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Zika virus, microcephaly, and calls to bring back DDT


If there’s one thing I’ve learned over the last decade-plus of blogging about medicine and alternative medicine, it’s that any time there is an outbreak or pandemic of infectious disease, there will inevitably follow major conspiracy theories about it. I saw it during the H1N1 pandemic in the 2009-2010 influenza season, the Ebola outbreak in late 2014, and the Disneyland measles outbreak last year, when cranks of many stripes claimed that either the outbreaks themselves were due to conspiracies (usually, but not limited to, conspiracies to promote the “depopulation” vaccination agenda of—who else?—Bill Gates) or that nefarious forces were seizing on the outbreak to take away our freedom. The second thing I’ve learned is that inevitably people will try to impose their ideology on to the disease and try to use outbreaks to push their own ideological agenda. Indeed, the Ebola outbreak, for example, was rapidly seized on by politicians to promote quarantines and to halt immigration from the affected countries. This year, the biggest infectious disease-related story thus far is the Zika virus outbreak in Brazil that has been linked to microcephaly and other birth defects, and it’s a case of the same stuff, different year.

The Zika virus is a mosquito-borne flavivirus related to dengue virus and transmitted primarily by Aedes aegypti mosquitoes. On the surface, this virus would appear to be relatively benign, with 80% of those infected by it remaining asymptomatic, while the other 20% suffer from what is usually a self-limited, relatively mild illness characterized by fever, rash, arthralgias (joint aches), and conjunctivitis. In the grand scheme of things, after decades of being endemic in many tropical areas Zika virus infection probably didn’t seem so bad and didn’t appear to be much of a public health priority in the regions where Aedes aegypti mosquitoes live, mainly tropical regions in South and Central America, Africa, southeast Asia, and the Pacific islands. Then came the evidence that prenatal infection might cause microcephaly, and everything changed. Not surprisingly, conspiracy theories galore arose with social media speed, as did the ideologically motivated overselling of proposed solutions, such as bringing back DDT to combat the mosquito carrying the disease.

Posted in: Basic Science, Epidemiology, History, Politics and Regulation

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Did chiropractic neck manipulation kill Katie May?


Well, we’re back.

Yes, after having our WordPress database somehow borked to the point where no new posts could be added and no existing posts could be edited since Friday, Science-Based Medicine is back in business—finally! As a result, some of you might have seen this post elsewhere, as it was considered to be somewhat time-sensitive, and I didn’t want to delay, particularly given that I didn’t know how long SBM would be down. Fortunately, we’re back a bit sooner than I thought; so let’s look at something that was in the news over the weekend.

Katie May was a model, and by all accounts a very successful one, having appeared in Playboy, Sports Illustrated, and other magazines and websites. Self-proclaimed the “Queen of Snapchat,” she also had nearly two million Instagram followers and was a major social media force, having recently parlayed her modeling and social media career into entrepreneurship. She also died unexpectedly on Thursday night at the too-young age of 34, leaving behind a seven-year-old daughter. What makes May’s tragic death an appropriate topic for SBM is not so much her young age but rather the circumstances surrounding her death, particularly the cause. Basically, May died of complications due to stroke, as her family confirmed in a statement issued on Friday:

“It is with heavy hearts that we confirm the passing today of Katie May – mother, daughter, sister, friend, businesswoman, model and social media star – after suffering a catastrophic stroke caused by a blocked carotid artery on Monday,” the statement reads.

“Known as MsKatieMay on the Internet and the “Queen of Snapchat,” she leaves behind millions of fans and followers, and a heartbroken family. We respectfully ask for privacy in this this difficult time. Those wishing to contribute to the living trust being set up for the care of her young daughter may do so at her GoFundMe page.”


Posted in: Chiropractic, Science and the Media

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When antivaccine pseudoscience isn’t enough, Bill Maher fawns over Charlie Sheen’s HIV quack

Bill Maher (right) expresses admiration for HIV quack Samir Chachoua (right), who claims to be able to cure people of HIV and cancer using milk from arthritic goats.

Bill Maher (right) expresses admiration for HIV quack Samir Chachoua (left), who claims to be able to cure people of HIV and cancer using milk from arthritic goats.

I know I must be getting older because of Friday nights. After a long, hard week (and, during grant season, in anticipation of a long, hard weekend of grant writing), it’s not infrequent that my wife and I order pizza, plant ourselves in front of the TV, and end up asleep before 10 or 11 PM. Usually, a few hours later, between midnight and 3 AM one or both of us will wake up and head upstairs to bed, but not always. Sometimes it’s all Friday night on the couch.

Last Friday was a bit different. It wasn’t different in that I did fall asleep on the couch sometime around 10 PM. However, unlike the usual case, when I woke up around 1:30 or 2 AM to head upstairs I was stone cold wide awake, feeling like Alex in A Clockwork Orange, eyes held wide open. So I did what I do when insomnia strikes. I popped up the computer and checked my e-mail and Facebook. Immediately, I saw messages asking me if I had seen Real Time With Bill Maher that night and, oh boy, I really should watch Maher. Apprehensive but curious, I fired up the DVR and watched.

And, shortly after the monologue, was totally appalled by this;

Funny, how the segment hasn’t yet been posted to Bill Maher’s YouTube page, as many of his interviews are. If he ever does post it, I’ll switch out the video above for the “official” source. Somehow, though, I doubt that the video will ever be posted, the reason being that it contains an embarrassingly fawning 10 minute interview with “Dr.” Samir Chachoua, better known (at least to skeptics) as Charlie Sheen’s HIV quack. Somehow, when Charlie Sheen was on The Dr. Oz Show a couple of weeks ago, other things were going on and I didn’t blog about it. Fortunately, Steve Novella did. Now, with Sheen’s very own quack who failed him being fawned over by Bill Maher, it gives me a chance to take down three birds with one stone: Bill Maher, Dr. Oz, and, of course, Sam Chachoua. Sadly for Bill Maher, America’s Quack Dr. Mehmet Oz comes off looking a lot better than he does, and that’s saying something.

Posted in: Basic Science, Cancer, Health Fraud, Vaccines

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Science-based medicine versus the Flint water crisis

This is exactly the sort of cover story you don't want to see about your city in TIME.

This is exactly the sort of cover story you don’t want to see about your city in TIME.

One aspect of science-based medicine that is not covered frequently on this blog, aside from vaccines and antivaccine pseudoscience, but perhaps should be, is the intersection of SBM and public health. Unfortunately, living as I do in southeast Michigan right now, I’ve been on the receiving end of an inescapable lesson in what happens when the government fails in its mission to enforce science-based public health issues. I’m referring, of course, to what has become known worldwide as the Flint water crisis. The Flint water crisis has become so famous that unfortunately it now has its very own Wikipedia page. That is not an “honor” I like to see for my state, and I’m sure the residents of Flint, which is an hour’s drive north of where I live, would agree. This crisis provides an unfortunate illustration of what can easily happen when multiple layers of government fail in a science-based public health task as basic as providing clean water to the citizens they ostensibly serve.

For those of you who haven’t heard of it yet, the Flint water crisis refers to the ongoing contamination of the tap water in Flint, MI with unacceptably high levels of lead that resulted from change in its water supply nearly two years ago to Flint River water. Because river water is more corrosive than the previous supply that came from Lake Huron (why I’ll explain later) and Flint river water was not properly treated to decrease that corrosiveness, the new water leached lead from old pipes. This resulted in the contamination of the drinking water with dangerous levels of lead in many homes in the city. In addition, there has been a marked increase in the number of cases of Legionnaires’ disease thought to be linked to the new water supply.

I was born and raised in Detroit. My parents didn’t move to the suburbs until I was ten years old, and I stayed in southeast Michigan until I graduated from medical school and ended up in Cleveland for my surgical residency and, ultimately, my PhD work. From there I bounced to Chicago and New Jersey. Then, in 2008, nearly twenty years after I had left my hometown, I ended up back in the Detroit area. The point of this story is that my roots in the Detroit area run deep. Michigan is my state, for better or for worse, which is why I get annoyed when bad things happen here. I particularly become outraged when a preventable tragedy occurs here, one that science told us how to prevent but the government went ahead and did anyway. It’s a horrific tale of how science was basically ignored because of politics, and legitimate scientific concerns about a policy that changed the water source for an entire city were downplayed, derided, and even denied by state officials at every level of government. The story has now gone international. Indeed, our state and the city of Flint are featured on the cover of this week’s TIME Magazine.

Posted in: Politics and Regulation, Public Health

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The cost of repealing mandatory motorcycle helmet laws


It’s a seldom mentioned aspect of my professional history that I used to do a lot of trauma surgery in my youth. I did my residency at a program that included a county hospital with a busy trauma program where I saw quite a bit of vehicular carnage and an urban hospital (which has since closed) where I saw a fair amount of what we in the surgery biz call gun and knife club action. During my time as a PhD student, I moonlighted as a flight physician for the local helicopter rescue service, Metro Life Flight, where I took care of patients with everything from cardiac disease requiring transfer to the Cleveland Clinic to near-drownings during the summer at the Lake Erie resorts, particularly Put-in-Bay, to obstetrical transfers (which terrified me) to, of course, the unfortunately copious run-of-the-mill vehicular trauma. I saw the sort of tragedy that could result. Then, in the late 1990s, as I did research for my surgical oncology fellowship in Chicago, I also moonlighted as a trauma attending at a local suburban level II trauma center.

At that point, I realized that trauma was not my thing, as I couldn’t see myself at my present advanced age doing the sort of physically and emotionally demanding work that required fast decisions. It stressed me out too much; which is part of the reason why I went into surgical oncology in the first place. However, I have an appreciation for those who do do trauma. I also realize that trauma is, in a way, the “purest” form of surgery in that it involves taking a body broken by mechanical forces and trying to repair it, all the while keeping the patient alive until the repairs can heal. I will, however, miss the enjoyment I get hearing presentations on tree stand falls during hunting season.

I don’t mention my youthful flirtation with trauma surgery so much because I think it’s something so fascinating that I must tell it. (If that were the case, I’d have been mentioning it much more frequently in my blogs and social media than I have before.) Rather, it lets you know why I was so distressed when this story was forwarded to me a few days ago. It’s a Reuters report entitled “Injuries soar after Michigan stops requiring motorcycle helmets“:

Posted in: Politics and Regulation, Public Health, Surgical Procedures

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Is “harnessing the power of placebo” worthwhile to treat anything?

We frequently write about placebo effects here on Science-Based Medicine. The reason is simple. They are an important topic in medicine and, at least as importantly, understanding placebo effects is critical to understanding the exaggerated claims of advocates of “complementary and alternative medicine” (CAM), now more frequently called “integrative medicine” (i.e., integrating pseudoscience with science). Over the years, I (and, of course, others) have documented how CAM advocates have consistently moved the goalposts with respect to the efficacy of their pseudoscientific interventions. As larger and better-designed clinical trials have been done demonstrating that various CAM therapies without a basis in science—I’m distinguishing these from science-based modalities that have been co-opted and “rebranded” as CAM, such as exercise and nutrition—have no specific effects detectable above placebo effects, CAM advocates move the goalposts and claim that CAM works through the “power of placebo” and do their best to claim that “harnessing” that “power of placebo” is a justification to use their treatments. It turns out, however, that when placebo effects are examined rigorously there’s just not a lot of there there, so to speak. Results are underwhelming, and trying to “harness the power of placebo” without an intervention that actually impacts the pathophysiology of disease can even be dangerous. That’s not to say that learning to maximize placebo responses (whatever they are) while administering effective medical treatments isn’t important; rather, it’s to point out that, by themselves, placebo effects are not of much value.

Unfortunately, none of this has stopped what Steve Novella refers to as the “placebo narrative” from insinuating itself into lay discussions of medicine. That narrative proclaims in breathless terms (as Steve put it) the “surprising power of the placebo effect” without putting it into reasonable perspective or even really defining what is meant by “placebo effect.” First, as we have tried to explain time and time again here, there is no single “placebo effect.” There are placebo effects. Second, the only really correct reference to “the placebo response” or “placebo effect” is the outcome measured in the placebo arm of a clinical trial. The problem is that, all too often, discussions of placebo responses conflate the placebo effect measured in a clinical trial with all the other various placebo effects that add up to the response that is measured in that trial. Those effects include reporting biases, researcher biases, regression to the mean, conditioning, and many other components that contribute to what is measured in the outcome of a clinical trial. Another common misconception about placebo effects is that they are somehow “mind over matter,” that we can heal ourselves (or at least reduce our symptoms) through the power of will and mind. This is not true. Placebo effects are not the power of positive thinking.

Posted in: Acupuncture, Basic Science, Clinical Trials, Homeopathy, Science and the Media

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You’ve been diagnosed with breast cancer. How soon do you need treatment?

Breast Cancer Surgery
A new year is upon us yet again, and Science-Based Medicine has been in existence for eight years now. It seems only yesterday that Steve Novella approached me to ask me to be a contributor. Our part-serious, part-facetious predictions for 2016 notwithstanding, one thing about 2016 is certain: I will almost certainly encounter some form of cancer quackery or other and deconstruct it, probably multiple forms. In any case, a topic I’ve been meaning to write about is based on a couple of studies that came out three weeks ago that illustrate why, even if a patient ultimately comes around to science-based treatment of his cancer, the delay due to seeking out unscientific treatments can have real consequences.

When a patient with breast cancer comes in to see me, not infrequently I have to reassure her that she doesn’t need to be wheeled off to the operating room tomorrow, that it’s safe to wait a while. One reason, of course, is that it takes years for a cancer to grow from a single cell to a detectable mass. The big question, of course, is: What is “a while”? Two studies published online last month attempt to answer that question. One study (Bleicher et al) comes from Fox Chase Cancer Center and examines the effect of time to surgery on breast cancer outcomes; the other (Chavez-MacGregor et al) is from the M.D. Anderson Cancer Center and examines the effect of time to chemotherapy on outcome. Both find a detrimental effect due to delays in treatment.

Posted in: Cancer, Surgical Procedures

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The fine line between quality improvement and medical research


As I’ve mentioned before, the single biggest difference between science-based medicine (SBM) and what I like to call pseudoscience-based medicine, namely the vast majority of what passes for “complementary and alternative medicine” (CAM) or “integrative medicine” is that SBM makes an active effort to improve. It seeks to improve efficacy of care by doing basic and clinical research. Then it seeks to improve the quality of care by applying the results of that research to patient care. Yes, the process is complicated and messy, and it frequently doesn’t progress as fast as we would like it to. Sometimes it goes down blind alleys or takes wrong turns, such as when a treatment is adopted too rapidly and determined later to be ineffective. Overall, however, improvement does occur, and it continues to occur. New treatments that work better are discovered. Old treatments that don’t work as well (or that don’t work at all) are abandoned.

There is, however a blurry line between what constitutes medical research and what constitutes quality improvement (QI). A couple of years ago, in one of those unexpected turns that a career can take, an opportunity presented itself for me to become co-director of a statewide quality improvement consortium for breast cancer care in my state. As I’ve alluded to before, it was a case of unexpectedly being in the right place at the right time, of seeing an opportunity and being willing to take it. How I ended up making quality improvement a large part of my career is unimportant. What is important is that it puts me in a unique position among all the other SBM contributors to discuss the interface between science and quality. (It’s also important that I lay down a disclaimer here that this post represents my opinion and my opinion alone; it does not represent the views of the QI with which I’m affiliated, my cancer center, or my university.) In particular, there are ethical considerations that are not obvious, apparently even to someone as brilliant as Steven Pinker, who Tweeted yesterday:

Posted in: Clinical Trials, Medical Ethics, Quality Improvement

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Is scientific peer review a “sacred cow” ready to be slaughtered?

Peer Review

I’ve frequently noted that one of the things most detested by quacks and promoters of pseudoscience is peer review. Creationists hate peer review. HIV/AIDS denialists hate it. Anti-vaccine cranks like those at Age of Autism hate it. Indeed, as a friend of mine, Mark Hoofnagle, pointed out several years ago, pseudoscientists and cranks of all stripes hate it. There’s a reason for that, of course, namely that it’s hard to pass peer review if you’re peddling pseudoscience, although, unfortunately, with the rise of “integrative medicine,” it’s nowhere near as difficult as it once was.

Be that as it may, peer review, the process by which scientific papers are evaluated by scientific “peers” to look for problems with the science and decide if the paper is appropriate for publication in a scientific journal, is a concept that dates back hundreds of years. However, for the most part, before the middle of the 20th century, the ultimate determination of whether a paper was appropriate for scientific publication was made by editors or editorial committees. Opinions of external reviewers were sometimes sought when deemed appropriate by journal editors, but by no means was this the practice for most manuscripts. Over the last six or seven decades, external peer review by scientists chosen by the journal editor evaluating a submission has become the standard. Similarly, decisions regarding whether or not to fund grant applications are now generally made by a panel of external reviewers. In the case of the NIH, these panels are called study sections and consist of scientists with expertise in the types of applications being referred to the study section for evaluation, along with (usually) a statistician or two and officials from the NIH who take care of organizing and running the meetings of the panel. The scientific members of a study section usually include “permanent” members, who are assigned to fixed terms on the study section, and ad hoc members, called in for one or a few meetings as needed and deemed necessary by the NIH.

Posted in: Basic Science, Clinical Trials, Science and Medicine

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Michigan HB 5126: Who thought it was a good idea to make it easier for parents to obtain nonmedical exemptions to school vaccine mandates and harder for local county health officials to do their jobs?

The Michigan House of Representatives: Not the sharpest knives in the drawer.

The Michigan House of Representatives: Not the brightest bulbs on the Christmas tree.

We have a problem with antivaccinationists here in Michigan. It’s a problem that’s been going on a long time that I first started paying attention to in a big way a few years ago when we started seeing pertussis outbreaks again due to low vaccine uptake. It’s a problem that’s persisted as last year we suffered from outbreaks of pertussis and measles, again because of pockets of low vaccine uptake. And what is the reason for these pockets of low vaccine uptake? Well, consistent with what we already know, namely that the risk of pertussis outbreaks is elevated in states where exemptions to school vaccine mandates are easier to get, it’s because our state is one of the worst in the country when it comes to nonmedical exemptions to vaccines. Indeed:

Michigan has one of the highest vaccine-waiver rates for kindergartners in the country, three times the national median, according to the Centers for Disease Control and Prevention. And the number of kindergartners getting vaccine waivers is growing. In five years, it’s increased 23 percent, the CDC says.


Posted in: Politics and Regulation, Public Health, Vaccines

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