Sharon Begley, the Science Editor for Newsweek, wrote about translational research in the latest issue, and the tone of the essay reminded me of Begley’s previous piece on comparative-effectiveness research. Being an MD/PhD student (just defended!) I am very interested in the process of communicating “from bench to bedside.” New to science as I may be, I found Begley’s arguments to be overly simplistic and short-sighted. (more…)
Archive for Science and Medicine
A Digression: The Politics of Chinese Medicine in the People’s Republic of China (The Early Years)
A Partial Book Review: Chinese Medicine in Early Communist China, 1945-63: a Medicine of Revolution, by Kim Taylor
Mao’s was a complex personality. He was by nature a control freak, highly secretive, quickly suspicious, ruthless in revenge. These were all personal characteristics that were to determine the flow of politics in early Communist China. (Taylor, p. 4)
We have already seen that attempts to create ‘acupuncture anesthesia’ began in the People’s Republic of China (PRC) in 1958. As suggested by the title of this series, this resulted from neither rigorous research nor the serendipity that occasionally heralds important discoveries. Rather, the apparent prominence of acupuncture in health care in the PRC was a matter of governmental fiat. Even before the Communist victory in 1949, it was clear to Chairman Mao Zedong that there were not enough ‘Western’ trained physicians to handle the massive health problems of the country, which included an infant mortality rate of 1 in 5, an overall death rate of 30 per 1000 per year, and widespread disability. Most of this was due to malnutrition and infectious diseases, including many that sound exotic and ominous to the modern ear:
…schistosomiasis, filariasis, ancyclostomiasis, Kala-azar, encephalitis, plague, malaria, smallpox and venereal disease…measles, dysentery, typhoid, diphtheria, trachoma, tuberculosis, leprosy, goitre, Kaschin-Beck’s disease…(Taylor, p. 103)
Pre-scientific Chinese medicine, acupuncture in particular, was identified by Mao and other Communist leaders as worthy of cultivating:
Our nation’s health work teams are large. They have to concern themselves with over five hundred million people [including the] young, old, and ill. This is a huge enterprise, and one that is extremely important. Thus our responsibility weighs heavily…At present, doctors of Western medicine are few [10,000-20,000], and [thus] the broad masses of the people, and in particular the peasants, rely on Chinese medicine to treat illness. Therefore, we must strive for the complete unification of Chinese medicine. –Mao Zedong, 1950, quoted in Taylor (p. 33)
Taylor writes that there may have been 500,000 doctors of ‘Chinese Medicine’ at the time. It is tempting to conclude that Mao’s call for the ‘unification of Chinese medicine’ was a cynical way to make it appear that the Chinese Communist Party (CCP) could provide adequate health care in a much shorter time than would be required to train sufficient numbers of modern physicians and to build and equip modern facilities. This is undoubtedly true, but Taylor argues that there were additional considerations:
…Mao evidently saw the profession of Chinese medicine not so much as a therapeutic practice, but more as a large, and therefore significant, body of people. Mao’s support of Chinese medicine during this time can be linked to a concern for adequate health care manpower, and by extrapolation, to a concern for social stability. If the Chinese medical practitioners were ignored and not forcibly, as it were, integrated into the new Communist society, and if their medicine was not encouraged, it would mean hundreds of thousands of people would be without a livelihood. Including their dependents, this would mean that there would be hundreds of thousands of people without any means of support. It is likely that Mao interpreted the more serious problem to be one of economics, and the importance of keeping people usefully employed within society, rather than the dangers of supporting a potentially ineffective medicine. (Taylor, p. 35)
Mao also wrote:
Although we should have an all-round and correct understanding of Chinese medicine, Chinese medicine also has to transform itself. We must accept this slice of our old heritage critically. To look down upon Chinese medicine is not correct. To claim that everything about Chinese medicine is good, or too good, this is also not correct. Chinese and Western medicines must unite. (Mao Zedung, 1954, quoted in Taylor, p. 35)
Thus there was, according to Taylor, to be a ‘scientification’ of Chinese medicine. This did not mean ‘scientific’ in the familiar sense:
In Mao’s definition of this ‘new democratic culture’, he was to use three words which were to describe its development. These were ‘new’ (xin), ‘science’ (kexue), and ‘unity’ (tuanjie). The term ‘new’ implied free from superstition and the heavy links to a feudal past. Instead the components of the new culture would have to be forward moving and enterprising. Mao advocated that such a change would be possible through the use of ‘science’. By ‘science’ Mao was not so much referring to the science linked with the Western investigation of nature, but more to the Marxist ideal of science as the criteria for true knowledge. For Mao stated that ‘this type of new democratic culture is scientific. It is opposed to all feudal and superstitious ideas; it stands for seeking truth from facts, it stands for objective truth and for unity between theory and practice’. ‘Unity’ was the third criterion in the building up of a new China. Everybody had to join together and fight for the same cause, and this included all classes of Chinese society, from the upper bourgeoisie to the peasantry, so long as their beliefs were not against those of the Party. It also implied a unity of knowledge, and this had particular implications for the revolutionary intellectual. (Taylor, pp. 15-16)
In other words, as Mao later asserted,
In the future there will be only one medicine; that is to say a [single] medicine guided by the laws of dialectical materialism, and not two [separate] medicines. (Quoted in Taylor, p. 35)
It might seem a bit undemocratic, but science, like medicine or dentistry, is a profession. One doesn’t become a scientist by fiat but by education and training. I am not a scientist. I apply science. My colleague Dr. Gorski is a scientist (as well as physician). He understands in a way that I never will the practical process of science—funding, experimental design, statistics. While I can read and understand scientific studies in my field, I cannot design and run them (but I probably could in a limited way with some additional training). Even reading and understanding journal articles is difficult, and actually takes training (which can be terribly boring, but I sometimes teach it anyway).
So when I read a newspaper article about science or medicine, I usually end up disappointed—sometimes with the science, and sometimes with the reporting. A recent newspaper article made me weep for both. Local newspapers serve an important role in covering news in smaller communities, and are often jumping off points for young, talented journalists. Or sometimes, not so much.
The article was in the Darien (CT) Times. The headline reads, in part, “surveys refute national Lyme disease findings.” Epidemiologic studies, such as surveys, are very tricky. They require a firm grounding in statistics, among other things. You must know what kind of question to ask, how many people to ask, how to choose these people, etc, etc, etc. So what institution conducted this groundbreaking survey on Lyme disease?
The tick borne spirochete infection known as Lyme disease was named after Lyme, CT – a part of the country where the disease remains endemic. It is therefore especially poignant that the Connecticut state senate unanimously passed Public Act No. 09-128: AN ACT CONCERNING THE USE OF LONG-TERM ANTIBIOTICS FOR THE TREATMENT OF LYME DISEASE.The bill had previously passed the state House, also unanimously.
This is a terrible bill that is both anti-science and anti-consumer protection. How it passed both houses without dissent reflects exactly why such micro-management decisions should not be made by politicians. It is the result of lobbying by a narrow interest group and does not reflect either the state of the science on Lyme disease nor the proper role of regulation to ensure standards of care within medicine.
This is also not an isolated case. There is already a similar law in Rhode Island, and there have been similar bills proposed in Pennsylvania, Massachusetts, and New York, and a bill in Maryland that would compel insurance companies to pay for antibiotic treatment for chronic Lyme disease CLD. This is part of a coordinated effort by individuals and organizations who hold an ideological opinion regarding the cause and treatment of CLD. They wish to use the political process to win a victory for their view that they have been unable to win in the arena of science (sound familiar).
The bill now awaits Governor Rell’s signature, which given the heavy political support for this bill seems almost certain.
This bill represents much which is wrong with the state of science and medicine in the US.
One of the concepts we often discuss around here is “what is disease?” As we’ve seen in the discussion of Lyme disease and so-called Morgellons syndrome, this is not always an easy question to answer. Knowing what states are disease states does not always yield a black-or-white answer. The first step is usually to define what a disease is. The next problem is to decide who in fact has that disease. The first question is hard enough, especially in disease states that we don’t understand too well. The second question can be equally tricky. To explore the scientific and philosophical issues of diagnosing an illness we will use as a model diabetes mellitus (DM). This won’t be quite as boring as you think, so don’t click away yet. (Most of the information here refers more specifically to type II diabetes, but most of it is valid for type I as well.) (more…)
EDITOR’S NOTE: Unfortunately, this weekend, I was forced to get my slides together for the upcoming SBM Conference, plus editing a manuscript for resubmission, plus working on a manuscript that I should have submitted six months ago, plus reading over some grants, plus…well, you get the idea. What this means is that, alas, I didn’t have any time to prepare one of the new, long posts that you’ve come to love (or hate). Fortunately, there are a lot of other things I’ve written out there that can be rapidly adapted to SBM. For instance, what I am about to present now. Since I wrote this, I’ve thought of a couple of things that I should have said the first time (and was kicking myself for not having done so); so publishing an updated version here allows me to rectify those omissions.
A couple of weeks ago, there was a lot of hype about a study that hadn’t been released yet. Indeed, there was a story in Wired entitled To Survive Cancer, Live With It and an editorial by the study’s lead author in Nature entitled A change in strategy in the war on cancer. Not bad for a study that hadn’t been released yet. Intrepid medical and science blogger that I am, I waited until the actual study was published a week ago the June 1 episode of Cancer Research. It’s a clever study, but the hype over it was a bit overblown. For example:
For all the weapons deployed in the war on cancer, from chemicals to radiation to nanotechnology, the underlying strategy has remained the same: Detect and destroy, with no compromise given to the killer. But Robert Gatenby wants to strike a peace.
A mathematical oncologist at the Moffitt Cancer Center, Gatenby is part of a new generation of researchers who conceive of cancer as a dynamic, evolutionary system. According to his models, trying to wipe cancer out altogether actually makes it stronger by helping drug-resistant cells flourish. Rather than fighting cancer by trying to eradicate its every last cell, he suggests doctors might fare better by intentionally keeping tumors in a long-term stalemate.
Maybe I’m being a bit picky, but what annoys me about the news reports on this study is that the concept of turning cancer into a manageable chronic disease like diabetes or hypertension is not by any means a new idea. Remember, one of my major research interests is the inhibition of tumor angiogenesis. Consequently, I know that the late, great Judah Folkman first proposed the concept of using antiangiogenic therapy to turn cancer into a chronic disease at least as early as the mid-1990’s. The only difference is the strategy that he proposed. The idea had also been floating around for quite a while before that, although I honestly do not know who first came up with it.
But let’s see what Dr. Gatenby proposes. What makes it interesting is that his study actually looks at how scientists have applied evolutionary principles to cancer until recently, argues that we’ve been doing it wrong. He then proposes a way to use the evolutionary dynamics of applied ecology. He may well be on to something. First, here’s the problem:
I’d just like to take a moment to engage in a little bit of shameless self-promotion and point out that an SBM post has actually seen print. Specifically, my post about the malign influence Oprah Winfrey’s promotion of dubious medical practices on her show (The Oprah-fication of Medicine) has been adapted (with heavy cutting and editing) into an op-ed piece in The Toronto Star, entitled Is Oprah Winfrey Giving Us Bad Medicine?
No one was more shocked than I was when the editor of Sunday Insight section of The Toronto Star contacted me earlier this week to ask if he could adapt my post to a newspaper editorial. Actually, he and his editors did the vast majority of the work in whittling my usual logorrheic prose down to a manageable size and paraphrasing the sections of the NEWSWEEK article on Oprah that I had quoted liberally from. (After all, I didn’t want to be accused of plagiarism.) It was a rather educational experience, actually. Unfortunately, reading the finished version again, I don’t think it quite makes the link between Oprah and the infiltration of pseudoscientific CAM practices into modern medicine as clear as the original post, perhaps because the context of all the other blog posts on the topic by SBM bloggers is missing, which is why I hope that some Star readers will find their way here and be able to read the full length version.
In any case, compare:
The Oprah-fication of medicine (the original, full-length blog post)
Is Oprah Winfrey Giving Us Bad Medicine? (the heavily edited op-ed piece)
And see what you think.
Some infections can be eradicated from the face of the planet. Smallpox is the one example of disease eradication to date. Smallpox still exists in US and Russian labs, but there has been no wild cases since 1977. It is, like the Dorothy, history.
Why were we able to eradicate smallpox? Three reasons:
1) There is only one form of smallpox. Unlike influenza that changes from year to year. So only one vaccine needed.
2) By what appears to be a once in a universe miracle, every county cooperated with the WHO (much like we all cooperate with the IRS) so the entire planet received the vaccine. Once enough people were vaccinated, the disease was unable to perpetuate itself and spread and so died out.
3) Unlike bacteria, there are no asymptomatic smallpox carrier states. Eradicable viruses usually cause symptomatic disease and do not result in asymptomatic, infectious carrier states that serve as a reservoir for infecting others. HIV and Herpes cause chronic asymptomatic infections and will probably never be eradicated.
There are other diseases that are theoretically eradicable, like measles and polio. They have one antigenic type, have no carrier state and, if the entire world could be vaccinated, the disease would cease to exist in the wild. I am sure there would be biologic weapons labs that would always carry a vial or 2 of every infection. Just to be safe.
In the US children must have proof of vaccination before entering the public school system, although it is becoming easier in many states for parents to gain exemptions from this requirement. In the UK there is no such requirement. This distinction has allowed for a comparison of the impact of scaremongering about the safety of vaccines and the effectiveness of campaigns to improve vaccination rates.
In the UK the scare that the MMR vaccine may be connected to autism (it isn’t) triggered by the bogus study by Andrew Wakefield resulted in a precipitous drop in vaccination rates down to about 78% overall. This is far below what is necessary for herd immunity, when immunity is prevalent enough to prevent a disease from spreading around a population. And the 78% figure is an average – but there are pockets where the number is even lower. This resulted in a surge of measles – from a low of less than 100 cases per year to 1,348 cases in 2008. The surge contniues despite an aggressive campaign to inform the public about the safety of the MMR vaccine.
By contrast the US has seen continued high overall vaccination rates of about 90%. The MMR and other vaccine scare came to the US a bit later than the UK but it is in full swing here, without much effect on overall vaccination rates. However, we are beginning to see the emergence of low vaccination rates in specific communities, with subsequent outbreaks of measles (131 cases in 2008), mumps, and whooping cough.
Unfortunately, a frequent topic on SBM has been the anti-vaccine movement, personified these days by celebrity spokesmodel for Generation Rescue Jenny McCarthy and her dimmer than dim boyfriend comedian and actor Jim Carrey. Unfortunately, it is a topic that is unlikely to go away. We’ve all speculated why the anti-scientific emotion-based notion that vaccines somehow must cause autism persists in spite of mountains of evidence to the contrary, but I think the question goes much deeper than that because it’s not just about vaccines. The anti-vaccine movement is but one of the most visible components of a much deeper problem in our public discourse, a problem that values feelings and personal experience over evidence, compelling stories and anecdotes over science.
I’m referring to the Oprah-fication of medicine in America.