The idea that “natural” products are safe and effective has been so effectively marketed to us that many don’t recognize it as a fallacy. Much of the supplement industry is built around an appeal to nature. Supplements are described as natural, gentle, and “holistic”. Medicine, especially prescription drugs, is the opposite. They’re “chemicals”. They’re risky and dangerous – just look at that list of side effects! Supplements are packaged beautifully, have impressive claims, and are for sale at Whole Foods. Drugs are hazardous: They may come in a plain vial, with warning labels, detailed information sheets, and cautious statements about their effectiveness. Is it any wonder that many consumers, when faced with health concerns or medical issues, instinctively think of supplements as a safer alternative? Purveyors of supplements and alternative medicine have leveraged this fallacy so effectively that it’s even guided the regulations that allow their sale. Regrettably, the result is a marketplace that puts consumers’ interests last. The supplement industry has completely stacked the odds against the consumer, challenging their ability to make informed decisions about their health. Most supplements on the market have never been properly tested for safety or effectiveness. And those that have been tested have largely been shown to be ineffective – or in the case of products like vitamins, often unnecessary. And while there are undoubtedly some ethical companies out there, the industry is regularly revealed to resemble a wretched hive of scum and villainy. Despite this, the industry has gone from success to success – in terms of sales, at least. In 1994 supplement sales were about $4 billion in the US. It’s now a $37 billion industry that is remains only lightly regulated – or largely unregulated. With recent action taken against fraudulent products, there are more questions than ever about how to force the supplement industry to make consumer protection a priority. A new paper in Drug Testing and Analysis makes a provocative suggestion: Local and state governments already regulate another hazardous product: tobacco. Can lessons learned from the tobacco wars improve the safety of supplements? (more…)
Archive for Public Health
Recently, I was sitting in a meeting and reached for the dispenser of Purell hand sanitizer sitting on the conference room table. A colleague of mine gave a small, rueful shake of her head to the person on her other side. Apparently I had erred. I asked what was the matter, and got a brief answer to the effect of “because superbugs.” We exchanged nothing more about it; the interaction was over before the alcohol had dried from my hands.
I wouldn’t have thought anything of such an interaction with anyone else, but my colleague is a PhD student in immunology, six years older and more schooled than I, doing her doctoral research in a lab run by a physician-scientist — a specialist in infectious disease, no less. A touch ironic.
And so I noticed a need for some mythbusting: alcohol-based hand sanitizers do not breed resistant bacteria. (more…)
UPDATE: Dr. Katz has responded to this post in his usual venue, The Huffington Post.
Alternative medicine was all about “potential” from the get go:
In 1991, the Senate Appropriations Committee responsible for funding the National Institutes of Health (NIH) declared itself “not satisfied that the conventional medical community as symbolized at the NIH has fully explored the potential that exists in unconventional medical practices.”
Thus, the Committee, led by chair Sen. Tom Harkin, directed the NIH to create an advisory panel that would “fully test the most promising unconventional medical practices.”
The advisory panel became the Office of Alternative Medicine, which became the National Center for Complementary and Alternative Medicine, which became the National Center for Complementary and Integrative Medicine, its current iteration.
This effort to unlock the “potential” of unconventional (renamed alternative, renamed complementary and alternative, renamed integrative) medicine forced an uncomfortable alliance between science and pseudoscience from the beginning. Advocates like Harkin, and his two quackery-promoting constituents, Berkeley Bedell (colostrum and something called “714-X,” derived from camphor) and Frank Wiewel (immuno-augmenative therapy for cancer), were all for “fully testing” until they realized what “fully testing” meant to a scientist: double-blind, placebo controlled trials. It was thus that the true believers discovered the value of special pleading: they “favored quick field studies that would validate alternative treatments.”
Taxpayer monies flowed into legitimate medical and scientific research institutions to conduct alternative medicine research: the Maryland School of Medicine, Harvard Medical School, University of California at Davis, and the Texas Health Science Center, among others, received funds for the study of antineoplastons, cartilage products, magnets, mind-body control, and even Bedell and Wiewel’s beloved “714-X” and immuno-augmentative therapy. (more…)
Antivaccinationists and the Nation of Islam protest in front of the CDC, but don’t you dare call them “antivaccine”
If there’s one thing that’s guaranteed to anger most antivaccine activists, it’s a skeptic calling them “antivaccine.” The reason, of course, is that (1) many of them actually believe they are “not antivaccine” but rather “pro-vaccine safety,” even though their words and actions proclaim otherwise and (2) they crave legitimacy. They want desperately to be taken seriously by the government and scientific community. The problem is that, again, by their very words and actions they make it almost impossible for anyone who knows anything about vaccines to take them seriously, except as a threat to public health. They have no one but themselves to blame, as a critical perusal of Age of Autism, The Thinking Moms’ Revolution, VacTruth (and VaxTruth), or any number of antivaccine websites and blogs will indicated to anyone of a scientific bent who has the intestinal fortitude to plunge down any or all of those rabbit holes of magical thinking and pseudoscience.
Another thing that I’ve come to understand over the more than a decade that I’ve been doing this is that there is a profound tension between what I like to call the two wings of the antivaccine movement. Basically, as is the case in most political or ideological movements, antivaccine activists gravitate towards one of two views. The first (and most prominent view) tends to be the pragmatic view. These are the antivaccinationists who deny vociferously that they are “antivaccine” and instead portray themselves as “pro-safe vaccine.” They want to appear reasonable and are willing to take partial victories on an incremental path towards achieving their ends. Then there are the “loud and proud” antivaccine activists. They don’t eschew or hide from the term “antivaccine.” They embrace it and proudly proclaim that they believe that vaccines are irredeemably toxic, that they don’t protect against disease, that big pharma is a criminal syndicate intent on poisoning their children and turning them autistic, and that the CDC is complicit in the whole plot. Of course, like all ideological movements, there is not a dichotomy; rather, there is a continuous spectrum between the two. Also, in this case, the two groups differ more on tactics than actual beliefs. As I’ve found many times, push a “reasonable” antivaccinationist, one who proclaims herself “not antivaccine” but “pro-vaccine safety,” and it’s usually not hard to get them to say things indistinguishable from the hard core antivaccinationists. They’ll basically cling to their self-perception as “pro-safe vaccine, while making the same evidence-free claims that vaccines cause autism, sudden infant death syndrome (SIDS), autoimmune diseases, diabetes, and all the other conditions on which antivaccinationists blame vaccines.
One of the things that feels the weirdest about having done the same job, having been in the same specialty, for a longer and longer time is that you frequently feel, as the late, great Yogi Berra would have put it, déjà vu all over again. This is particularly true in science and medicine, where the same issues come up again and again and again, often with the same arguments on either side. Sometimes the same players are even involved. So it is with mammography recommendations. Indeed, I’m feeling déjà vu all over again right now, as I read headlines like “Women advised to get mammograms later, less often“, “American Cancer Society, in a Shift, Recommends Fewer Mammograms“, and “ACS: Breast cancer screening should begin at age 45“. What provoked these headlines was a major revision in the American Cancer Society’s recommendation for mammographic screening for breast cancer in women at average risk of the disease. In a seeming replay from 2009, when the United States Preventative Services Taskforce (USPSTF) sent shockwaves through the breast cancer world by recommending that most women not start mammography until age 50 and then only to have it done every two years instead of every year, the American Cancer Society (ACS) has now just similarly ratcheted back its recommendations for screening mammography, just not as much as the USPSTF did. The new recommendations were communicated in a special communication published by JAMA on Tuesday.
What changed regarding mammography recommendations
Before we get to the issues, how, specifically, did the ACS change its mammography recommendations? Before this change, the ACS basically recommended the same thing that most other American professional societies dealing with breast cancer did: yearly mammography starting at age 40 for the rest of a woman’s life. The new guidelines now recommend that women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years and continuing annually until age 54. From age 55 and older, the ACS recommends that women transition to every two years. (More details below.) As I Tweeted when I saw these recommendations, basically it appears that the ACS has more or less split the difference between the old recommendations and the USPSTF recommendations.
So why is the ACS changing its recommendations? And what does this say about the science and our values regarding cancer screening? If you’ve been reading this blog, you know that over the last several years there has been a steady drip, drip, drip of studies that range from highlighting the downside of widespread mammographic screening to downright questioning the value of mammography. That’s why I’ve been discussing rethinking screening for breast cancer since at least 2008. Basically, you can go back and read my old posts and, if you have a lot of time and are enough of a glutton for punishment to read them all, watch the evolution of my thinking about breast cancer screening over the last seven years.
Back in the day, I used to fully support breast cancer screening beginning at age 40 and proceeding yearly throughout. As I examined more and more of the evidence, I became less enthusiastic about screening so intensely and started to believe that starting at 40 was too young for most women. Indeed, I was probably the only breast cancer doctor at my cancer center in 2009 who supported the USPSTF recommendations when they were announced, which led to some—shall we say?—interesting discussions about what should be said to the press and what a press release our cancer center wanted to release ASAP should actually say. I also got myself into a little…trouble…for criticizing colleagues in radiology—not from my institution, I hasten to add!—for some rather blatant turf protection. Let’s just say that a prominent radiologist, one who’s achieved far more renown in his field than I ever have in mine, was most displeased with some of my commentary and let me know about it. I found this displeasure odd, given that I am most definitely not a nihilist with respect to mammography screening (and, make no mistake, there are quite a few of those out there these days). I’m just a lot more balanced and aware of its limitations than I used to be. On the other hand, I did call him out for some of his more obnoxious comments that implied that those who question mammography are cackling gleefully at the thought of more women dying of breast cancer. Interestingly, I don’t seem to get asked to contribute to such press releases that much anymore, but in fairness neither do most of the other breast cancer clinicians I work with; so I probably can’t blame it on my previous outspokenness.
What brought me to this point is an increasing understanding of the concepts of overdiagnosis and lead time bias, coupled with a string of studies that show more modest benefits (and, in one case, no benefit) from screening mammography. To be honest, the attack dog reaction by some mammography supporters to some of these negative studies also set my skeptical antennae a’twitchin’ as well.
“Liquid biopsies” for cancer screening: Life-saving tests, or overdiagnosis and overtreatment taken to a new level?
I’ve written many times about how the relationship between the early detection of cancer and decreased mortality from cancer is not nearly as straightforward as the average person—even the average doctor—thinks, the first time being in the very first year of this blog’s existence. Since then, the complexities and overpromising of various screening modalities designed to detect disease at an early, asymptomatic phase have become a relatively frequent topic on this blog. Before that, on my not-so-super-secret other blog, I noted that screening MRI for breast cancer and whole body CT scans intended to detect other cancers early were not scientifically supported and thus were far more likely to cause harm than good. That was well over ten years ago. Now we have a company offering what it refers to as a “liquid biopsy” for the early detection of cancer. I fear that this is the recipe for the ultimate in overdiagnosis. I will explain.
The problem, of course, is that disease progression, including cancer progression, is not always a linear process, in which the disease progresses relentlessly through its preclinical, asymptomatic phase to symptoms to complications to (depending on the disease) death. There is such a thing as disease that remains asymptomatic and never progresses (at which point it’s hard to justify actually calling it a disease). As I pointed out in my first SBM post on the topic, at least three-quarters of men over 80 have evidence of prostate cancer in autopsy series. Yet nowhere near three-quarters of men in their 80s die of prostate cancer—or ever manifest symptoms from it. This is what is meant by overdiagnosis, the diagnosis of disease that doesn’t need to be treated, that would never cause a patient problems.
When teaching medical students and residents, I frequently emphasize that overdiagnosis is different from a false positive because overdiagnosis does diagnose an actual abnormality or disease. For example, ductal carcinoma in situ (DCIS) diagnosed by mammography leading to a biopsy is a real pathological abnormality; it is not a false positive. We just do not know which cases of DCIS will progress to cancer and which will not, leading to a question of how DCIS should be treated or at the very least whether we should treat it as aggressively as we do now, particularly given that the apparent incidence of DCIS has increased 16-fold since the 1970s, all of it due to mammographic screening programs and the increased diagnosis of DCIS and early stage breast cancer has not resulted in nearly as much of a decrease in the diagnosis of advanced stage breast cancer as one would expect if early diagnosis were having an impact in reducing the diagnosis of late stage disease.
Overdiagnosis would not be such an issue if it didn’t inevitably lead to overtreatment. DCIS, for instance, is treated with surgery, radiation, and anti-estrogen drugs. Early stage prostate cancer used to be treated with radical prostatectomy, but now more frequently with radiation. Many of these men and women didn’t actually need treatment. We just don’t know which ones. This is why over the last six or seven years a significant rethinking of screening for breast and prostate cancer has occurred. There has been a backlash, of course, but the rethinking seems to have taken hold.
Not everywhere, of course. (more…)
Despite the remarkable advances in medicine over the past 20 years, cardiovascular disease and cancer will still kill half of us. Beyond the deaths, millions survive heart attacks, strokes and cancer, but many are left with disability and a reduced quality of life. While lifestyle changes can improve our odds of avoiding these diseases, they do not eliminate our risk. Finding ways to medically prevent these diseases before they occur, a term called “primary prevention”, is a holy grail in medicine. Primary prevention can be a tough sell, personally and medically. It means taking medicine (which may cause side effects) when you’re well, with the hope of preventing a disease before it occurs.
The US Preventative Services Task Force (USPSTF) released draft guidelines on the primary prevention of cardiovascular disease and colorectal cancer last week. The USPSTF is now recommending daily aspirin in some age groups who have at least a 10% risk of cardiovascular disease in the next 10 years. This isn’t the first guideline that’s recommended aspirin for primary prevention of cardiovascular disease, but it is the first major guideline to endorse aspirin to prevent colorectal cancer. Given these recommendations will apply to millions of people, they have attracted considerable controversy. Is this strategy going to reduce deaths and disability? Or are we about to start “medicalizing” healthy people inappropriately? (more…)
My mother had a favorite saying that rhymed: “All you need from dawn to dawn is someone else to blame it on.” WiFi involves mysterious emissions that you can’t see and that sneakily permeate our environment, and they have become a popular target for blame.
A lawsuit has been filed against the Fay School in Massachusetts on behalf of a 12-year-old boy designated as “G,” alleging that the school violated his rights under the Americans with Disabilities Act and failed to use ordinary care for his safety. They allege the school was negligent in failing to make accommodations to protect the boy from extremely high levels of radiofrequency/microwave radiations. He allegedly suffers from Electromagnetic Hypersensitivity Syndrome (EHS). The family is seeking $250,000 in damages.
After the school upgraded its Wi-Fi system in 2013, G began to have headaches, itchy skin, rashes, nosebleeds, dizziness, chest pains, and nausea. He frequently went to the school nurse and had to leave school early. His symptoms would usually resolve after he had been home for several hours, and he did not experience “the intense symptoms” on weekends and holidays.
When the Pacific NW secedes from the Union it is to be part of a new country, Cascadia. The capital would be Portlandia, I suppose. Somehow, I think not. But when I watch the devolution of health care in Oregon, I think back to The Onion (?) when they reported that the United Kingdom was to be sold to Disney, being renamed as “The United Magic Kingdom.”
That is health care in Oregon due the steady insinuation of naturopathy and other pseudomedicine into real health care.
Oregon Health and Pseudoscience University
Growing up my alma mater was the University of Oregon Medical School. Since then it has undergone two name changes, first to Oregon Health Sciences University and then to the current Oregon Health & Sciences University (OHSU)—with, it should be noted, an ampersand. Not an ‘and’.
Perhaps they need one more name change, since they are not always that interested in the “Science” part of their name.
Some background is needed.
Portland has a trifecta of pseudoscience schools: Naturopathic (National College of Natural Medicine), Chiropractic (University of Western States) and ‘Oriental’ (Oregon College of Oriental Medicine).
As an aside my kids let me know that the word ‘Oriental’ as used to describe people from the East, the term I grew up using, is persona non grata. I understand the reasoning. The proper term, they tell me, is Asian. So I have a mental cringe every time I see the name “Oregon College of Oriental Medicine”.
All three schools are steeped in pseudoscience and pseudomedicine, removed from known reality. As examples, the naturopathic school teaches homeopathy (and more), the chiropractic school teaches the subluxation complex, and the ‘Oriental’ (cringe) school teaches acupuncture. Reading the curricula of the schools suggests that there is no pseudomedical stone left unturned. (more…)
Here we go again with the whole “CDC Whistleblower” thing, this time with a book about the recorded conversations between Brian J. Hooker and William Thompson. Well, not the whole conversations, of course. If they were to release the whole conversations, we might get the truth, and the truth always gets in the way of the antivax crowd. Instead, we get an edited transcript of the conversations between those two in which, according to them and the book’s editors and authors, there is some sort of massive cover-up at all levels of science, government, and public health. What’s the cover-up? As usual, vaccines are evil and whatnot.
I’m not going to review the whole book for you because Dr. Gorski has already done so, and Dorit Reiss has discussed the legal aspects of what is discussed in the book. You can go read his review and/or Prof. Reiss’ analysis and then come back, or stay here and read what I have to say about the failed attempts at epidemiology from both BS Hooker and Thompson.
Let’s start by reviewing BS Hooker’s credentials. He is a bioengineer and chemical engineer, not an epidemiologist, despite what the author of the book wants you to believe:
With the publication of Kevin Barry’s Vaccine Whistleblower: Exposing Autism Research Fraud at the CDC, any claims of credibility for the CDC’s science has collapsed. Barry built his book upon four legally taped conversations between CDC senior vaccine safety scientist Dr. William Thompson and Simpson College professor and epidemiologist, Dr. Brian Hooker.
Later in the book, in the transcript of one of the conversations between BS Hooker and Thompson, BS gets a list of things he needs to do to earn an “honorary” degree in epidemiology. Among those things was to look at some of the earlier studies that Thompson had coauthored. And BS did. He would go on to write a flawed paper that I critiqued here and ended up being retracted, as I told you about here. That paper alone should tell you everything you need to know about BS Hooker’s epidemiological understanding, but the transcripts given to us by his camp in the form of the book really reveal his ignorance.
So let’s go through the calls we have transcripts for and pick at the epidemiological and biostatistical missteps that Thompson suggests for BS Hooker. (more…)