The LA Times recently published their analysis of data provided them by the state of California and found that there are pockets of high rates of exemption from vaccines among kindergarteners. In the US public schools require that all children receive the recommended vaccines. However, states can allow exemptions for the religious beliefs of the parents.
Over the years anti-vaccine activists have been successful in many states in expanding the rules for exemption. In California, for example, parents may seek excemption if they have “philosophical” objections to vaccines – which means there really isn’t any criteria beyond the parent’s wishes. The anti-vaccine movement has been active not only in pushing for the weakening of vaccine requirements but also in teaching parents how to use the laws to evade vaccination for their children.
The LA Times found that, while state wide the exemption rate was only 2%, exemptions were largely clustered in certain schools. They report:
In all, more than 10,000 kindergartners started school last fall with vaccine exemptions, up from about 8,300 the previous school year. In 1997, when enrollment was higher, the number of exempted kindergartners was 4,318.
At Ocean Charter School in Del Rey, near Marina del Rey, 40% of kindergartners entering school last fall and 58% entering the previous year were exempted from vaccines, the highest rates in the Los Angeles Unified School District.
Three kids on the same block were diagnosed with leukemia last year. That couldn’t happen just by chance, could it? There MUST be something in the environment that caused it (power lines, the chemical plant down the street, asbestos in their school, iPods, Twinkies?). Quick, let’s measure everything we can think of and compare exposures to other blocks and find an explanation.
That may be the common reaction, and it may seem plausible to the general public, but it’s not good science.
I have just read a book that does a great job of elucidating the pitfalls of epidemiologic studies, the problematic interface between science and emotion-laden public concerns, and the way environmental hazards have been hyped far beyond the evidence. Hyping Health Risks: Environmental Hazards in Daily Life and the Science of Epidemiology by Geoffrey C. Kabat.
He covers the uses, strengths and limitations of epidemiology, discusses the pros and cons of different study designs, and explains how to judge whether an association is causal.
Here at Science-Based Medicine we’ve been getting a lot of letters from medical students. This is a good thing and a bad thing. I’m glad people see us a a resource for SBM, but I’m unhappy that medical students: 1) need us; 2) don’t have someone to approach on campus. Let’s explore some of the more subtle ways cult medical practices infiltrate medical education.
In order to give all of their students experience in outpatient medicine, most med schools must reach out to the community. Sure, some med schools have big enough clinics to support an experience for all of their students, but that’s the minority. For their internal medicine, pediatrics, and family medicine rotations, med students often spend time at private doctors’ offices. These offices are minimally vetted, and I’d venture to guess that the vetting does not include checking for non-standard practices. In fact, schools are so desperate for spots, that almost any office will do. It’s good for students to see how medicine is practiced in the “real world” but that real world often involves cult medicine practices. Along the same lines, many practitioners are not up to date on the most recent best practices. I remember a family doc I worked with who used to give huge doses of intramuscular steroids to people for seasonal allergies. This isn’t the best idea, but I was a student. Who was I to tell him how to practice medicine?
We don’t police our colleagues very effectively—we have surrendered that duty largely to the courts. However, if doctors want a medical school affiliation, it seems a small price to allow the school to come in and see if the office practices medicine according to the standard of care. In addition to checking for the most minimal quality standards, it would rule out docs who are offering voodoo in place of medicine.
Early in the history of this blog, I wrote a rather long post expressing my dismay at the infiltration of unscientific “complementary and alternative medicine” (CAM) or “integrative medicine” (IM) modalities into American medical schools. In it, I listed the medical schools that had embraced pseudoscience through having started a CAM/IM program (a list desperately in need of an update). Moreover, we have also complained vociferously here about a clear effort on the part of advocates of faith-based medicine to infiltrate bastions of science-based medicine and to piggyback their agenda onto President Obama’s health care reform initiative in a clear political strategy to slip CAM/IM into any health care reform legislation as a form of “preventative medicine.” It’s all part of a multi-pronged strategy to claim popular and legal legitimacy in the absence of scientific legitimacy. At one point I even despaired because of the apparent success of half physician, half CAM huckster Dr. Andrew Weil at developing a CAM/IM curriculum that would be part of the mandatory training program in several family medicine residencies, while the rest of us watch Senator Tom Harkin try to promote pseudoscience in the halls of the Senate.
However, since one of our newest co-bloggers, medical student Tim Kreider, arrived, I’ve come to appreciate that medical schools and medical school curriculae are ground zero in the battle for science- and evidence-based medicine. Besides the infiltration of non-science-based modalities into the standard curriculum, another technique for making medical students believe that woo is equal to science is the student “campus CAM group” that invites, for example, homeopaths and naturopaths to give talks to medical students, too many of whom are too timid to challenge them on their pseudoscience. However, a reader of a “friend” of mine wrote me an e-mail that truly appalled me. In fact, it appalled not just me, but all of my co-bloggers who read it. It’s from a medical student in an American medical school. It’s not Harvard or a huge famous medical school. However, it is in medical schools like this one where the vast majority of medical students are trained in this country. If the infiltration of CAM/IM into medical schools continues in this way, we’ll have more than just “integrating” woo into the medical school curriculum from day one. We’ll have more tales like this; eventually, no one will find such tales unusual or even unacceptable anymore. The shruggies will no longer even shrug anymore. Such clinics will become simply the way medical students are educated. The following e-mail is de-identified, and I’ve edited it a bit to make as sure as I can that it is not traceable:
The best way to prevent sexually transmitted infections is the proper use of condoms. That being said, it’s not the only way to prevent STI’s. Abstinence is one way, but it involves an amputation of sorts—the removal of a critical human behavior. Another amputation (of sorts) that prevents STIs is circumcision. Male circumcision has been found in several good studies to reduce the rate of HIV transmission, and now a study out of Uganda shows a significant decrease in rates of genital herpes infections (HSV-2), human papilloma virus (HPV) infection (the strains that cause penile, cervical, and anal cancer), but no decrease in syphilis infection.
This study complements the our knowledge on the benefits of circumcision to prevent disease. The authors emphasize that circumcision alone is not sufficient, but may be a useful adjunct to prevent serious STIs. In fact, STI’s tend to travel together, and ulcerative diseases such as herpes increase transmission of HIV.
More than any other time in history, mankind faces a crossroads. One path leads to despair and utter hopelessness. The other, to total extinction. Let us pray we have the wisdom to choose correctly.
~ Woody Allen
No good deed goes unpunished.
The website whatstheharm.net is a depressing recitation of the harm that humans do to themselves and others from participating in various forms of nonsense in the attempt to do good. It my backfire, and instead pain and death result.
I would bet that most practitioners of medical woo are true believers. They do not intend to harm people, and believe they are doing good for their patients. Certainly the consumers of alternative therapies intend to have good benefits from their use of sCAM modalities. Most want to get better, and do not intend to hurt themselves or others.
Unfortunately, actions always have unintended consequences. Sometimes the harm is directly to the patient. Sometimes the harm in indirect, with collateral damage to people or the environment. My hospital system has an extensive recycling program to handle the huge amounts of waste generated by the need to insure that all manner of materials are sterile. Patients in isolation consume large amounts of paper and plastic to keep infection confined. My hospitals actively look for ways to decrease their environmental impact and carbon footprint and still deliver high quality medical care. Legacy Health System, where I work, is an award winning leader recycling medical waste, which is a lot more difficult to dispose of than the pop cans and paper bags in your house. Hopefully the trash in your house is not covered with pus, blood and other potentially hazardous medical waste. We try to be good global citizens.
I wonder if some branches of the alternative medical industrial complex are so environmentally conscious.
I thank everyone for my warm welcome to the SBM community. Although vaccine myth is of particular interest to me, I promise that my posts wont all be vaccine related. There is, unfortunately, much to discuss. In fact I had a difficult time deciding which vaccine-related issue to write about for my inaugural post. In the end I came up with more of an opinion piece, but it’s an issue worth airing. Things in anti-vaccine land may be reaching a dangerous turning point.
It is not uncommon for Science Based Medicine to receive complaints about the tone of our writing. Some people feel that it is indelicate to use the “q” word (for the uninitiated, “q” is for “quack”) when describing practitioners who promote disproven therapies with jubilant fervor. Others believe it unkind to lump “well meaning” alternative medicine experts in with those who are engaged in overtly illegal activities.
We are all affected by the tension between wanting to call a spade a spade and respecting our cultural need to be polite. Perhaps one of the clearest examples of this inner conflict is Orac’s Respectful Insolence blog. As the name implies, Orac is both thoughtful and brutally honest – he expresses our communal reticence to make waves, but follows up with a reasoned hostility that is quite understandable, given the circumstances described in each post. Respectful Insolence is fun to read because it is educational, persuasive, and expressive – and it captures how many of us feel about various forms of hucksterism. However, snake oil salesmen and their sympathizers are unlikely to enjoy the blog.
Here at Science Based Medicine, readers find a wide range of expression with a common commitment to science and reason. Just as physicians have different practice styles (some are more nurturing in temperament, others offer “tough love”) so too do we authors vary in tone. For those readers who favor one style over another – I hope you’ll find the voice that suits you and return regularly for more. Please don’t assume that one particular post is representative of the entire blog, and please don’t be offended by the legitimate exasperation of writers who have suffered through decades of observing swindlers swindle.
When beginning a discussion of a controversial topic I like to establish the common ground upon which most or all people can agree. Everyone seems to agree that real conflicts of interest in medical research and practice is a bad thing and steps should be taken to minimize, eliminate, and illuminate any such conflicts. The controversy revolves around what constitutes a real conflict of interest.
There is broad agreement that researchers should not have a personal financial stake in the outcome of their own research – they should not make more money if their research is positive than if it’s negative. That creates a clear and powerful bias. There is also now broad agreement and adoption of standards that speakers, authors, and researchers should disclose any potential conflicts of interest – primarily the source of their funding. If someone is being paid by a drug company to say that their drug is effective for a particular disease, they should disclose that up front.
These same standard are now being applied to IRBs – institutional review boards, and that seems apprpriate. Every institution that does biomedical research must have an IRB, which is a committee of appropriate professionals (and there are rules as to the IRB’s constitution) that review all human research proposals to make sure they meet ethical guidelines and that subjects are adequately protected. This is a good system that generally works.
In the 1950s, 558,000 people were in mental institutions in the U.S. Many were there against their will and were being warehoused or treated badly. Deinstitutionalization was intended to restore their civil rights and improve their lot. Did it? By 2006, there were only 40,000 people in institutions. What happened to the other 518,000?
Some of them are living in the community with supportive family members, taking their medications, and contributing to society. Some of them have been ghettoized in halfway houses or group homes in crime-ridden and run-down neighborhoods. Some of them are homeless, living on the streets and eating out of garbage cans. Some of them are in jail. Some of them have killed family members or have killed multiple people in “rampage” murders provoked by their psychotic delusions.
Accurate numbers are difficult to obtain. By some estimates, as many as 30-50% of the homeless (and even more of the hard-core homeless) and as many as 40-50% of the jail population are mentally ill. There are more mentally ill people in jails than in hospitals. The mentally ill are more likely to be victims of violence and rape and are more likely to be shot by the police in “justifiable homicide” incidents.
Mentally ill people who are adequately treated are no more violent than the non-mentally ill, but a disproportionate number of murders are committed by the mentally ill. The risk of violence increases with past history of violence, substance abuse, anosognosia with medication noncompliance, antisocial personality disorder, paranoid symptoms, and male sex. (more…)