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Influenza Deaths

“There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don’t know. But there are also unknown unknowns. There are things we don’t know we don’t know.”- Donald Rumsfeld

How do we know what we know? It is said by some anti-vaccine proponents that vaccines are not needed because the diseases they prevent are either gone or no longer as severe as they were in pre vaccine times. People may have suffered and died in the distant past, but no longer. The risk now is from the vaccines not the diseases they no longer prevent.

36,000 people, more or less, die every year from influenza. That is the number of deaths according to the CDC web site; the NEJM review uses the higher number of 56,000 (7). Which number is correct? Isn’t that why the flu vaccine is recommended: to prevent all those people from dying.

36,000 is a lot of people. That’s about 120 deaths per million people in the US. In Oregon, population about 3 million, that would be about 360 people a year, which is two deaths a day for the six month flu season.

“Death is caused by swallowing small amounts of saliva over a long period of time.”–George Carlin.

2,400,000 people die every year in the US, about 6600 a day. In Oregon, that is about 65 deaths a day. No one outside a epidemiologist is going to notice 2 extra deaths a day during flu season. I have seen a lot of people die of influenza, but I have a biased experience: I am an infectious disease doc, so I am likely to see people with influenza, especially patients with disease severe enough to kill them.

About the same number of people die from car accidents and die from handguns in the US each year as die from influenza. I have never known a person in my real, as opposed to my professional, life to die from influenza or handguns or a car accident. My personal experience suggests no one dies from these causes, but since I take care of patients at one of the Portland trauma hospitals, I know what cars and guns do to people. My professional life confirms that people do indeed die from being shot or car accidents. I would wager that most people reading this blog have not known anyone who has died from influenza, guns or car accidents. The fact that people do die of influenza seems contradicted by experience. Why get the vaccine? I don’t get the flu and and no one I know has ever died from it.

As an illustrative example, a relative of mine, a retired physician, mentioned that he thought the shingles vaccine was a waste of time and money as he had never known anyone to get shingles. Using personal experience to judge disease prevalence is unreliable. If I applied the same rationale to driving, I would not wear a seat belt as I have never been in a high speed crash.

36,000 people die of influenza each year. What is the source of that statistic? From “Mortality associated with influenza and respiratory syncytial virus in the United States”. JAMA 2003. Is that really how many deaths are there from influenza? It depends on what you mean by ‘death’ and what you mean by ‘influenza’ and what you mean by ‘from’.

“It depends on what the meaning of the words ‘is’ is.” – Bill Clinton

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Posted in: Basic Science, Public Health, Vaccines

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Quackery tolerance – a learned response

Academic politeness turns to the vicious  This is more on the theme of academic and postmodern roots of sectarianism-quackery’s advance on medicine. I illustrate through the personal experience of a noted combatant – Mary Lefkowitz – in the front lines of the war with intellectual and academic buffoonery passing as scholarship. The joke is not in the buffoonery, though. The joke is turning on us.

Some of you are familiar with Prof.Lefkowitz’s academic dispute from publicity last spring. Prof. Lefkowitz is on the list of academic opponents to relativism and postmodernism. Lefkowitz’s travail began in 1993 when another Wellesley faculty member who led a department or course of Africana Studies claimed in lectures that ancient Greek and Roman intellectual advances were lifted from libraries and other sources of ancient Egypt, and that furthermore, those Egyptians were black Africans.

You recognize this as Afrocentrism, one of relativism and postmodernism’s multi-pronged attack on intellectualism and Western civilization. I attended a session on the problem in 1992 (or so) at the AAAS in San Francisco, and did not appreciate or understand what was going on, or why the raised rhetoric and voices. I do now, especially having read excerpts from Lefkowitz’s book, History Lesson, published earlier this year.
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Posted in: Basic Science, Medical Academia, Science and Medicine

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Vitamin C strikes (out) again

I didn’t think I’d be revisiting this topic again so soon. After all, I wrote one of my characteristic magnum opuses (opi?) less than two months ago, when I asked whether a recent animal study had vindicated Linus Pauling’s belief that high dose vitamin C is a highly effective cancer treatment. After that tsunami of verbiage that can only be exceeded by my fellow blogger Dr. Atwood when he’s on a roll doing a multipart deconstruction of some woo or other, I thought it would be best to give it a rest for a while. I guess less than two months will have to be enough.

The reason struck me as I was perusing the very latest issue of Cancer Research, hot off the presses October 1. As I did so, it didn’t take me long to come across an article from the Memorial-Sloan Kettering Cancer Center and the Herbert Irving Comprehensive Cancer Center at Columbia entitled Vitamin C Antagonizes the Cytotoxic Effects of Antineoplastic Drugs, whose first author is Dr. Mark Heaney.

Once more into the fray!
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Posted in: Basic Science, Cancer, Herbs & Supplements, Nutrition

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Postmodernist attacks on science-based medicine

The postmodernist critique of science consists of two interrelated arguments, epistemological and ideological. Both are based on subjectivity. First, because of the subjectivity of the human object, anthropology, according to the epistemological argument cannot be a science; and in any event the subjectivity of the human subject precludes the possibility of science discovering objective truth. Second, since objectivity is an illusion, science according to the ideological argument, subverts oppressed groups, females, ethnics, third-world peoples.

Postmodernism and science

I detest postmodernism.

Well, it’s not really postmodernism per se that I detest. In the humanities, I don’t mind it so much, although reading postmodernist texts in college did make my head hurt. I suppose that in the humanities postmodernism provides a sometimes useful methodology for providing insights into interpretation of a wide variety of subjects in literature and the arts, although much of the time it seems to exist mainly to try to make texts mean exactly the opposite of what the words on the page say. Relying as it does on deconstruction, which is primarily a form of literary analysis, postmodern analysis is built on questioning the assumptions underlying any text, “deconstructing” its meaning. The problem is, it’s rare that a postmodernist critique of anything doesn’t consist of some of the densest, most impenetrable verbiage in existence.

Since I don’t claim to be a philosopher, and I haven’t studied postmodernism since college, I don’t intend to embarrass myself by trying to do a detailed–ahem–deconstruction of what postmodernism is. Many are the trees that have been killed to write books trying to explain what postmodernism is and how to apply it to various subjects. I do know, however, that postmodern philosphy is skeptical–even nihilistic–when it comes to the values of what is considered “modernity.” Unfortunately, to some, science is one of these modern values that is viewed with extreme skepticism, even to the point of representing the very essence of science as nothing more than one narrative among many. True, Spiro was writing primarily about anthropological science, but medicine is a “soft” enough science to be just as easily attacked in such a manner, and postmodernists don’t limit themselves to the “soft” sciences, anyway. Even worse, these sorts of arguments often claim that science (or, in this case, evidence-based medicine) is nothing more than a sort of hegemony of the power structure being imposed upon the very definition of “data” or “reality,” the implication that it’s us white males whose hegemony is being served (and whose hegemony, presumably, must be resisted) doing the imposing, as if there are no inherent characteristics in science that make it a more reliable means of assessing reality as it exists than, for example, personal anecdote and “experience.”

No wonder woo-meisters and those who hate the very concept of evidence-based medicine (as opposed to the deficiencies in how EBM ranks evidence, which in fact were the reason why this blog is called Science-Based Medicine and not Evidence-based Medcine) love postmodernism so much. It’s the perfect tool for them to appeal to other ways of knowing and try to make it seem as though scientific medicine is no more valid a construct to describe reality than that of the shaman who invokes incantations and prayers to heal, the homeopath who postulates “healing mechanisms” that blatantly contradict everything we know about multiple areas of science, or reiki practitioners who think they can redirect “life energy” (or qi) for therapeutic effect. In the postmodernist realm all are equally valid, as there is no solid reason to make distinctions between these competing “narratives” and the “narrative” of scientific or evidence-based medicine.

Perhaps the best quick explanation of how postmodernism is used to attack science comes from Rob Helpy-Chalk:

Knowledge was always in some way relativized to culture, so that it was possible to talk about many “equally valid ways of knowing” of which enlightenment science was only one. For instance, contemporary biologists say that the cassowary (an ostrich-like creature) is a bird, albeit one that cannot fly. The Karam people of New Guinea, who live alongside the cassowary, say that the cassowary does not belong in the same category as the birds (which they call yakt) but bats do belong to that category. So who’s to say that the biologists are right and the Karam are wrong? Knowledge is all relative.

Claims to knowledge were also always in some way “constructed” or “socially constructed” in the postmodernist movements. This meant that they had less to do with grasping the way the world actually works and more to do with creating social structures that advanced the interests of the people who claimed to have knowledge. The science of thermodynamics was not really a description of the properties of heat. It was about convincing people to buy steam engines and arranging society so that they would be happy when they bought one.

Thus, one of the key tenets of some strains postmodernism is that knowledge is relative and “socially constructed,” usually for the purpose of reinforcing the existing power structure or furthering the interests of the “elite” who have the knowledge. It is therefore not surprising that critics of evidence-based and science-based medicine would find postmodernism to be a very attractive philosophical mantle in which to wrap their objections to the science that does not support their favored understanding of how disease works or what treatments are effective. After all, if all knowledge is relative, then why shouldn’t their way of knowing be just as valid as that of science, given that in the postmodernist view as used (or, as many philosophers would characterize it, abused) by “postmodernist” critics, science is just “another narrative.”
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Posted in: Basic Science, Clinical Trials, Medical Academia, Science and Medicine

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Snipers – A Short Reflection

The blogosphere held no fascination for me before my involvement with sciencebasedmedicine.com. I had checked into a few blogs, and found some capturing attention, allowing exploration of ideas and personal views in greater scope than allowed for in scientific papers. But many seemed not to expand discussion after an original post.  When the blogger would describe some series of events or ideas, there would follow a series of pro and con short commentaries, whose authors seemed to enjoy sniping at irrelevant issues. The emotional level rose with each series of exchanges. One had to search for pages with comments that expanded knowledge, and were not just argumentative.Some commenters took off on small details in the original.. Then ensued a series of yes I did – no I didn‘t, you said – I said, you said – I meant, you‘re a blank – you’re a worse blank, and on, as readers know.

I wrote an article or two for an online ‘zine, and the format allowed for extended exchanges, like the blogs. Comments followed a similar pattern. They continued for 2 weeks. Same thing happened when I critiqued traditional Chinese medicine, implausible claims, ethics of “CAM” in editorials in an online journal. Questions there were screened by editors, but I filled more space  elaborating answers than I was allowed by the word limit to the original articles. I noted that even news items in online news sources were followed by series of comments, challenges, counterchallenges and on they went, often getting uncomfortably personal. Lost in some of this was the meat of the original article as small point after smaller point appeared.

All this is old stuff to most of you readers, but to me, it was new. And I wondered not only about the format and policies that allowed ongoing sniping, but had to look at my own reactions, often surging in the same direction of telling people off. I keep telling myself not to answer snipes, but the temptation sometimes wins. Too much chance to show cleverness and to enjoy that basic, innate joy of putting it to someone who wrote something that really ticked me off.
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Posted in: Basic Science, Science and Medicine

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High dose vitamin C and cancer: Has Linus Pauling been vindicated?

ResearchBlogging.orgTHE ZOMBIE RISES AGAIN

Vitamin C as a treatment for cancer is back in the news again.

I’m not surprised. This is one therapy favored by advocates of “alternative” medicine that keeps popping up periodically (seemingly every couple of years or so). This latest bit of news has turned up almost right on time after the last time there was a push for rehabilitating vitamin C as a cancer cure a couple of years ago. Back in the spring of 2006, there were two studies published (more on them later) which were touted by the “complementary and alternative medicine” (CAM) crowd as evidence that Linus Pauling was supposedly vindicated. A little less than two weeks ago, an animal study was published suggesting that high-dose intravenous vitamin C had antitumor activity in mouse models. A couple of weeks prior, there had also been published a phase I clinical trial that showed that megadoses of IV ascorbate were safe and well-tolerated in cancer patients if they were appropriately screened for renal disease. Given the latest studies of this particular modality against cancer, it seemed like an opportune time for me to examine this new evidence and ask the question: Has Linus Pauling been vindicated?

I’ll cut to the chase. The short answer is: Not really, with the qualification that it depends on what you mean by “vindicated.” The long answer follows.
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Posted in: Basic Science, Cancer, Clinical Trials, Nutrition, Science and the Media

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Animal rights terrorists endanger science-based medicine

I’m a bit ticked off right now, enough that I thought I’d break with tradition and do an extra post today. Don’t worry; it’ll be brief. It will also be angry, more so than you are perhaps used to hearing on this blog. However, I think my anger is justified, and I hope that Steve Novella–and you–will understand. I view the problem that I am about to discuss to be at least as serious a threat to science-based medicine as any infiltration of woo into medical schools or residency programs.

Remember back in February, when I discussed how animal rights terrorists had been harassing a researcher at the University of California Santa Cruz (UCSC)? At the time, protesters attempted a home invasion of a researcher, leading to a police response where a home was searched by the police. This time around, however, these animal rights thugs have turned violent–again:

SANTA CRUZ — The FBI today is expected to take over the investigation of the Saturday morning firebombings of a car and of a Westside home belonging to two UC Santa Cruz biomedical researchers who conduct experiments on animals.

Santa Cruz police officials said Sunday the case will be handed to the FBI to investigate as domestic terrorism while local authorities explore additional security measures for the 13 UCSC researchers listed in a threatening animal-rights pamphlet found in a downtown coffee shop last week.

“The FBI has additional resources and intelligence into groups and individuals that might have the proclivity to carry out this kind of activity,” police Capt. Steve Clark said. “The FBI has a whole other toolbox of tools for this kind of investigation.”

The front porch of a faculty member’s home on Village Circle off High Street was hit with a firebomb about 5:40 a.m. Saturday, police said. The bomb ignited the front door of the home and filled the house with smoke, police said. About the same time, a Volvo station wagon parked in a faculty member’s on-campus driveway on Dickens Way was destroyed by a firebomb, police said.

Clark described the bombs as devices, which he said investigators have seen used by animals rights activists in the past, as “Molotov cocktail on steroids.”

That no one was seriously injured or died, especially the researcher’s children, is incredibly fortunate. As in previous cases, these two firebombing attacks were the culmination of a campaign of intimidation:

This appears to be the latest in a string of incidents targeting UCSC researchers and others in Santa Cruz.

Fliers identifying 13 UCSC scientists, some of whom use mice, fruit flies and other nonprimate creatures in their research, were discovered at a downtown coffee shop Tuesday. The fliers say, “Animal abusers everywhere beware; we know where you live; we know where you work; we will never back down until you end your abuse.” The names, home addresses, home phone numbers and photos of researchers were published on the fliers.

Fruit flies? Drosophila? How messed up do you have to be to threaten violence over Drosophila experiments? Why aren’t they threatening violence over the trillions upon trillions of E. coli or yeast that die in the name of science in molecular biology labs every day?
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Posted in: Basic Science, Medical Academia, Politics and Regulation, Science and Medicine

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Why would medical schools associate with quackery? Or, How we did it.

Why would medical schools risk association with quackery?

…a question from a Washington Post reporter in 1998.

The following hypothetical answer composed in response was never sent. It awaited a proper forum. Could this be one?

Well, Jeff, quackery is a pejorative term. Some time ago we recognized that words raise emotions and mental pictures. We recognized the cognitive dissonance raised by them, so we tried to eliminate quackery. We recognized the cognitive dissonance raised when one discusses acupuncture, chiropractic, homeopathy, and healing at a distance as if they were quackery when we made claims. For a century, most people just could not allow for the possibility that these things really work.

So over time we recognized that we had to do something about our language. That would be the first step in enabling the thought revolution that is upon us, and changing the paradigm in medicine and science. We simply changed the adjectives, and gave alternate names to the methods, added a few phrases to eliminate negative reactions, and shifted the negative terms to descriptions of the Medical Establishment (and, note the caps in that one.)
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Posted in: Basic Science, Politics and Regulation, Science and the Media

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Monkey business in autism research

NOTE: I had originally planned on posting Part II of a series on cancer screening. However, something came up on Friday that, in my estimation, requires a timely response. I should also inform readers that, because next Monday is a holiday here in the U.S., I haven’t yet decided whether I will be doing a post next week or not. Stay tuned and check back.

I get e-mail.

Sometimes the e-mail is supportive. Other times, as you might imagine, given some of my posts, it is anything but. On Friday afternoon, I happened to notice an e-mail from an “admirer” of mine that said something like this:

You are a complete jack-ass.

– Generation Rescue

Appended to the e-mail was a link to this article on the Age of Autism blog.

Generation Rescue, as you may recall, is an organization that promotes the idea that vaccines cause autism, and this e-mail almost certainly came from the founder and head of GR, a man named J.B. Handley. In case you don’t know who he is, Handley is a man who is, even by the standards of antivaccinationists, incredibly boorish and possessed of a bull-in-a-china shop manner that alienates even some potentially sympathetic people, although parents who believe that vaccines cause autism seem to love him. He is also quite–shall we say?–flexible in his notions of how vaccines cause autism. Until about a year ago, the Generation website stated unequivocally:

Generation Rescue believes that childhood neurological disorders such as autism, Asperger’s, ADHD/ADD, speech delay, sensory integration disorder, and many other developmental delays are all misdiagnoses for mercury poisoning.

About a year ago, it changed to:

We believe these neurological disorders (“NDs”) are environmental illnesses caused by an overload of heavy metals, live viruses, and bacteria. Proper treatment of our children, known as “biomedical intervention”, is leading to recovery for thousands.

The cause of this epidemic of NDs is extremely controversial. We believe the primary causes include the tripling of vaccines given to children in the last 15 years (mercury, aluminum and live viruses); maternal toxic load and prenatal vaccines; heavy metals like mercury in our air, water, and food; and the overuse of antibiotics.

The kind interpretation is that GR was changing its hypothesis given that the data being published consistently and strongly refuted the myth that mercury in vaccines somehow cause autism. In reality, though, it’s fairly clear that GR was pivoting effortlessly to a hypothesis that not only was nearly completely unfalsifiable but also allowed GR to continue to blame vaccines for autism, which is what it’s really about. More recently, as I have pointed out before, antivaccinationist rhetoric has also pivoted even further and equally as effortlessly to blame unspecified “toxins” or “combinations of toxins” in vaccines. Be that as it may, having felt the love, I have to admit that Mr. Handley sure does know how to charm a guy. When he draws my attention to some abstracts so politely, abstracts that he clearly considers to be very important evidence, how can I refuse to take a look? After all, Mr. Handley himself apparently very much wanted to point me in the direction of these three abstracts, and it would be downright churlish of me to deny him and refuse to look at the studies with as open a mind as possible.
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Posted in: Basic Science, Medical Academia, Neuroscience/Mental Health, Politics and Regulation, Public Health, Vaccines

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Barriers to practicing science-based surgery

ResearchBlogging.orgMuch to the relief of regular readers, I will now change topics from those of the last two weeks. Although fun and amusing (except to those who fall for them), continuing with such material for too long risks sending this blog too far in a direction that no one would want. So, instead, this week it’s time to get serious again.

A few weeks ago, I wrote about factors that lead to the premature adoption of surgical technologies and procedures or the “bandwagon” or “fad” effect among surgeons. By “premature,” I am referring to widespread adoption “in the trenches,” so to speak, of a procedure before good quality evidence from science and clinical trials show it to be superior in some way to previously used procedures, either in terms of efficacy, cost, time to recover, or other measurable parameters. As I pointed out before, laparoscopic cholecystectomy definitely fell into that category. The popularity of the procedure spread like wildfire in the early 1990s before there was any good quality data supporting its superiority to the “old-fashioned” gold standard procedure of open cholecystectomy. Another example, although not nearly as dramatic because the number of patients for whom the procedure would be appropriate is much smaller, is transanal endoscopic microsurgery. However, the difficulties in practicing science- and evidence-based medicine don’t just include fads and bandwagon effects. The example of laparoscopic cholecystectomy notwithstanding (which was largely driven by marketing and patient demand), surgical culture is deeply conservative in that it can be very reluctant to change practice even there is very strong evidence saying that they should.
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Posted in: Basic Science, Cancer, Surgical Procedures

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