Archive for the ‘medicine’ Category
My current health condition 1: it’s bizarre
I can bear any pain as long as it has meaning
Haruki Murakami
I haven’t written for a while because I have a new health problem which flared up last Saturday, February 29, 2020. I had been feeling mild pain in my shoulder and I was lying on my bed reading when I tried to get up. Shooting pain from my shoulder down my left arm was so excruciating that I fell back on the bed and and lay down for a while before trying to get up again. Again I couldn’t get up because of the pain. I called for help but even with two of us it was difficult. I may have had a panic attack and exaggerated the pain of rising – I was gasping a lot. To cut a long story short Sarah called an ambulance (and the paramedic got me into a sitting position easily enough). I spent the next few hours in emergency at the Royal Adelaide Hospital.
Due to being given Panadol in the ambulance, and a long wait in reception while the painkiller took effect, by the time the friendly, efficient and strikingly beautiful (oh dear) young intern saw me, the pain, my only symptom, had much reduced. She found that, yes, I could move my arm above my shoulder, flex my elbow and my wrist, and no, I couldn’t precisely describe the nature or location of the pain. She checked my arm for swelling or redness (none), and asked about any recent history of injury to the region (none). I was beginning to feel like a fraud, a malingerer, a milquetoast.
So after some more prodding and questioning and advice from higher authorities, I was released with a report for my local doctor.
I’m very left-handed, so this left arm pain is quite a problem for me. I was due to work on the Monday and I needed some pain relief. It would have to be over the counter at first. The report’s only solid conclusion was ‘skeletal-muscular pain’. Since I needed to work on Monday and Tuesday I could only get to the GP on Wednesday. So on Sunday I started doing what research I could. I’ve never taken regular medication for anything, and I’ve never experienced regular pain like this. The only over-the-counter treatments for pain are ibuprofen and paracetamol as far as I know. Only ibuprofens is an anti-inflammatory. Paracetamol works on pain centres in the brain. Which one would work best? Was it all in my mind? But don’t we always feel pain via the brain? Isn’t that how the nervous system works?
I obtained both medicines. Over the next day or so I experimented with both, singly and in combination, and I got through Monday and Tuesday’s work. The pain never went completely away, though the teaching days, when I had to concentrate on and interact with my students and other teachers, helped to distract me from it, which gave me that guilty ‘it’s all in the mind’ feeling.
Even so, on Wednesday (March 4), the pain came roaring back. My subjective sense told me that the paracetamol was much more effective than the ibuprofen, another surprise. I visited my GP, who smiled at the hospital report, saying, ‘yes, they wanted you out of there as soon as possible – they’re there for acute, intensive care stuff, it’s understandable – a GP can refer you to a specialist, and we can go from there’. So he filled out a referral form for St Andrews Hospital, for an x-ray and an ultrascan. I rang them and organised an appointment, for Friday, March 6 at 11am.
I was still in pain, though. The OTC medication had reduced the pain to more bearable levels, but I still hadn’t worked out which worked best. Unlike me, Sarah was on many medications, for pain and other problems, including Prodeine (paracetamol plus codeine) and a set of tablets which combined paracetamol and caffeine. I was taking the tabs at the upper level of what was recommended, and beyond. I was trying to monitor the pain, what it felt like. It was always a low-level throbbing, which increased and became a shooting pain if I used the arm too much. It was a strange delayed pain – I would engage in a flurry of physical activity, such as preparing a quick meal, and then lie down, knowing that the pain would rise up as a result of the activity, then slowly subside. I had difficulty sleeping, and I dreaded dressing myself in the morning. Typing this is giving me an ache, and I’m experimenting with dictation – I find the Apple dictation system a pain (mentally speaking). I have to learn more about how to use it effectively.
Stupidly, I hadn’t asked my GP about stronger prescription medication. The day after the consult (Thursday, March 5) I had Sarah ring the surgery – I was experiencing bouts of serious pain, and was finding it hard to track what medication was working, or not. The doctor wrote a prescription, which Sarah collected and had made out at the pharmacy around the corner. It was for ibuprofen (200mg) and codeine phosphate hemihydrate (12.8mg). I was skeptical about the efficacy of ibuprofen, and I had been researching anti-inflammatories, and inflammation generally.
What, exactly, is inflammation? There are, supposedly, five signs of it, remembered under the acronym PRISH – pain, redness, immobility, swelling and heat. My only symptom was pain. There was certainly no redness or swelling. Immobility wasn’t a real problem either. I could move my arm above the shoulder, I could flex my elbow, etc, but some pain would come afterwards. Heat wasn’t something I could measure, but it didn’t seem an issue. Only pain. And I hadn’t pinpointed any cause of all this. I remembered what I’d said, quite often (or at least I thought I did – maybe I was mostly saying it to myself) to the intern at emergency: ‘It’s bizarre!’
Anyway, I’ll wind up this piece, and start on a new one, dealing with my time at St Andrews Hospital, the x-ray and the ultrasound.
a brief history of radical mastectomy
Siddhartha Mukherjee is an oncologist, an academic and an astonishingly gifted writer and story-teller, in the Indian tradition of seemingly effortless, self-effacing wordsmiths. I read, and learned heaps from, his 2016 book The Gene a while back, and now I’m being educated by his first book The Emperor of all Maladies, a history of cancer.
The book twists together different threads of cancer treatment in the modern era, most notably various forms of chemotherapy, and surgery. I’m focusing solely on surgery here, as it pertains to breast cancer, because it highlights the relation between experts (very predominantly male) and sufferers (exclusively female).
The term mastectomy is a bit of a mystery, at least to me. The suffix –ectomy is clear enough, meaning ‘cutting out’, or surgical removal, and ‘lumpectomy’ is a slightly dismissive term for the surgical removal of lumps (from the days when full-blown excision was king) . Maybe mastectomy refers to the removal of a mass of tissue, though why it wouldn’t be called massectomy or masectomy, and why it refers only to the breast, I don’t know. It has nothing to do with mast cells.
The radical mastectomy – the concept refers to ‘root’ as in rooting out, rather than quasi-political radicalism – is most associated with an American physician, William Halsted, though radical surgery in the treatment of cancer was far from unknown when Halsted began practising in the 1870s. Cancer at the time was recognised as the growth and spread of malignant tissue, at mysteriously varying rates, and the surgical removal of that tissue seemed the obvious response. Nineteenth century developments in anaesthesia helped to make the procedure more bearable for all, but operations in the US were often ad hoc and unsanitary. In the late 1870s Halsted made a trip to Europe, which radically changed his outlook and practice. He encountered and absorbed the ideas of various pioneers in surgery and anatomy, including Joseph Lister, Theodor Billroth, Richard von Volkmann and Hans Chiari, then returned to the US, and in the 1880s he quickly established a reputation for boldness and skill as a surgeon. Having become familiar with cocaine, which he recommended as an anaesthetic, he soon became addicted to the drug, which gave him seemingly boundless energy. He tried using morphine to kick the habit, and then found himself in a struggle with both drugs, but this barely damped his work-rate.
Hasted had become particularly interested in Volkmann’s surgical work on breast cancer, and noted that, though the surgeries became more extensive, the cancers returned. An English surgeon, Charles Moore, was experiencing the same problem. Moore’s painstaking analysis of the operations and the following relapses showed that malignant cells had begun to proliferate around the edges of previous surgeries. It seemed clear to him that the surgeries just weren’t extensive enough, and by limiting the surgery to the clearly evident cancerous tissue, and not widening the margins to ensure that the malignant region was properly cleaned out, surgeons were exercising ‘mistaken kindness’. Of course, the problem with this argument was that more radical surgery could itself be life-threatening as well as permanently disfiguring and debilitating. What was also not known at the time was the detailed mechanism of cancer’s metastatic spread throughout the body via the blood and lymph systems. However, this was a time when medical expertise tended to go unquestioned. Halsted and his surgical followers were considered heroes, and the delayed return of the cancers tended not to be dwelt on. The surgeons certainly did buy time for their patients, but often at great cost. Volkmann, for example, had taken breast surgery further by removing not just the breast but the muscle beneath it, the pectoralis minor, to try to ensure the complete removal of the cancer. Impressed, Halsted took things to the next level, cutting through the more vital pectoralis major, essentially killing off movement of the shoulder and arm. Radical mastectomy had now truly arrived, and was to become even more radical, with the collarbone and the group of lymph nodes beneath it becoming the next target, and it didn’t stop there, as cancer kept recurring. As Mukherjee describes it:
A macabre marathon was in progress. Halsted and his disciples would rather evacuate the entire contents of the body than be faced with cancer recurrences. In Europe, one surgeon evacuated three ribs and other parts of the rib cage and amputated a shoulder and a collarbone from a woman with breast cancer.
Siddhartha Mukherjee, The Emperor of all Maladies, p65
There were, of course, no female surgeons at this time, and precious few female doctors, and the male-female power imbalance was coupled with that of the expert and his suffering if not panicking victim to create a kind of juggernaut of largely unnecessary suffering. It took years to reverse this radicalising trend. Nowadays, radical mastectomies are very rarely performed, but with so many giants in the field – who often controlled the nature of clinical trials related to cancer – having earned their reputations through their surgical expertise, change was slow in coming, in spite of a gradual increase in often heroic dissenting voices. For example, Rachel Carson, the author of Silent Spring, refused to undergo a radical mastectomy, which would in any case have offered only brief respite as the cancer had already spread to her bones. Changing attitudes to experts and their secret and superior knowledge was of course a feature of the sixties and seventies, when the turning point really occurred. Developments in the field of course played their part. The knock-out blow for the procedure is largely associated, according to Mukherjee, with another surgeon, not unlike Halsted in energy and drive.
Bernard Fisher had been analysing the data of Halsted’s critics, notably Geoffrey Keynes in England and George Crile in the US, and became increasingly convinced, for a number of reasons, that radical mastectomy was a wrong-headed approach. In 1967, Fisher became the chair of a national consortium in the US, the National Surgical Adjuvant Breast and Bowel Project (NSABP), and began an uphill battle to run large-scale trials to test the efficacy of different treatments of breast cancer. Patients were reluctant to engage, and most surgeons were hostile. The process took years, but results were finally made public in 1981. Here’s Mukherjee’s summary.
The rates of breast cancer recurrence, relapse, death and distant caner metastasis were statistically identical among all three groups [i.e treated with radical mastectomy, with simple mastectomy, or with surgery followed by radiation]. The group treated with the radical mastectomy had paid heavily in morbidity, but accrued no benefits in survival, recurrence or mortality.
Siddhartha Mukherjee, The Emperor of all Maladies, p201
So. Richard Feynman once famously/notoriously said ‘science is the belief in the ignorance of experts. When someone says science teaches us such and such, s/he’s using the word incorrectly – science doesn’t teach us, experience teaches us.’ I agree. Science isn’t a person, let alone an expert person. Science is, to me, an open-ended set of methods based on experience. Experience creates new methods out of which new experiences are created, and we move on, trying to right the wrongs and to minimise the damage, while always maintaining our skepticism.
Reference
The Emperor of all Maladies: a biography of cancer, by Siddhartha Mukherjee, 2011
some thoughts on regression to the mean and what causes what
Regression effects are ubiquitous, and so are misguided causal stories to explain them. Daniel Kahneman
Canto: So here’s an interesting thought, which in some ways is linked to the placebo effect and our attributing recovery from an illness to something we ate, drank or did, rather than to the silent and diligent work of our immune system. You know about the regression to the mean concept?
Jacinta: Of course. It’s a statistical phenomenon that we tend not to account for, because we’re always looking for or imagining causal effects when they don’t exist.
Canto: Well, they do exist but we attribute the wrong causal effects – we don’t account for ‘bad luck’, for example, which of course is caused, usually by factors we can’t easily uncover, so for convenience we give it that name. For example, a golfer might be said to have had an unlucky day with the putter because we observe that she she went incredibly close to dropping a number of difficult long putts, but none of them went in, so she made five over par instead of even. Of course every one of those failed putts was caused – one because her aim wasn’t quite true, another due to a tuft of grass, another because of a last moment gust of wind and so on…
Jacinta: And some of those causes might be deemed unlucky, because on a less windy day, or with a better maintained green, those putts might’ve gone in.
Canto: Okay okay, there is such a thing as luck. But luck, I mean real luck, like the effect of a sudden gust of wind that nobody could’ve factored in, tends to even itself out, which is part of regression to the mean. But let me get back to illness. Take an everyday illness, like a cold, a mouth ulcer (which I suffered from recently)…
Jacinta: Or a bout of food poisoning, which I suffered from recently…
Canto: Yes, something from which we tend to recover after a few days. So the pattern of the illness goes something like this – Day 1, we’re fine. Day 2, we feel a bit off-colour. Day 3 we definitely feel much worse. Day 4, much the same. Day 5, starting to feel better. Day 6, definitely a lot better. Day 7, we’re fine. So it follows a nice little bit of a sine wave – two peaks and a trough – as shown above.
Jacinta: So you’re saying that getting back up to the peak again is regression to the mean?
Canto: Well, sort of, but you’re getting ahead of me. Maybe it isn’t precisely, because a mean is the midpoint in a fluctuation between two extremes. Sort of. Anyway, let me explain. When you’re ill, you can choose to ride it out, or you can go to a doctor, or take some sort of medication, or some concoction recommended by a friend, or a reflexologist, whatever. But here’s the thing. You’re not likely to go to the doctor/acupuncturist/magus on day 2, when you’re just starting to feel queasy, you’re much more likely to go when you’re at the bottom of the trough, and then you’ll attribute your recovery to whatever treatment you’ve received, when it’s really more about regression to the mean. Sort of.
Jacinta: Hmmm. I agree that we’re unlikely to rush to the doctor or even the medicine cabinet when we’re just feeling a bit queasy, but that’s probably because experience tells us we’ll feel better soon – that maybe we’re already at the bottom of a little trough. But when we start going into a deeper trough, naturally we start getting worried – maybe it’s pneumonia, or tuberculosis…
Canto: Or diphtheria, malaria, typhoid, cholera, bubonic plague, acute myeloid leukaemia….
Jacinta: Don’t mock, I’ve had all of those. But it’s interesting to think of illness and wellness in this wave form. I’m not sure if it works as regression to the mean. Because wellness is just, well, feeling well. Feeling ‘normal’ or okay. We don’t tend to feel super-well – do we?
Canto: You mean you don’t believe in biorhythms? So you think the line pattern would be like, a straight horizontal one with a few little and big troughs here and there, and then finally off the cliff and straight down to death?
Jacinta: Well, no, isn’t it a slow decline into second childhood and mere oblivion – sans teeth, sans eyes, sans taste, sans everything?
Canto: Haha well not so much with modern medicine – though my hearing’s starting to go. But one of them-there invisible implants should fix that, at a price. But you’re probably right – what we call wellness at sixty is a lot different from the wellness we felt at twenty, but we’re probably lucky we can’t feel our way back to that twenty-something feeling. But getting back to the case of the person who applies a treatment and then gets better, there are, I suppose, three scenarios. The treatment caused the improvement, the treatment had no effect (the person improved for other reasons – such as our super-amazing immune system), or the treatment actually had a detrimental effect, but the person got better anyway, probably due to our wondrous immune system.
Jacinta: So that’s where the placebo idea comes in. And our tendency to over-determine for causality. You mention something like a cold, which is generally a viral infection, and mostly rhinoviral. The symptoms, like a runny nose and a sore throat, are actually caused by a mixture of the virus itself and the immune system fighting it, but mostly the latter….
Canto: Yeah, is that about antigens, or antibodies, I always get confused…
Jacinta: Well, it’s very very complicated, with T cells, immunoglobulin and whatnot, but essentially antigens are the baddies which trigger an antibody response, so antibodies are the goodies. So, if someone has a cold then unless they know their immune system is compromised in some way, the best thing is to let their immune system do its job, which might cause a few days’ discomfort, like extra phlegm production as the system, the antibodies or whatever, attempts to expel the invaders.
Canto: Yes, but the immune system is invisible to us, and is vastly under-estimated by many people, who tend to like to see something, like a big bright red pill, or a reflexology foot massage, or a bunch of needles needling their chi energy points, or unblocking their chakras…
Jacinta: Can they see their chakras?
Canto: No, but the magus can, with his various chakra-probing methods, and aural and oratorical senses developed over a lifetime – that’s why he’s a magus, dummy.
Jacinta: Yeah, and I’m sure we can all feel when our chakras are unblocked. It’s sort of like body plumbing.
Canto: So, getting back to reality, there is definitely something like this regression to the mean, to our own individual ‘normal’, but maybe ever-declining physical and mental state, that our wonderful immune system helps us to maintain, a system we rely on more than we realise….
Jacinta: Yes, but you know, it’s good that we don’t realise it so much, because think of all the acupuncturists, Alexander technicians, anthroposophicalists, antipharmaceuticalists, aromatherapists, auriculotherapists and ayurvedicists whose jobs might be on the line – and that’s just the A’s! Then we have the baineotherapist, the bead therapists and the bowen therapists, not to mention the chakra scalpel weaponmasters… can you imagine all those folk not being able to make a living?
Canto: Okay, that’s enough. It truly is a sad thing to think upon, but never fear, your horror scenario will never eventuate, my faith in human nature tells me….
The statin controversy
Never edit your own writing! Brian J Ford.
I read Ben Goldacre’s quite demanding book Bad pharma some years ago, and that’s where I learned about statins, but I don’t recall much. I do recall that, not long after I read the book, I was at a skeptics meet-up when Dr Goldacre’s name came up. The man next to me started literally spitting chips at the mention – he was eating a massive bowl of chips and was grossly overweight (not that I’m assuming anything from this – just saying, haha). He roolly didn’t like Dr Goldacre. What went through my head was – some people may be really invested in having a magic pill that allows them to live forever and a day no matter what their diet or lifestyle.
I’ve just discovered that Goldacre has a new book out, entirely on this topic, which I intend to read, but my current decision to explore the issue is based on listening to Dr Maryanne Demasi’s talk, ‘statin wars – have we been misled by the evidence?’, available on YouTube. I very much recall the massive Catalyst controversy a few years ago, when a two-part special they did on statins led finally to the demise of the program. Without knowing any details, I thought this was a bit OTT, but when I heard Dr Norman Swann, a valued health professional and presenter of the ABC’s Health report, railing about the irresponsibility of the statin special, I frankly didn’t know what to think.
So statins are lipid-lowering medications that come in various flavours, including atorvastatin, fluvastatin, lovastatin and rosuvastatin. Lipitor, a brand name for atorvastatin manufactured by Pfizer, is the most profitable drug in the history of medicine. I’ve never taken statins myself, and I’m starting this piece as a more or less total beginner on the topic. I’ve read the Wikipedia entry on statins, which is quite comprehensive, with a very long reference list. Of course it’s not entirely comprehensible to a lay person, but that’s not a criticism – immunobiology and related research fields are complex. It’s also clearly pro-statin. It includes this interesting sentence:
A systematic review co-authored by Ben Goldacre concluded that only a small fraction of side effects reported by people on statins are actually attributable to the statin.[63]
It’s interesting that Goldacre, and nobody else, is mentioned here as a co-author. It makes me wonder…
My only quibble, as a lay person, is that the positive effects of these statins, and their relatively few side-effects, seems almost too good to be true. I speak, admittedly, as a person who’s always been ultra-skeptical of ‘magic bullets’.
Which brings me to issues raised in Dr Demasi’s talk, and not addressed in the Wikipedia article. They include the idea, promoted by an ‘influential group’, that statin use should be prescribed for everyone over 50, regardless of cholesterol levels. Children with high cholesterol levels are being screened for statin use and Pfizer has apparently designed fruit-flavoured statis for use by children and adolescents. Others have suggested using statins as condiments in fast-food burgers, and even adding statins to the public water supply. It’s easy to see how such ‘innovations’ involve making scads of money, but this isn’t to deny that statins are effective in many if not most instances, and we should undoubtedly celebrate the work of the Japanese biochemist Akiro Endo, who pioneered the work on enzyme inhibitors that led to the discovery of mevastatin, produced by the fungus Penicillium citrinum.
But Demasi made some other interesting points, firstly about how drug companies like Pfizer might seek to maximise their profits. One obvious way is to widen the market – for example by lobbying for a lowering of the standard level of cholesterol in the blood considered dangerous. From the early 2000s in the US, ‘high cholesterol’ was officially shifted down from as high as 6.5 down to below 5, moving vast numbers of people onto having a ‘need’ for these cholesterol-lowering drugs. Demasi points out that this lowering wasn’t based on any new science, and that the body responsible for these decisions, the National Cholesterol Education Program (NCEP), was loaded with people with financial ties to the statin industry. To be fair, though, one might expect that doctors and specialists concerned with cholesterol to be invested, financially or otherwise, in ways of lowering it. They might also have felt, for purely scientific reasons, that the level of cholesterol considered dangerous was long overdue for adjustment.
Another change occurred in 2013 when two major heart health associations in the US decided to abandon a single number in terms of risk factors for heart disease/failure. Instead they looked at cholesterol, blood pressure, weight, diabetes and other factors to calculate ‘percentage risk’ of cardiovascular problems. They evaluated this risk so that if it was over 7.5% in the next 10 years, you should be prescribed a statin. A similar percentage risk system was used in the UK, but the statin prescription started at 20%. Why the huge discrepancy? Six months later, the Brits brought their threshold down to 10%. The US change brought almost 13 million people, mostly elderly, onto the radar for immediate statin prescription. The method of calculation in the US was independently analysed, and it was found that they over-estimated the risk, sometimes by over 100%. Erring on the side of caution? Or was there a lot of self-interest involved? It could fairly be a combination. The term for all this is ‘statinisation’, apparently. It’s attributed to John Ioannidis, a Stanford professor of medicine and a noted ‘scourge of sloppy science’. If you look up statinisation, you’ll find a storm of online articles of varying quality and temper on the issue – though most, I notice, are five years old or more. I’m not sure what that signifies, but I will say that, while we’ll always get the anti-science crowd baying against big pharma, vaccinations and GM poison, there’s a clear issue here about vested interests, and the need to, as Demasi says, ‘follow the money’.
This brings up the issue of how trials of these drugs are conducted, who pays for them, and who reviews them. According to Demasi, the vast majority of statin trials are funded by manufacturers. Clearly this is a vested interest, so trial results would need to be independently verified. But, again according to Demasi (and others such as Ioannidis and Peter Gotzsche, founder of the nordic Cochrane Collaboration) this is not happening, and ‘the raw data on statin side-effects has never been released to the public’ (Demasi, 2018). This data is held by the Cholesterol Treatment Triallists’ (CTT) collaboration, under the Clinical Trial Service Unit (CTSU) at Oxford Uni. According to Demasi, who takes a dim view of the CTT collaboration, they regularly release meta-analyses of data on statins which advocate for a widening of their use, and they’ve signed agreements with drug companies to prevent independent examination of research findings. All of this is described as egregious, which might seem fair enough, but Elizabeth Finkel, in a long-form article for Cosmos magazine in December 2014, takes a different view:
.. [the CTT] are a collaboration of academics and they do have access to the raw data. It is true that they do not share that data outside their collaboration and are criticised by other researchers who would like to be able to check their calculations. But the trialists fear mischief, especially from drug companies seeking to discredit the data of their rivals or from other people with vested interests. Explains [Professor Anthony] Keech, “the problem with ad hoc analyses are that they can use methods to produce a particular result. The most reliable analyses are the ones done using the methods we published in 1995. The rules were set out before we started.” And he points out these analyses are cross-checked by the academic collaborators: “Everything is replicated.”
As a regular reader of Cosmos I’m familiar with Finkel’s writings and find her eminently reliable, which of course leaves me more nonplussed than ever. I’m particularly disturbed that anyone would seriously claim that everyone over fifty (and will it be over forty in the future?) should be on these medications. I’m 63 and I take no medications at all, which I find a great relief, especially when I look at others my age who have mini-pharmacies in their homes. But then I’m one of those males who doesn’t visit doctors much and I have little idea about my cholesterol levels (well yes, they’ve been checked and doctors haven’t raised them to me as an issue). When you get examined, they usually find something wrong….
In her talk, Demasi made a comparison with the research on Tamiflu a few years ago, when Cochrane Collaboration researchers lobbied hard to be allowed to review trial data, and it was finally revealed, apparently, that it was certainly not as effective and side-effect free as its makers, Roche, claimed it to be. The jury is still out on Tamiflu, apparently. Whether it’s fair to compare the Tamiflu issue with the statin issue is a matter I can’t really adjudicate on, but if Finkel is to be believed, the CTT data is more solid.
There’s also an issue about more side effects being complained of by general users of statins – complaints made to their doctors – than side effects found in trials. This has already been referred to above, and is also described in Finkel’s article. Many of these complaints of side-effects haven’t been able to be sheeted home to statins, which suggests there’s possibly/probably a nocebo effect at play here. But Demasi suggests something more disturbing – that many subjects are eliminated from trials during a run-in period precisely because the drug disagrees with them, and so the trial proper begins only when many people suffering from side-effects are excluded. She also notes, I think effectively, that there is a lot of play with statistics in the advertising of statins (and other drugs of course) – for example a study which found that the risk of having a heart attack on statins was about 2% compared to 3% on placebos was being advertised as proving that your heart-attack risk on statins is reduced by a third. This appears to be dodgy – the absolute percentage difference is very small, and how is risk actually assessed? By the number of actual heart attacks over period x? I don’t know. And how many subjects were in the study? Were there other side-effects? But of course we shouldn’t judge the value of statins by advertising guff.
Another interesting attack on those expressing doubts about the mass prescription of statins has been to call them grossly irresponsible and even murderers. This seems strange to me. Of course doctors should be all about saving lives, but they should first of all be looking at prevention before cure as the best way of saving lives. Exercise (mental and physical) really is a great form of medicine, though of course not a cure-all, and diet comes second after exercise. Why the rush to medicalise? And none of the writers and clinicians supporting statins are willing to mention the financial bonanza accruing to their manufacturers and those who invest in them. Skepticism is the lifeblood of science, and the cheerleaders for statins should be willing to accept that.
Having said that, consider all the life-saving medications and procedures that have preceded statins, from antibiotics to vaccines to all the procedures that have made childbirth vastly safer for women – who cares now about the pharmaceutical and other companies and patentees who’ve made their fortunes from them? They’re surely more deserving of their wealth than the Donnie Trumps of the world.
So, that’s my initial foray into statins, and I’m sure the story has a way to go. In my next post I want to look at how statins work. I’ve read a couple of pieces on the subject, and they’ve made my head hurt, so in order to prevent Alzheimer’s I’m going to try an explanation in my own words – to teach myself. George Bernard Shaw wrote ‘those who can, do, those who can’t teach (it’s in Man and Superman). It’s one of those irritating memes, but I prefer the idea that people teach to learn, and learn to teach. That’s why I love teaching, and learning…
By the way, the quote at the top of this post seems irrelevant, but I keep meaning to begin my posts with quotes (it looks cool), so I’m starting now. To explain the quote – it was from a semi-rant by Ford in his introduction to the controversial dinosaur book Too big to walk (I’ve just started reading it), about writers not getting their work edited, peer reviewed and the like, and being proud or happy about this situation. This, he argues, helps account for all the rubbish on the net. It tickled me. I, of course, have no editor. It’s hard enough getting readers, let alone anyone willing to trawl through my dribblings for faults of fact or expression. Of course, I’m acutely aware of this, being at least as aware of my ignorance as Socrates, so I’ve tried to highlight my dilettantism and my indebtedness to others. I’m only here to learn. So Mr Ford, guilty as charged.
References
Dr Maryanne Demasi – Statin wars: Have we been misled by the evidence?
https://en.wikipedia.org/wiki/Statin
https://cosmosmagazine.com/society/will-statin-day-really-keep-doctor-away
https://en.wikipedia.org/wiki/John_Ioannidis
https://www.smithsonianmag.com/science-nature/what-is-the-nocebo-effect-5451823/
kinesiology, TCM and depression
a kinesiology wheel – proof positive of profundity
Jacinta: So, Canto, the new USSR hasn’t posted recently on old Wesley Smith and his wellness treatments. I think we should post on another one of those.
Canto: Oh god, do we have to? I’d rather talk about black holes or the edge of the universe…
Jacinta: I know I know, but, you could think of Wesley’s treatment centre as a black hole of sorts…
Canto; Yes, and like the other kind, the more you look for them the more you find them, and they all have similar properties…
Jacinta: Hopefully, though, they’re not as dangerous…
Canto: Well, that depends. The real black holes are light years away, whereas there’s a black hole of a wellness centre just around the corner from me.
Jacinta: Kinesiology. That’s the subject for today. Know anything about it?
Canto: No, except that, presumably, old Wesley offers it as a treatment. And kinetic energy is energy of motion, right? So, let me guess, kinesiology is the science of getting your energy system moving so fast that it flings your toxins out of every available orifice leaving you feeling not only light-headedly well, but thoroughly exercised, and of course exorcised.
Jacinta: Well I doubt if it’s as scientific as that, but you’re on the right track. Actually there are two meanings of kinesiology. It’s the scientific study of bodily movement, in humans and other animals, which means applying anatomy, physiology, biomechanics, neuroscience, and even robotics, to the understanding of movement. And then there’s the naturopathically bullshittical meaning of kinesiology as deepily ancient chi-based treatment, much along the lines you just mentioned. And it’s this second meaning, as presented by the Australian Kinesiology Association (AKA), that we’ll be focusing on.
Canto: Chi wizz, this could be fun. Are they really into chi?
Jacinta: Oh yes. Their website gushes with it. It’s teeth-gnashing stuff actually. Apparently it combines western science with traditional Chinese medicine (TCM) to promote your spiritual well-being, among other things.
Canto: Hey, I’ve got an idea. You’ve heard about James Randi’s million-dollar challenge?
Jacinta: The one to psychics, promising a million to anyone who can provide scientific proof of their psychic abilities?
Canto: That’s the one, and I don’t know the details, and of course they all argue that it’s rigged against them, but it’s a good kind of bad publicity for psychics at least, but what if we offered a million dollars to anyone who can provide solid, or liquid, or gaseous evidence of the existence of chi?
Jacinta: Canto, we don’t have a million dollars.
Canto: But we don’t need a million dollars, we know there’s no such thing, right?
Jacinta: Uhhh I don’t think it would work that way. We’d need a rich backer, but in any case we wouldn’t get any takers. Having looked at a few forums discussing chi, its supporters usually say that, though it’s undoubtedly real, it’s not detectable or measurable by western methods, because it’s part of a wholly different mindset, a different way of knowing, a spiritual understanding that takes years to develop. They say, for example, that only by believing in chi can you unlock its healing powers.
Canto: So it’s placebo energy?
Jacinta: Okay small-minded little-faith man, let’s move on to kinesiology. The practice clearly takes advantage of the scientific cachet of kinesiology as body movement studies. Here’s what the AKA has to say about it:
Kinesiology encompasses holistic health disciplines which use the gentle art of muscle monitoring to access information about a person’s well being. Originating in the 1970’s, it combines Western techniques and Eastern wisdom to promote physical, emotional, mental and spiritual health. Kinesiology identifies the elements which inhibit the body’s natural internal energies and accessing the life enhancing potential within the individual.
Canto: aka bullshit.
Jacinta: Ha ha, but get what it has to say next:
The maturity of ‘Complementary Therapies’ is shown by some of Australia’s major health funds now paying rebates for many therapies, including Kinesiology. This acknowledges what is happening in the health sciences in the 21st Century. Australians spend over $1 billion annually on therapies not part of mainstream medicine. Kinesiology is one of the fastest growing of these and is now practised in over 100 countries.
Canto: Popularity as evidence. They’re really keen to show how legit they are.
Canto: Their choice, isn’t it? Survival of the brightest?
Jacinta: Maybe so, but I think the phenomenon’s worth pondering more deeply. How long does it take to become a qualified doctor in this country?
Canto: A GP? Well, for example, the University of Adelaide offers a six-year MBBS, that’s a Bachelor of Medicine and Bachelor of Surgery, to start off, but in order to get into that you need really good year 12 results – what they call your ATAR score (Australian Tertiary Admissions Rank) plus you have to pass a UMAT test, that’s a 3 hour multiple choice thing. UMAT stands for Undergraduate Medicine and Health Sciences Admission Test. Oh, and then you have to do well in an interview before a medical panel. So once you’ve been accepted and done your 6-year MBBS, you can apply to do Australian General Practice Training (AGPT) – or maybe you can apply while you’re doing the MBBS and integrate it into your undergraduate degree, I’m not sure. Anyway the AGPT takes another 3 0r 4 years, so it’s a pretty long journey.
Jacinta: Well, thanks for that fulsome response, it well illustrates the gap between evidence-based medicine and naturopathy. I see they’re very much into four-letter acronyms (FLAs) in that field. TLAs aren’t good enough?
Canto: Yes they like to consider themselves more lettered than others. But I should also point out that once they’ve been accepted into the ranks of GPs, or any other medical specialisation, they’ll automatically be able to access the latest medical knowledge in their field. In fact they’ll be bombarded with it, and will be expected to keep up to date. Whereas naturopaths are usually relying on ‘traditional’ techniques and ‘ancient’ herbal treatments, none of this new-fangled invasive or big pharma stuff.
Jacinta: Well I suppose there are a few properly qualified doctors who are into naturopathy, but by and large you’re right. So why is it that so many people are choosing naturopaths over these highly-trained and knowledgable practitioners of the latest evidence-based medicine?
Canto: Well, isn’t it because they aren’t getting what they want from GPs or other specialists? Whatever that might be. Holistic treatment, as they like to call it. A sense of trust. Something psychological, I suspect.
Jacinta: Yes, there’s that – some doctors are still not getting the message about how to share information with their clients, and how to see the approach to health as an interactive process. But it could be that evidence-based medicine is the victim of its own success?
Canto: How so?
Jacinta: Well these days, and WHO figures bear this out, patients are increasingly presenting with chronic conditions. That’s to say, the ratio of chronic illness to acute illness is increasing, and I’d say that’s largely due to the success of evidence-based medicine in the treatment of acute illness. Now of course chronic conditions can be serious and life-threatening – 60% of the world’s population die of them, according to the WHO – but they represent a whole gamut of complaints, from degenerative diseases to niggling backaches, neuralgia and the more difficult to pin down stuff such as chronic fatigue syndrome and fibromyalgia, or the chronic itching that some attribute to Morgellons disease. And then there’s depression…. So some of these ailments are met with skepticism or at least contradictory responses from trained medicos…
Canto: ‘Medical experts are baffled… ‘
Jacinta: Precisely, and many naturopaths see this area as their niche. They can get in and ‘listen’ to the client and treat her ‘holistically’ – that’s to say sympathetically. Much of it is feel-good treatment, so much more pleasant than what’s offered by hard-nosed, know-it-all, condescending doctors.
Canto: So it’s all perfectly harmless, then?
Jacinta: Well perhaps mostly, but there are obvious problems with giving too much legitimacy to these largely bogus treatments. An example of this is precisely what the AKA says on its website, that the ‘maturity’ of naturopathy is proven by the fact that many of their therapies are attracting health fund rebates. This is complete BS, it’s simply a populist move from the health funds, who know full well that naturopathy is here to stay, regardless of evidence. This of course gives the Wesley Smiths of the world more legitimacy and increases the chances of people with serious health issues being led to think that naturopathic shite can cure them.
Canto: Well, doesn’t that get back to survival of the brightest?
Jacinta: Maybe, but what about the scenario – and this has been played out – that a seriously sick child has been given a bogus treatment in lieu of real medicine, and has died of something perfectly curable, courtesy of her parents?
Canto: Mmm, couldn’t that be handled case by case? The parents could be up for gross neglect, and the associated naturopath could be had up for bogus claims leading to the death of a minor or something, and be barred from practising… or given some more serious penalty. Anyway we need to wind this up. Is there anything more specific about kinesiology we should be concerned about?
Jacinta: Kinesiology is generally associated with chiropractic, which is about as bad as it gets. As with naturopaths in general, some kinesiacs are more into woo than others, but the AKA website goes on about acupressure and meridians, and no credible evidence has ever been presented that acupressure points or meridional points actually exist. They’re of course part of TCM, along with vital energy and various other concepts and treatments that have no evidence or coherent mechanism of action to back them up.
Canto: You mean rhino horns and the penis bones of dogs don’t cure anything?
Jacinta: Sorry but rhinos are going extinct for an ignorant fantasy, not to mention the 12,000 or so asiatic black bears being kept on farms so that their bile can be extracted for ‘medicine’, which often drives them to suicidal frenzy. Other creatures being decimated by TCM include sharks, seahorses, tigers, turtles and saiga antelopes….
Canto: OK enough, I’m getting depressed. The final verdict on kinesiology?
Jacinta: Well it seems to be just a variant of chiropractic stuff, though probably even more unregulated, with a greater admixture of TCM woo. I have nothing more positive to say about it than that.
Canto: Whatever next…
introducing canto and jacinta: solutions for the post-antibiotic era?
Florence Nightingale
Jacinta: Well hello Canto, let’s welcome each other to the Urbane Society of Skeptical Romantics, where we like to talk… and not much else.
Canto: Very productive and constructive talk Jacinta, but the proof will be in the pudding.
Jacinta: Well I hope it’s not a recipe for disaster. What shall we talk about today?
Canto: Well I’m thinking medicine today – the discipline, not the stuff you consume.
Jacinta: Well I don’t consume much medicine at the worst of times, being fit, positive, eternally youthful and beautiful.
Canto: That’s okay, I’ll take your share – so you know there’s a bit of a crisis with antibiotic resistance.
Jacinta: Yes, natural selection in action, or is that human-induced, unintended-consequence-style artificial selection?
Canto: Well I’m not intending to delve into the natural v artificial quagmire here, or even into the science of antibiotics. I’ve just been reading about a couple of alternative ways – one old and one new – of killing off nasty infecting bacteria in hospitals. Ever caught one of those secondary infections in hospital Jass? No of course you haven’t.
Jacinta: Last time I was in hospital I was the infection – had to be forcibly removed from the victim by a crack team of medicos and placed in isolation until deemed safe to take my chances at thriving and multiplying along with my fellow bugs.
Canto: Well I’m sure they made the right decision.
Jacinta: The jury’s still out. Tell me of the ways.
Canto: Remember Florence Nightingale?
Jacinta: One of my heroes, apart from her valetudinarianism. Though I suspect that might just have been her way of keeping everyone at a distance so she could get on with things in her way. She was a voluminous correspondent just like Darwin, another sufferer from mysterious ailments. So what about her?
Canto: She revolutionised nursing and hospital treatment, sanitation and such, right? One of her many insights was that patients convalescing from the Crimean battlefields benefitted enormously from throwing open the windows of the rather unhygienic field hospitals set up for them. Nightingale wards were built to her design, with high sash windows kept open to renew the air around the sick. This worked a treat, though it took more than a century to verify the effect experimentally, using E coli in an open rooftop environment. The bugs died within 2 hours in the open air, but in an enclosed environment they lived on.
Jacinta: Right, so this has obvious relevance to those horrible superbugs they talk about…
Canto: Like MRSA?
Jacinta: Yeah. What’s that?
Canto: Multi-resistant, or more accurately methicillin-resistant staphylococcus aureus.
Jacinta: Yeah, golden staph, just as I thought. So that’s interesting. I don’t see modern hospitals blowing in the wind really. Sounds far too hippy for the 21st century. Isn’t it all tightly controlled and air-conditioned these days? Recycled air and legionnaire’s disease? Okay, only kidding, I’ve not heard of any hospital outbreaks of that, but these hospital superbugs must surely be caused by a contaminated environment, yes? Should we bring back Nightingale wards? And why did they go out of fashion?
Canto: Well, not only did she get fresh air right, she had the windows faced to let in as much sunlight as possible, and it was only learned later that sunshine was a great germ-killer, especially in the case of tuberculosis, which ravaged all the crowded cities…
Jacinta: Yeah and picked off all those writers, like Chekhov, and the Brontës, and D H Lawrence, and Keats. Didn’t he write an ode to Florence Nightingale?
Canto: No no that was another nightingale, but at its height TB was killing one in five in the cities; but it’s probable that the sunlight was boosting levels of vitamin D, which in turn boosts the immune system. So by the turn of the century, fresh air and sunlight was all the go. TB patients were wheeled onto balconies, to be exposed to the bracing elements.
Jacinta: Ah, but of course all that changed with the discovery of antibiotics.
Canto: Right, and thanks to these miracles of modern medicine, rotten air and dark dankness came back into fashion, sort of. I mean, all sorts of infections were being vanquished by these pills and it seemed as if diseases would fall like ninepins.
Jacinta: I suspect you’re oversimplifying..
Canto: Well it must’ve seemed that way to the general public. And of course fresh air could turn into howling winds, and sunlight into clouds and rain. Controlled temperatures and conditions might’ve seemed safer, and the cleansing power of aircons was over-estimated.
Jacinta: Oh yes… Climat air-conditioning, Breezair, Bonaire – more than an air-conditioner, a tonic to the system.
Canto: But now of course the diseases are returning in resistant forms, and we’ve hit a wall in terms of antibiotic manufacture. There’s very little new stuff coming on-stream. And now, hospitals are being seen as a problem again, just as in Ms Nightingale’s day.
Jacinta: Yes, but there are new post-antibiotic treatments in the pipeline, such as phage therapies, in which bacteria are destroyed by genetically engineered viruses, and drugs that…
Canto: Okay Jass, that’s for another conversation, and these new treatments are a bit futuristic as yet. Meanwhile, we need to heed Ms Nightingale’s hygienic advice. Apparently, the recent emphasis on simple hand washing has been paying huge dividends, in reducing the incidence of MRSA and Clostridium difficile.
Jacinta: So we were getting complacent, forgetting the basics?
Canto: Well, we’d been lulled by the success of modern medicine into thinking the old precautions needn’t apply. And further studies have confirmed the cleansing power of even the mildest breezes, and hospitals have begun to open up in response.
Jacinta: But not only that, we now know more about good old-fashioned sunlight and its curative powers, don’t we?
Canto: Okay, the stage is yours.
Jacinta: Well, there was some breakthrough research done using standard UV lamps in a TB ward. Guinea pigs were used (I mean real guinea pigs), and their signs of infection were drastically reduced. Now, there are some regions of the world with high rates of TB, and of HIV, which of course weakens their immune system and makes them susceptible…
Canto: I thought TB was just about eradicated.
Jacinta: Well it’s now resurgent in some parts, so we’re back to looking at other modes of prevention. So UV lighting is proving very effective, but not applied directly, because direct exposure is quite dangerous – think of tanning beds and the like. But what is interesting is that they’ve experimented with different UV wavelengths – ultraviolet light covers the spectrum from 10 to 400 nanometres – and found a sweet spot at 207 nm. At that wavelength the UV light is absorbed by proteins and penetrates a little way into human cells but doesn’t reach any DNA to effect mutations. But it does affect bacteria, drastically. They absorb the light and die.
Canto: Very clever.
Jacinta: Quite. This sweet spot technology was first used in operating theatres, to kill airborne bacteria that could immediately settle in open incisions and the like. There’s a suggestion now that UV lamps at that wavelength should be deployed in all hospitals.
Canto: So that’s one solution, but getting back to fresh air, has anyone found a solution that eliminates the drawbacks? I mean, knocking equipment around, bringing in pollution and pathogens from outside, not to mention patients falling out of windows?
Jacinta: Well, some of those risks could easily be minimised, but there are more technological fixes. The production of hydroxyl radicals has been shown to kill bacteria…
Canto: Hydroxyl radicals? WTF?
Jacinta: Molecules with a short lifespan, produced in the atmosphere when ozone, the unstable allotrope of oxygen, reacts with water. This reaction is catalysed by organic molecules in the air, and a while back a company managed to build machines that produce these hydroxyls, for use in hospitals. They were quite effective, but the company went bust. So we’re back to good ventilation and getting patients out on balconies. And perhaps locating hospitals out of the way of cities.
Canto: Okay, so back to the future.
Jacinta: Or forward to the past.
Canto: Well thanks for this charming discussion and we look forward to many more.
Here’s an interesting commercial video about how a hydroxyl generator works
https://www.youtube.com/watch?v=a_V9HbBVM6Q
hat-tip to: Frank Swain, ‘A breath of fresh air’ in New Scientist Collection: Medical Frontiers.
something to send you to sleep
sleep apnoea mask – looks great, feels even worse?
I went to a Science in the Pub talk last night, not knowing what to expect. The three speakers were all researching sleep, and the focus was mainly on insomnia and sleep apnoea. How fortunate, for I’m having a problem with insomnia at the moment. I may well have a problem with apnoea too, but because I sleep alone I can’t monitor it. Sleep apnoea is about blocked airways that reduce the intake of oxygen, causing sleep disturbance. Here’s an extract from the Better Health Channel on the subject:
In most cases, the person suffering from sleep apnoea doesn’t even realise they are waking up. This pattern can repeat itself hundreds of times every night, causing fragmented sleep. This leaves the person feeling unrefreshed in the morning, with excessive daytime sleepiness, poor daytime concentration and work performance, and fatigue. It’s estimated that about five per cent of Australians suffer from this sleep disorder, with around one in four men over the age of 30 years affected.
So it’s much more common among older males, and it correlates with excessive weight and obesity. Some years ago, when I had a sleeping partner, she expressed a concern about what she thought might be my sleep apnoea, but since then I’ve lost a lot of weight, and my overall health – apart from my bronchiectasis – has improved, so I don’t intend to worry needlessly over that, but it was interesting to hear about the CPAP mask and other treatments being offered, including the possibility of surgery to the uvula and tongue. Also that the evidence is mounting about the long-term effects of sleep apnoea, upon the heart particularly, though not surprisingly with obesity, confounding factors are hard to control for. The problem I’m having at the moment, though, is ‘advanced circadian rhythm’ insomnia, which has only been happening over the past few weeks and which I’m hoping will sort itself out. Our roughly 24-hour circadian rhythms, our body clock, when running at its best, gives us at least eight hours sleep, optimally between 11pm and 7am, though there is enormous individual variation, and huge variation in tolerance of sleep deprivation, possibly due to genetic factors. Amongst the many varieties of body clock-related sleep disorder, two were focused on last night; delayed-phase and advanced-phase circadian rhythms. The terms are largely self-explanatory. In the delayed-phase type, you stay up late and find it hard to get up in the morning, a common teenage problem (or habit). In the advanced-phase type, which I’m now experiencing for the first time in my life, you find yourself falling asleep alarmingly early, and then waking up – and being alarmingly wide awake, at 4am or sometimes even earlier.
The Circadian Sleep Disorders Network is a great place to learn about the problems, and possible solutions for having a body clock that’s out of synch with the day-night cycle or with your work or other commitments. These problems can lead to all sorts of stresses, but what I took from last night’s session, though it was never explicitly stated, was that your attitude to wonky sleep patterns might be causing more stress than the patterns themselves. In my case, though it’s irritating, I tell myself I needn’t stress over it as I have to get up around 6am for work anyway, and as long as I’m awake and fully operational until 5pm, or 7pm for cooking and eating dinner, it’s no big problem. I’ve not noticed excessive daytime sleepiness or poor concentration (but maybe I’m not concentrating enough). Though I do hope it will right itself, just because being abnormal feels – abnormal. Then again, I’m abnormal in so many other ways that are far more stressful.
Advanced-phase sleep disorder is apparently much less common than delayed phase, though that might just be that it’s less often reported precisely because it doesn’t disrupt work routines. The main treatment is the use of bright light, though I’ve found myself falling asleep in the bright light of the lounge room, or in my bedroom with a bright reading lamp left on. But there’s more to it than just leaving the light on. Here’s a summary from the Sleep Health Foundation:
Bright light visual stimulation should occur in the evening before you go to bed. The light should be brighter than normal indoor lighting. You can obtain it from specialized light boxes, or portable devices that you can wear, e.g. eye glasses. A few examples can be found by a web search for “bright light therapy”. You may need an hour or two of bright light therapy before bed. Some will benefit from nightly use for a week. Others will need longer, sometimes several weeks, to get maximum benefit. It is best used late in the evening, perhaps turning the bright light device off half an hour before bed.
Something to think about if this keeps up. Another treatment is with melatonin, the ’sleep hormone’:
One option is to take a 2mg slow release melatonin tablet (Circadin™) as close to your new (later) bedtime as possible. A second option is to take a small dose of melatonin (0.5 mg), about half way through your sleep period. This could be at a time when you wake up on your own. To change your hours of sleep, you should gradually delay your bed time (e.g. 20 minutes later each night) until you get it to the time that you want. As you delay your bedtime, you will also be delaying the time of your bright light exposure and melatonin intake.
Obviously, neither of these treatments are simple or guaranteed to be effective. Cognitive behaviour therapy was suggested by the experts, if these approaches were unsuccessful, but I know next to nothing about that. For now I’m not too worried, I just hope the problem goes away without my noticing.
it’s all about evidence, part 2: acupuncture and cupping
a picture of health
Okay, having been sick myself with my usual bronchial issues, I haven’t made much progress on researching the ‘alternative’ treatments offered by Wesley Smith and his colleagues at the Wellness Centre. I must admit, too, that I’ve found it a bit depressing focusing on these negatives, so I’ve been working a bit on my Solutions OK blog (a few posts still in preparation) which focuses on being positive about global issues.
So before briefly dealing with acupuncture, I’ve discovered accidentally through looking up Mr Smith that ‘wellness centres’ or ‘total wellness centres’ are everywhere around the western world, including at least one more in Canberra itself. It seems that this is a moniker agreed on by practitioners of holistic medical pseudoscience world-wide, to create a sense of medical practice while avoiding the thorny issue of medicine and what it actually means. But maybe it does partially mean treating people kindly? I’m all for that. Laughter is often quite good medicine, especially for chronic rather than acute ailments.
It’s an interesting point – ‘alternative’ medicine is on the rise in the west, and the WHO informs us that by 2020, due to its own great work and that of other science-based medical institutions, the proportion of chronic ailments to acute ones will have risen to over 3 to 1. It’s in the area of chronic conditions that naturopathy comes into its own, because psychology plays a much greater part, and vague ‘toxins’ and dubious ‘balance’ assume greater significance. That’s why education and evidence is so important. There are a lot of people out there wanting to smile and seduce you out of your money.
Acupuncture
There’s no reason to suppose acupuncture is anything other than pure placebo. It’s similar to homeopathy in that it proposes a treatment involving physical forces that, when tapped, can produce miraculous cures, and it’s also similar in that these forces have never been isolated or measured or even much researched. In the case of homeopathy, Samuel Hahnemann, its inventor, conducted ‘research’, but with no apparent rigour. See this excellent examination of his approach.
Acupuncture posits Qi (pronounced ‘chee’) as an energy force – apparently invisible and undetectable by mere science – which operates under the skin and is ‘strongest’ at certain nodes where experts insert needles to stimulate it. There’s not much agreement as to where exactly these nodes are, how many there are, or how deep under the skin they’re to be found. Is everybody’s Qi the same? Is the Qi of other mammals identical? If you haven’t enough Qi, can you have a Qi transfusion, or will you be contaminated by the wrong Qi and suffer a horrible death? Amazingly, acupuncture practitioners have no interest whatever in these life and death questions. Why has nobody thought to operate on a patient and withdraw a sample of her Qi, considering that the stuff has been known about since ancient times? It’s a puzzlement. And with that I’ll say no more about acupuncture.
Cupping
Cupping, or cupping therapy, is fairly new to me – I mean I’ve heard about it over the years but I’ve never bothered to research it. It was apparently used in Egypt 3,000 years ago, and it’s considered a part of TCM (traditional Chinese medicine). How it got from Egypt to China is anyone’s guess, but when used there, it’s associated with our old friend, the non-existent Qi. Yes, according to TCM, much disease is due to blocked Qi, and cupping is one way to fix it.
Briefly, there are two kinds of cupping, wet and dry, with wet cupping being the more ‘invasive’ and used for more acute treatments. The idea is to create a vacuum which draws the skin up in the cup and increases the blood flow. The cup, or the air inside it, is heated, and when the cup is applied to the skin and allowed to cool, the air contracts, ‘sucking up’ the skin. With wet cupping the skin is actually punctured, so that those nasty but never-quite-indentifial ‘toxins’ can ooze out. By the way, next time you go to your naturopath to get your toxins removed, ask them for a sample, and don’t forget to ask them to name those toxins. Perhaps you could look at them under a microscope together.
There’s very little in the way in the way of evidence to support the effectiveness of cupping, and as you might expect, the best ‘evidence’ comes from the most poorly controlled trials. Serious and obviously dangerous claims have been made that cupping can cure cancer. Here’s the American Cancer Society’s response:
“There is no scientific evidence that cupping leads to any health benefits….No research or clinical studies have been done on cupping. Any reports of successful treatment with cupping are anecdotal. There is no scientific evidence that cupping can cure cancer or any other disease.”
If cupping was effective, this would be easily provable. No proof has been offered in thousands of years, and there’s no credible scientific mechanism associated with the treatment. You’ve been warned. It’s your money. Why hand it over to these parasites?
it’s all about evidence – part 1
I wrote an open letter to a homeopath recently, and received an interesting response, which I’ve promised to deal with publicly. My letter was sent by email at the same time that it was posted on this blog, and this was followed by another couple of emails back and forth. Here they are.
Wesley Smith to myself, April 13 2015
Hi Stewart
I thank you for the courtesy of bringing your article to my attention.
Can you please publish the following corrections to your blog:
To the best of my knowledge, Wesley Smith has never made any claim to be a medical practitioner and I wish to correct any inference in my article “An open letter to a Homeopath” that Wesley Smith misrepresented his qualifications or is not suitably qualified under Australian law to practice or write about complementary medicine. At the time of publishing I was unaware that Wesley Smith is a AHPRA registered Chinese Medicine practitioner (CMR0001709253). Furthermore I withdraw any implication that the phrase “the depth of crazy in which our Wesley is mired” may suggest that Wesley is not of sound mind, or is not fit to either educate people about or practice complementary medicine. Furthermore I acknowledge that I have no knowledge of the appropriateness or otherwise of the qualifications of any of the practitioners at the Live Well Spa & Wellness Centre and therefore I withdraw any inference that any of Live Well’s practitioners may be practicing in their chosen fields without appropriate qualifications.Stewart I have absolutely no interest in debating you, please advise me when you have published the corrections.
Kind regards
Wesley
Myself to Wesley Smith, April 18 2015
Hello Wesley
At no place in my blog post did I write that you claimed to be a medical practitioner, I simply pointed out that you were not one, as far as I could ascertain. Whether you (or your colleagues) are permitted under law to practise complementary medicine is neither here nor there, and I didn’t address that matter in my article. My concern is to point out that homeopathy is not a valid treatment, a view with which the NHMRC concurs. Nor are the other treatments I mentioned in my piece, none of which have scientific evidence to support them. I will of course not be making any changes to my article. Of course it doesn’t surprise me that you absolutely don’t want to debate me, as it would absolutely not be in your interest to do so.
Regards
Stewart Henderson
Wesley Smith to myself, April 20 2015
Hi Stewart
I would have had absolutely no concern if you kept your criticism focused on homeopathy or acupuncture. I don’t agree with you but I’m hardly going to loose sleep over that.
My concern is that you were lazy with your research and published your opinions as if they were fact. You also weakened your argument when you made it personal by disparaging me, Live Well and it’s practitioners. Not only is that sloppy writing and a lazy way to make an argument it is also defamation. I have given you the opportunity to make the appropriate corrections which you have rejected, therefore I will pursue the matter via legal action.
Stewart, my research into your background tells me that you have an arts degree, it’s interesting that you choose to write about a topic for which you seem to have no qualifications. Apparently you work, or have worked at Centacare in Adelaide? Their website homepage states “we believe that everyone has the right to be treated with respect and dignity.” Sounds like great advice and perhaps a tenet you personally would do well to reflect upon especially when dealing with people with whom you disagree.
Kind regards
Wesley
Myself to Wesley Smith, April 23 2015
Dear Wesley
Thanks for your response, which I will be posting in toto on my blog in the near future, together with my response. Your complete lack of interest in addressing the matter of evidence, which was clearly the issue of my blog post, is well noted. I don’t wish to have a private email correspondence with you, as I’m interested in complete transparency and openness. I’ll address all your ‘concerns’ on my blog, with my usual gusto and good humour.
Thanks
Stewart
So now we’re up to date, and I’ll try to suppress the sense of disgust and contempt I feel for this individual, and deal with the issues.
Firstly, let’s look at Wesley’s email number 1. It is, of course, intended to be threatening – ‘make these corrections to your blog, or else…’. The first ‘correction’ is to my ‘inference’ (it looks like old Wesley has been consulting a lawyer) that Wesley has been claiming to be a doctor when he isn’t. As I pointed out in my response, I made no such inference. The point is, when someone heads up an institution called the ‘Live Well Spa and Wellness Centre’, any reasonable soul might expect that individual to be a medical practitioner, working with a staff of medical practitioners. In fact that was exactly what I expected (oh and I think a court of law would agree, Wesley). Imagine my surprise when I found that there were no MDs on the premises!
The second ‘correction’ he wanted was the removal of the phrase ‘the depth of crazy in which our Wesley is mired’, because it suggested he wasn’t of sound mind. I’ll look more closely at that ‘depth of crazy’ shortly, but first I’ll make the obvious point that people believe all sorts of crazy things (though they don’t usually make their living out of them) – that the moon landing was a fake, that September 11 was an inside job, that vaccines cause all sorts of diseases, etc, but we don’t think they should be committed, we just try to get them (usually unsuccessfully) to think more reasonably. I’ve tried to do this with Wesley by pointing out the absurdity of homeopathy from a scientific perspective – again unsuccessfully, because he’s completely unwilling to even discuss the matter.
When I wrote of the ‘depth of crazy’, I really meant it, and this is not my opinion. My opinion isn’t worth a pinch of shit, actually, and nor is Wesley’s. All that matters is EVIDENCE.
EVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCE
Get it, Wesley?
So let’s do a review of the treatments Wesley’s clinic, or whatever he calls it, offers.
Homeopathy
I gave a fairly full account of homeopathy here, where I referenced Dr Ben Goldacre’s Bad Science, Chapter 4 of which gives an even more comprehensive account of the pseudoscience. I’ve also written more recently about it here, and of course in my criticism of Wesley Smith. I’ve also referenced Wikipedia’s excellent article on Homeopathy, and while I’m at it I’d like to defend Wikipedia as an excellent, and well-referenced source of reliable scientific information. If you feel unsure about what it presents, you can always check the references for original sources. I should remind readers, too, that Wikipedia has been put under pressure by practitioners of ‘holistic medicine’ to give more credence to their methods, and its founders and gatekeepers have heroically refused. I won’t go into detail here, but the story is well-presented by Orac on his Respectful Insolence blog.
So I’m not going to rehash the absurdity of homeopathy here, but since Wesley makes the claim that I was ‘lazy with my research’ and ‘published my opinions as if they were fact’ (when in fact I focused entirely on the NHMRC’s comprehensive and negative findings regarding the practice), I will give here a list of just some of the books, academic papers, scientific articles and government and medical society factsheets that report negatively on the multi-million dollar homeopathy industry, and pseudoscience in general, as well as the major figures in debunking medical pseudoscience. They’re in no particular order.
Dr Ben Goldacre, Bad Science, esp Chapter 4 ‘Homeopathy’ – Dr Goldsworthy works for the NHS in Britain and is a broadcaster, blogger and writer on science-based medicine
Raimo Tuomela, ‘Science, protoscience and pseudoscience’, in Rational changes in science.
Stephen Barrett, M.D, ‘Homeopathy, the ultimate fake’, on Quackwatch – a well-referenced site, but note the hilarious-sad reader responses!
Orac, aka Dr David Gorski – Gorski is a surgeon and scientist, and writer of the Respectful Insolence blog, which deals mostly with the health claims of pseudo-scientists. His posts on homeopathy are too numerous to mention here, just type in homeopathy on his blog.
Edzard Ernst, “A systematic review of systematic reviews of homeopathy”, and “Homeopathy: what does the ‘best’ evidence tell us?’ – Ernst, a former professor of complementary medicine, has published innumerable articles on the subject in academic journals. He co-wrote Trick or treatment? with Simon Singh, which deals critically with homeopathy, acupuncture and various other pseudoscientific treatments. His emphasis on scientific evidence has made him many enemies among the CAM (Complementary and Alternative Medicine) camp.
The Cochrane Collaboration – an independent, non-profit NGO – partnered since 2011 with the WHO – in which over 30,000 volunteers work together to provide the best healthcare evidence.
Shang et al, ”Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy”, The Lancet 366 (9487): 726–732 – This study, conducted by a number of scientific collaborators, is regarded as one of the best and most relevant studies available for proof of homeopathy’s lack of efficacy. To quote from its conclusion: ‘Biases are present in placebo-controlled trials of both homoeopathy and conventional medicine. When account was taken for these biases in the analysis, there was weak evidence for a specific effect of homoeopathic remedies, but strong evidence for specific effects of conventional interventions. This finding is compatible with the notion that the clinical effects of homoeopathy are placebo effects’.
World Health Organisation – the WHO has warned against the use of homeopathy for major diseases, though, generally speaking it has taken a softly, softly approach to the pseudoscience, presumably for political reasons. Here and here are reports about the WHO’s warnings.
NHMRC – Australia’s National Health and Medical Research Council. It has conducted a comprehensive review of homeopathy, which I reported on in my criticism of Mr Smith’s ‘wellness centre’.
Science-based medicine and the FDA (the US Food and Drug administration). The Science-based medicine blog, contributed to by a number of writers, is dedicated to expose as quackery everything that Mr Smith and his ilk are promoting. The report linked to above criticises the FDA for abdication of responsibility in dealing with homeopathy. It also points out that American pharmacists are calling for tighter regulations. Homeopaths have had it too easy for too long. The FDA is finally beginning its own investigation into the pseudoscience.
I could go on – there are many many more articles and sites I could mention, but you get the point. Homeopathy is a joke, and there are many videos poking fun at its ‘science’ – for example, here, here and here. A movement designed to expose its fraudulence, the 10:23 campaign, had people ‘overdosing’ on homeopathic pills, which usually have warnings about dosage levels on the bottles(!) And yet we still have people buying into this shite – quite possibly in increasing numbers.
I don’t know Mr Smith personally. It might be that he’s a very nice if deluded fellow who treats his clients very well, adding to the placebo effect of his ‘remedies’. The placebo effect appears to be very real and we’ve only just begun to investigate its power. On the other hand, Mr Smith may be a charlatan who is cynically exploiting the vulnerability of his rich but deluded patients – his ‘wellness centre’ is in a leafy suburb of Canberra, not exactly the poorest region of Australia. Of course it’s more likely that he’s a bit of both – we deceive others best when we’ve already deceived ourselves.
However, to judge by his email responses, Wesley isn’t as much of a sincere believer as he should be, because he’s far far more concerned with protecting his reputation and with making threats, than with exploring the evidence, and thence, the further application of these homeopathic treatments (I mean, if the ‘like cures like, in infinitesimal doses’ system works, then why couldn’t it cure every cancer known to humans?). In my earlier post I suggested to him an exciting project of getting his fellow homeopaths and their satisfied clients together to ‘crowd fund’ research which would prove homeopathy to be true once and for all. And yet Wesley doesn’t even effing mention the idea. AMAZING!!!!
Well, not, actually. Mention this idea to any homeopath, and the response would be the same. They’re totally uninterested in any real research. Testimonials and anecdotes are enough for them. They just want the evidence to be less rigorous – less real and more ‘imaginary’.
Wesley has made threats about defamation, presumably because I wrote that he’s mired in crazy – which he is. This post is already too long, so I’ll investigate the other crazy treatments he and his team offer in later posts, starting with acupuncture. But as to his threats, the man must be living on another planet if he’s not aware of the many websites, some of which are mentioned above, dedicated to exposing the pseudoscience practiced by people like himself, for financial gain. They generally use far harsher language than I have. If you’re going to set up a practice devoted to procedures which seem to share only one feature – that none of them are accepted as established science – then you’ll need to develop a thicker skin, even if you can’t develop any sensible arguments to support them.
And one more thing – Wesley has tried to cast aspersions on me as a mere English graduate. I think on my ‘about’ page I describe myself as a dilettante, which most certainly and proudly is what I am. However, as a blogger, I suppose my official position is that of a journalist. Freelance of course, with the emphasis on ‘free’, as I’ve never earned a cent from it. No defamation action could ever succeed against a journalist who’s trying to expose ‘sharp practice’ through the investigation of evidence, but perhaps Wesley thinks he can intimidate ‘small fry’ like me with his threats and arrogance. I don’t get much traffic here because I’m hopeless at and positively resistant to networking. But I do know how tight-knit and supportive the sceptical community is when anyone tries to threaten it as Wesley has, because I’ve been observing it for years, and if Wesley tries any further intimidation, I suppose I’ll have to pull my finger out and start letting people know what’s happening. It’ll probably do me a power of good.
Anyway, in later posts I’ll be looking at acupuncture (briefly, as I’ve already dealt with this one before), cupping, kinesiology, bowen therapy and other treatments offered by Wesley and his team.
an open letter to a homeopath
When I was in Canberra last year I came across an article in the Canberra Weekly, written by one Wesley Smith, director of the ‘Live Well Spa & Wellness Centre’ in Manuka, a Canberra suburb. It was called ‘Homeopathy in the cross-hairs’, and you can probably guess the rest.
I tore out the article, vaguely intending to do something about it, and promptly forgot about it, but having rediscovered it today, I’m thinking it’s not too late. An online version of Mr Smith’s (he’s not a doctor) article is here. On this centre’s website, I note that it advertises ‘holistic’ wellness (see my recent post), and offers ‘acupuncture, herbal medicine, kinesiology, naturopathy, remedial massage, meditation and yoga’ as some of its treatments – and reading the bios of Wesley’s quite large team tells me that cupping, EFT (Emotional Freedom Techniques), dry needling and ‘soft tissue therapy’ are also on offer, though I note that nowhere in these extensive bios is there any mention of a medical degree. The only mention of qualifications is in Wesley’s own bio – he has a Bachelor of Applied Science in Acupuncture from the University of Technology, Sydney (shame on the institution). But this gladbag of BS is too large to deal with, though it does indicate the depth of crazy in which our Wesley is mired. I’ll just keep to homeopathy, with maybe a dash of acupuncture (I can’t help myself).
So here’s a letter, which I’ll send by email to Mr Wesley Smith. It may mark the beginning of a rich relationship.
Dear Mr Smith
In reference to your article ‘Homeopathy in the cross-hairs’ published in the Canberra Weekly some time last year, I would like to point out some problems with your analysis of the situation with homeopathy.
Firstly, as you know, the NHMRC has now completed its review on homeopathy and its findings were made available online in March 2015. They are clear: there are no health conditions for which there is reliable evidence that homeopathy is effective. The review also states that
People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness. People who are considering whether to use homeopathy should first get advice from a registered health practitioner.
Having visited your website and read your biography, I’ve found that you’re not on the APHRA list of registered health practitioners. I could check out your team, but as I notice that no medical qualifications are mentioned for any of them, it’s probably reasonable to assume that none of them are in fact registered health practitioners.
I find it strange that in your summary of homeopathy in your article, which is reasonably accurate as far as it goes, you describe its principles as ‘challenging’, and suggest that it would be particularly so for those with some knowledge of basic chemistry and ‘a lack of imagination’.
While imaginative insight is indeed required to postulate a new theory, as with Maxwell’s insight about the relationship between electricity and magnetism, Einstein’s insight about the relationship between space and time, and Darwin’s insights about competition and variation, the really hard work involves proving the theory to be true, as I’m sure you’ll agree. Maxwell and Einstein had to develop accurate, watertight, explanatory equations as proofs of their theories, to enable them to be tested ad infinitum by others. Newton developed a whole mathematical calculus, which has since become one of the most valuable tools available to science, in order to precisely calculate his revolutionary laws of motion. Darwin devoted a whole lifetime to providing detailed evidence of adaptive development in a wide variety of species…
Yet it’s remarkable how little work has been done, especially by self-proclaimed homeopaths, to provide proofs of the efficacy of homeopathy. Imagination is hardly sufficient. It seems that, out of exasperation, as well as a sense of ‘duty of care’, the NHMRC, representing medical professionals, has decided to take on this proof-providing responsibility, and the results have been damning, but unsurprising to any one with a scientific bent and a respect for evidence.
You’ve defended homeopathy by claiming there ‘must be’ hundreds of thousands of Australians who’ve been ‘astounded’ at how their bruises respond to homeopathic arnica. Surely you can’t expect any medically trained person to accept such claims as evidence. It would be like accepting someone’s word that hundreds of thousands of people have had their prayers answered by their god, therefore their god really exists and really does answer prayers. In order for such claims to be counted as evidence – as you well know – information would have to be gathered about this multitude of individuals, the nature of their ‘bruises’, and the mechanism by which the bruises responded to the treatment. You would think that homeopaths the world over would be enormously interested in how arnica, in such infinitesimally minute doses, has this miraculously curative effect. The fact is surely sensational and would revolutionise the treatment of bruising – essentially, internal haemorrhaging – around the world, saving millions of lives. Yet homeopaths appear not to have the slightest interest in causal mechanisms. They’re only interested in claimed effects. There are no laboratories working on how homeopathic treatments work, in testing and developing their theoretical underpinnings, in finding further applications for these truly extraordinary ‘principles’. Why ever not? How can homeopaths be so irresponsible? So completely incurious?
You claim that it’s impossible to dismiss the curative effects of this treatment as due to placebo. In other words, you know that it works. That’s fantastic news, now all you have to do is prove it. I cannot believe that this would be difficult for you, since you claim that hundreds of thousands of Australians (and presumably hundreds of millions worldwide) are astounded at the treatment’s efficacy. Considering this, you must be astounded, in your turn, at the NHMRC’s final report. How could they have got it so wrong? Furthermore, how is it that in Britain a study by Edzard Ernst (himself a professor of complementary medicine), which made a systematic review of the Cochrane Database of reviews (the Cochrane Database being justly famous for its rigour), found, again, that homeopathy had no discernible effect beyond placebo? Is there a conspiracy happening here? You seem to be suggesting as much when you write of the huge profits for pharmaceutical companies in successfully trialling their products, compared to the difficulties for poor homeopaths. But homeopaths could surely unite, with each other and with these millions of delighted clients, to provide the proof you need in the form of double-blind, placebo-controlled, randomised trials with large sample sizes. After all, you yourself have testified that the treatment is nothing short of sensational. It would surely haver wider application than simply healing bruises. If these principles really work, why wouldn’t they be effective for curing cancer, ebola, malaria, or any other scourge to humanity? The benefits would be such that you would be criminally negligent not to pool your resources and provide these proofs for humanity’s sake. There would certainly be a Nobel Prize for medicine in it for you if you were to organise the trials that led to these revolutionary cures, not to mention eternal fame and the gratitude of billions…
But let’s not get carried away. The ‘revolution’ of homeopathy has been around for over two hundred years, and it has never progressed beyond the French characterisation of it as médicine douce, the kind of medicine you take when you don’t need medicine, our fabulous immune system being what it is. If it really was as effective as you claim, pharmaceutical companies would have financed the research trials in a jiff, thereby turning their millions of dollars of profits into billions. Not to mention the fact that if homeopathic ‘principles’ worked, much of the science we know would be up-ended, and most of our modern physics and chemistry would have to be scrapped.
The real situation is as described by Dr Steven Novella at Science-based medicine:
… proponents of homeopathy would have the world believe that one man, Samuel Hahnemann, stumbled upon a fantastic secret two centuries ago (actually, multiple secrets) that defy scientific explanation, have been ignored by 200 years of scientific progress, and yet to this day would turn our scientific understanding of the world upside down. For some reason, however, believers just can’t seem to produce any convincing evidence for any of it, not even that homeopathic products have any properties at all, let alone clinical efficacy. After 200 years all they can produce are endless excuses and demands for more research.
And what do we have in your article, Mr Smith? In its last lines, true to form, you make excuses about (200 plus years of) limited funding, and demands for more research. QED.