Editor’s note: Since I happen to be on vacation (sort of–in reality I plan on spending most of next week holed up in my Sanctum Sanctorum at home writing a grant that’s due in February) and because readership tends to be down during the week between Christmas and New Years’ Day, I thought I’d resurrect something from well over three years ago and revise it to fit this particular blog. In doing so, I hope to provide you with something amusing to read, as well as something to link to time and time again whenever you want to refer to a particular gambit beloved by promoters of quackery and pseudoscience. I present here….The “Pharma Shill” Gambit! Enjoy!
I’ve mentioned before on this blog at least once that I cut my skeptical teeth, so to speak, on Usenet, that vast untamed and largely unmoderated territory full of tens of thousands of discussion newsgroups which used to be a lot more active before the rise of the World Wide Web and then later blogs. These days, few ISPs even offer much in the way of Usenet access; it’s become pretty much irrelevant since Google archived Usenet in the form of Google Groups. My forays into skepticism started out with combatting Holocaust denial on a newsgroup known as alt.revisionism (as good an excuse as any to remind you that nearly all Holocaust “revisionism” isn’t historical revisionism but is actually denial) and then branched out into more general skepticism, particularly about the claims of creationists and, of course, promoters of “alternative” medicine, the latter of which ultimately led me to being the editor of this wild and woolly thing we call the Science-Based Medicine blog. After I began to participate in the debates in the main newsgroup where alternative medicine is discussed, misc.health.alternative, it didn’t take me long to encounter a favorite tactic of promoters of alt-med who were not happy with one who insists on evidence-based medicine and who therefore questions claims that are obviously not based in valid science: The “Pharma Shill” Gambit. This is a technique of ad hominem attack in which a defender of “alternative” medicine, offended by your questioning of, for instance, his/her favorite herb, colon or liver flush technique, zapper, or cancer “cure,” tries to “poison the well” by implying or outright stating you must be in the pay of a pharmaceutical company, hired for nefarious purposes.
Since I entered the blogosphere several years ago under another guise, I’ve only occasionally checked back at my old stomping ground, mainly because blogging is so much less constraining than posting to Usenet, where mostly I used to respond to the posts of others, rather than writing about what I wanted to write about. A while back, though, out of curiosity I checked back and found this interesting little tidbit from a poster calling himself PeterB that demonstrated such a perfect example of the “pharma shill” gambit that I thought it might serve as a perfect example of the sort of thing I’ve had to put up with ever since I started speaking out against quackery:
A reader recently sent in a link to a New York Times article that discussed an alternative breathing technique developed in Russia for the treatment of asthma called the Buteyko Method, or the Buteyko Breathing Technique (BBT), and asked for an evaluation of the claims on SBM. This post will attempt to be a reasonably comprehensive evaluation of Buteyko and his therapy so that subsequent discussions, should they be necessary, may be more terse.
The NYT article is primarily an anecdote of a friend of the author who suffered from severe asthma, but who had improved since he began using the BBT. The author briefly discusses asthma, the history and theory behind Buteyko and hyperventilation before wrapping up with an attempt to provide evidence to support the legitimacy of the story. The friend’s pulmonologist is quoted to confirm that “based on objective data, his breathing has improved…” She cites controlled clinical trials “in Australia and elsewhere” where patients have reduced their use of medications, including a purported British study of 384 patients where patients had a 90% reduction in rescue inhaler use and 50% reduction in steroids. She ends by pointing out that the British Thoracic Society has given BBT a “B” rating, and an admonition to “the pharmaceutically supported American medical community to explore this nondrug technique.”
Never having heard of BBT before, the NYT article left me with several questions. Who was Buteyko? How did he develop the BBT? What is BBT, what does it claim to do, and how does it claim to work? Is the evidence as presented in the NYT article accurate? And finally, what evidence exists within the literature that BBT is an effective treatment for asthma?
As 2009 comes to an end, it seems that everyone is creating year-in-review lists. I thought I’d jump on the list band wagon and offer my purely subjective top 5 threats to rational thought in healthcare and medicine.
Of course, it strikes me as rather ironic that we’re having this discussion – who knew that medicine could be divorced from science in the first place? I thought the two went hand-in-hand, like a nice antigen and its receptor… and yet, here we are, on the verge of tremendous technological breakthroughs (thanks to advances in our understanding of molecular genetics, immunology, and biochemistry, etc.), faced with a growing number of people who prefer to resort to placebo-based remedies (such as heavy-metal laced herbs or vigorously shaken water) and Christian Science Prayer.
And so, without further ado, here’s my list of the top 5 threats to science in medicine for 2009 and beyond:
They say that everything old is new again and that is certainly true in the world of “alternative” health. One of the axiomatic premises of contemporary “alternative” health puts its believers behind the times … by approximately 500 years.
A fundamental premise held by believers in “alternative” health is that we are swimming in a world of “toxins” and those “toxins” are causing disease. Like most premises in “alternative” health it has no basis in scientific fact; makes intuitive sense only if you are ignorant of medicine, science and statistics; and speaks to primitive fears and impulses.
The preoccupation with “toxins” is a direct lineal descendant of the obsession with evil humours and miasmas as causes of disease. It is hardly surprising that prior to the invention of the microscope the real causes of disease went undiscovered. The idea that disease is caused by tiny organisms that invade the body is not amenable to discovery in the absence of scientific instruments and scientific reasoning. And it goes without saying that the same people who were unaware that bacteria and viruses cause disease could not possibly imagine chromosomal defects, inborn errors of metabolism or genetic predispositions to disease.
Instead, people imagined that diseases were caused by excess evil humours, substances that were named, but never seen or identified in any way accessible to the senses. It was recognized that some diseases were contagious, and in that case, people invoked the idea of “miasmas” that somehow transmitted disease.
Multiple sclerosis (MS) is fascinating illness that can range from mild annoyance to debilitating nightmare. The frightening nature and unclear cause of the disease makes it a magnet for questionable medical therapies (i.e. quackery). A piece published last week in (surprise!) the Huffington Post helps fuel the fires of suspicion and paranoia while failing to shed any light on the future of MS research.
Multiple sclerosis is a disease of the nervous system. Its victims develop symptoms based on what part of the nervous system is affected. For example, if MS attacks the optic nerve, a patient may experience blurry vision or blindness. If it affects the motor areas of the brain that controls the left leg, the patient will develop weakness in the left leg. Typically, the symptoms will last a certain period of time and then improve, but often not completely back to normal. (more…)
It looks like the H1N1 pandemic is fading fast. I am amazed at how lucky we were, at least in the hospitals where I work. A month ago all the ICU beds were full, most of the ventilators were in use and we were wondering how we were going to triage the next batch of patients who needed advanced life support and we had none to offer. Then, right as we reached maximum capacity and had no more wiggle room, the rates plummeted. We skated right up to the edge of the precipice, looked down, and did not have to jump.
The pandemic has not been as bad as expected, but it was still no walk in the park. Nationwide H1N1 killed maybe 10,000, with 1,100 in children and 7,500 among young adults (ref). Oregon has had 1200 hospitalizations and 68 deaths. We had about 8 deaths from H1N1 in my hospital system. We would have had twice that number, but one of our hospitals is a trauma center and offers ECMO (Extra Corporeal Membrane Oxygenation) and we managed to save a number of people who would have died if they had been in a lesser hospital. The national statistics mirror our experience. None of the deaths were in the elderly. Pity the vaccine was slow to be produced as it could have prevented the majority of those deaths.
Are we done with H1N1? Will it become part of seasonal flu? Will it have a third comeback, fueled by holiday travel? Will it mutate and increase virulence? Will it recombine with avian flu to generate a new strain? Is this THE pandemic that comes every 30 years or so, and we will not see another until after I am long dead?
How am I supposed to know? I can’t see the future. Or can I? Mr. Randi, listen up: I am thinking I will be eligible for that million dollar prize. I am receiving future information from the Large Hadron Collider, curiously delivered inside a baguette. I think I can predict the next infection to sweep the US.
Credibility alert: the following post contains assertions and speculations by yours truly that are subject to, er, different interpretations by those who actually know what the hell they’re talking about when it comes to statistics. With hat in hand, I thank reader BKsea for calling attention to some of them. I have changed some of the wording—competently, I hope—so as not to poison the minds of less wary readers, but my original faux pas are immortalized in BKsea’s comment.
Lies, Damned Lies, and…
A few days ago my colleague, Dr. Harriet Hall, posted an article about acupuncture treatment for chronic prostatitis/chronic pelvic pain syndrome. She discussed a study that had been performed in Malaysia and reported in the American Journal of Medicine. According to the investigators,
After 10 weeks of treatment, acupuncture proved almost twice as likely as sham treatment to improve CP/CPPS symptoms. Participants receiving acupuncture were 2.4-fold more likely to experience long-term benefit than were participants receiving sham acupuncture.
The primary endpoint was to be “a 6-point decrease in NIH-CSPI total score from baseline to week 10.” At week 10, 32 of 44 subjects (73%) in the acupuncture group had experienced such a decrease, compared to 21 of 45 subjects (47%) in the sham acupuncture group. Although the authors didn’t report these statistics per se, a simple “two-proportion Z-test” (Minitab) yields the following:
Sample X N Sample p
1 32 44 0.727273
Difference = p (1) – p (2)
Estimate for difference: 0.260606
95% CI for difference: (0.0642303, 0.456982)
Test for difference = 0 (vs not = 0): Z = 2.60 P-Value = 0.009
Fisher’s exact test: P-Value = 0.017
Wow! A P-value of 0.009! That’s some serious statistical significance. Even Fisher’s more conservative “exact test” is substantially less than the 0.05 that we’ve come to associate with “rejecting the null hypothesis,” which in this case is that there was no difference in the proportion of subjects who had experienced a 6-point decrease in NIH-CSPI scores at 10 weeks. Surely there is a big difference between getting “real” acupuncture and getting sham acupuncture if you’ve got chronic prostatitis/chronic pelvic pain syndrome, and this study proves it!
We are nearing the end of the second wave of the 2009 H1N1 pandemic, and are now a few months out from the release of the vaccine directed against it. Two topics have dominated the conversation: the safety of the 2009 H1N1 influenza vaccine, and the actual severity of the 2009 H1N1 infection. Considering the amount of attention SBM has paid the pandemic and its surrounding issues, and in light of a couple of studies just released, it seems time for an update.
2009 H1N1 Vaccine Safety
This week the CDC released a report that evaluated the safety record of the 2009 H1N1 vaccine. The first two months of the vaccine’s use were examined, from October 1st through November 24th using data from two of the larger surveillance systems monitoring the 2009 H1N1 vaccine’s safety: the Vaccine Adverse Event Reporting System (VAERS) and the Vaccine Safety Datalink (VSD). This report represents the largest, and to date best, evaluation of the 2009 H1N1 vaccine’s safety profile since its initial testing and release. The findings are reassuring.
Several weeks ago I wrote the first in a brief series of posts discussing the different types of evidence used in medicine. In that post I discussed the role of correlation in determining cause and effect.
In this post I will discuss the basic features of an experimental study, which can sere as a check-list in evaluating the quality of a clinical trial.
Medical studies can be divided into two main categories – pre-clinical or basic science studies, and clinical studies. Basic science studies involve looking at how parts of the biological system work and how they can be manipulated. They typically involve so-called in vitro studies (literally in glass) – using test tubes, petri dishes, genetic sequencers, etc. Or they can involve animal studies.
Clinical trials involve people. They are further divided into two main categories – observational studies and experimental studies. I will be discussing experimental studies in this post – studies in which an intervention is done to study subjects. Observational studies, on the other hand, look at what is happening or what has happened in the world, but does not involve any intervention.