammography are confounded by issues such as lead time and length bias that make it difficult indeed to tell if mammography—or any screening test for cancer, for that matter—saves lives and, if it does, how many. Part of the problem is that mammography tends to detect preferentially the very tumors that are less likely to be deadly, and it’s not surprising that periodically what I like to call the “mammography wars” heat up. This is not a new issue, but rather a controversy that flares up periodically. Usually this is a good thing.
And these wars just just heated up a little bit again late last week.
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There is a movement in the US to oppose a public health measure that is backed by impressive evidence showing it is safe and effective, as well as highly cost effective. For as long as the government has supported this health measure, there have been those opposed to it, claiming (against the evidence) that it is unsafe, ineffective, and represents a violation of personal freedom and the right to refuse an unwanted medical intervention. I could be talking about vaccines and the anti-vaccine movement, but in this case I am talking about the fluoridation of public water supplies and the antifluoridation movement.
This social debate (there isn’t much of a scientific debate) crops up in the news every now and then – mostly prompted by an antifluoridation activist or group making noise, or by a local referendum to block fluoridation in a community. Recently there has been a Harvard study making the rounds of social media, Developmental Fluoride Neurotoxicity: A Systematic Review and Meta-Analysis. The actual findings of the study do not show that there is any risk to public water fluoridation (if anything, they show that it is safe), but the study was seized upon by antifluoridation activists and distorted for their propaganda purposes. Unfortunately, the internet is now fertile ground for the spreading of propaganda.
The NYS Coalition Opposed to Fluoridation put out a press release distorting the findings of the study. Their press release (“Harvard Study Finds Fluoride Lowers IQ – Published in Federal Gov’t Journal”) was then printed as a science news item by many online news outlets. Reprinting press releases, without any editorial filter, is a cheap and easy way to add news-like content to your website. The Sacramento Bee, for example, published the press release under their “News” tab. Near the top of the page, in small print, they did put a disclaimer (which is better than most sites):
This section contains unedited press releases distributed by PR Newswire. These releases reflect the views of the issuing entity and are not reviewed or edited by the Sacramento Bee staff. More information on PR Newswire can be found on their web site.
That’s better than nothing, but I wonder how many people reading the press release will notice and read the disclaimer. In my opinion, a news outlet should not reprint press releases sent out from advocacy organizations clearly intended to promote an agenda. They especially should not print them under the banner of “News.” The disclaimer is not adequate. The spreading of this “news item” around Facebook and other social media demonstrates this.
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