Archive for the ‘vaccines’ Category

The sky fell on me head

September 23, 2011

The ‘bits of satellite might fall on your head’ story that has been all over the news this week (see e.g. the Telegraph here) has provided a nice chance for people to get the wrong end of the statistical stick.

For instance, as I was having the last of my breakfast this morning I heard the BBC Today programme bods responding to emails and texts. Paraphrasing:

“In response to messages, we should make clear that it ISN’T a 1 in 3200 chance that you personally will be hit by a bit of falling satellite. It is a 1 in 3200 chance that someone, somewhere will be hit by some debris. The chance of it being any one particular person are millions and millions to one”

Which is, of course, the exact inverse of the lottery logic used to sell you tickets. The chance of you, personally, winning the lottery is many millions to one against. But the lottery company advertising plays strongly upon the idea that SOMEONE has to win:

“It could be you”….

…but only if you’ve bought a ticket. Or better still, several tickets – that’ll be five pounds, please.

The point is that they are deliberately playing on many people’s tendency to have trouble distinguishing logically between the odds of a rare event befalling somebody, and the odds of it befalling you in particular.

(BTW, for the satellite example, MSNBC have a discussion of where the numbers come from here).

Mind the reindeer

The mention of satellites falling to earth always reminds me of a famous story about “risk perception”, and one that I  sometimes use when teaching the medical students. The version that I know appears in Michael O’Donnell’s entertaining compendium Medicine’s Strangest Cases. I’ve told this one before on the blog, but it seems apposite here.

The story was that debris from a satellite in a decaying orbit was predicted to fall in an remote area of Lapland that was virtually unpopulated save for a few nomadic reindeer-herders. The Swedish Govt. offered to helicopter airlift the reindeer herders out of the area, at significant cost to the Swedish taxpayer.

Hermann Bondi, a famous British mathematician and Government science adviser, heard the story, crunched the numbers and confirmed that the probability of any reindeer herder who stayed put having the satellite land on them was several orders of magnitude less than the chance they would be killed in a helicopter crash on a routine helicopter flight.

So the Swedish Govt’s decision was plain daft.

Well, that depends.

Purely on the statistics, it was a wholly illogical decision. But Bondi pointed out that the Swedes had undoubtedly factored in that if they didn’t offer to evacuate people, and the satellite then landed on someone, the headlines would scream

“Heartless and negligent Govt leaves reindeer herders to die”.

While if a chopper crashed, the headline would be

“Tragic helicopter crash kills herders”

- and the Govt. would be off the hook.

The point being that it was less about the actual risk of events, and more about how people felt about both the event and the risk of it, and who was to be held responsible.

And also, looking at it from a 2011 perspective, how media reporting plays a major role in what things people worry about, and how much

Anyway, given the above, I dare say that the people hoping most fervently that the satellite debris splashes down harmlessly in an ocean somewhere are the men from NASA.

Perceptions not risk. Unfortunately.

Finally, there is another interesting point about people’s differing perception of the risks of different kinds of rare event.

Though the Today programme has obviously had some worried callers this morning, I dare say that relatively few people will be altering their actual behaviour much due to fretting about being hit by a bit of  communications satellite falling from the sky.

Similarly, the finite risk of a plane crashing does not seem to put the vast majority of people off travelling on airplanes.

But then compare the number of people – some of them among the parents at my kids’ school – who seem to believe that the exceedingly small risk of adverse events following vaccination is a good reason for not having their children vaccinated.

Risk, and perception of risk.

It’s a *****

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Update – Sat 24th: the reports are now telling us the satellite probably came down ‘somewhere over the Pacific’. Wonder if any of the bits will turn up on land?

Update – Sun 25th:  reports are still suggesting the debris probably fell into an ocean, with none reported on land. An amusing sequel is that someone apparently hoaxed some of the Canadian media with a video clip purporting to show the satellite burning up other Northern Canada.

Anecdata – mine good, yours LIES

November 5, 2010

This post is loosely inspired by the fact that some of the US sceptical bloggers, led by surgeon/blogger Orac and the good folks at Science-Based Medicine, have declared this week “Vaccine Awareness Week” (in a good way).  They were galvanised into doing this by some of the usual anti-vaccine suspects who had also declared Nov 1-6… “Vaccine Awareness Week” (not in a good way).  Anyway, I had hoped to post something more substantive on vaccines and vaccine reactions to join the crowd, but time has run out, and the internet connection is a bit hinky, so I’m afraid this rather navel-gazing piece will have to do.

One of the puzzles of debating people with weird ideas about health, and in particular the anti-vaccine lot, is their attitude to anecdotes.

Most of what one is told by Team Anti-vax “shows” that vaccines have caused harm to children / seizures / autism comes down to anecdotes.

Stories, if you prefer. Or “individual accounts”, if you find “stories” a bit loaded.

Now, there are many problems with stories as a form of evidence.

One is the accuracy with which things have been remembered.

Another is the veracity of the person relating the story.

(This latter can be true even if the person relating the story, or stories, is someone whose relating of them you would expect, for professional reasons,  to be as reliable – or as accurate – as possible. Let us mention no Andrew Wakefields in particular.)

But, before I get distracted into a rant about “Saint Andy”,  lets just say that stories – or single reports, or anecdotes – have quite a few problems as a form of medical or scientific evidence.

That does not, I should stress, invalidate them.

It just means “handle with care”.

One essential quality of the stories that come from the anti-vaccine people, and those that read, consume, repeat and promulgate them, is that any story that recounts something framed as “child damaged by vaccine” is automatically regarded as believable and accurate. The person recounting them could not possibly have misremembered, conflated, exaggerated, or downright made it up. Even inadvertently.

Indeed, the stories are regarded as so true, and so convincing, that the science that fails to find evidence for the stories’ contention must (in Anti-Vax world) be wrong. Or wrong and evil.This is actually a stock line of the anti-vaccine movement. A particularly florid recent version is here (Warning: contains nuts). A sample quote:

With voluminous accounts of parents detailing how the problems of their children began after a vaccination it’s nothing less than a crime that the medical authorities stop the science by claiming that the question has been “asked and answered.”

My anecdote = true. Your anecdote = lies.

In marked contrast, however, stories that do NOT back up the Anti-Vaxxers world-view are treated rather differently.

They are regarded, instead, as invented.

I have been having an interesting recent experience of this.

The background: US sceptical Major League doctor-bloggers Orac and Steve Novella have recently been having a public blog argument with Marya Zilberberg, another American doctor and lecturer who runs a blog called Healthcare etc.  Zilberberg had posted an article on “The Paternalism of Science based Medicine”, which the other two had called out for committing (as they saw it) a number of errors.

Among the things Dr Zilberberg said was the following:

“The vaccine debate is yet another completely different issue altogether. In our privileged society the specter of infectious epidemics is for the most part but a distant memory, yet our concerns for the safety of our children combined with a rampant, albeit not altogether unjustified, distrust of the pharmaceutical industry and the government, have colluded to promote a biased yet durable suite of misinformation about the risk-benefit profile of vaccinations. Some of this prevailing sentiment may be because, in my opinion, we have focused on the wrong outcomes (e.g., the economics rather than morbidity associated with chicken pox), or that we have overstated what we really know and understand, at the risk of sounding too confident and therefore not trustworthy partners in this important area of public health. But these are just my own speculations. What is more important is what we do know about “science-based” medicine.”

[NB The comments about chicken pox build on an earlier post she had written, which expands her ideas. She has since said some more about the chicken pox vaccination here].

Subsequently, a family physician (GP) in Ohio who blogs as “Dr Synonymous” commented:

“The chicken pox comment alone is worth a lot. I’ve seen many parents who were bullied about the importance of the [chicken pox] immunization by a school nurse or pediatrician. It’s the law in Ohio that you can’t start kindergarten without the cp shot. A sad misuse of our power generates a misuse of legislative power and people feel betrayed, leading to loss of trust in physicians.”

Which prompted Dr Zilberberg to respond:

“Thanks for your comment! Many if not most states require varicella [chicken pox immunisation] for school — agree that it is misuse of power breeding mistrust.”

Now, this annoyed me. Not because I believe in compulsory vaccinations – I don’t, and people should not be bullied to have vaccinations by healthcare workers – but rather because the way it was stated tended to suggest this was an open and shut case, and there was no possible sensible reason for people to have a varicella [chicken pox] vaccination. This struck me as a bit glib.  Of course, in the UK we do not vaccinate against chicken pox – we leave children to acquire natural immunity. You can read about the reasons for this policy here. But this is a “judgement call”, and other countries may well make different judgements. I don’t really buy Marya Silberberg’s argument that the US schools ask for vaccination simply because kids with chicken pox otherwise cause parents to have to take two weeks off work. I wonder myself whether it is more a worry of getting sued by the parents of a kid that catches chicken pox at the school. But anyway, I can certainly see reasons why a US school might want to require children to get immunized.

In fact, One of these reasons had been brought home to Mrs Dr Aust and I just the previous week, in a way that will become clear from the following comment I left on Dr Zilberberg’s blog:

“I find the comments here about vaccination from Drs Zilberberg and “Synonymous” quite alarming.

My daughter just brought home a letter from school which asks parents to be “vigilant” about not sending their kids to school with spots. The reason is that there is a little boy in the school who is having treatment for leukaemia and is consequently immunosuppressed.

Unfortunately, non-vaccination is pretty common among the middle class parents of my middle class enclave. And given that kids with varicella will be infectious days before the spots appear, keeping spotty kids out of school is locking the door after the horse has bolted.

From Marya and Dr Synonymous’ words I assume they think it is perfectly reasonable for this poor kid to be put at risk so that other parents can feel smug about exercising their “choice” about vaccinations. I wonder if I am alone in thinking their words will be music to the ears of anti-vaccine campaigners?

Would either Marya or Dr S like to comment on what is likely to happen to this poor boy if he gets chicken pox?

From where I am standing it seems like the legislators in Ohio have a point.”

I also posted a comment over at Respectful Insolence noting the comment I had made at Dr Zilberberg’s:

“[Dr Zilberberg’s] comments on vaccination, and those of a “Dr Synonymous” on her blog, made me quite angry. We just had a letter from our daughter’s school about “don’t send kids to school with spots”, probably because there is a kid in the school under cancer treatment.

Stuff like that tends to make you see requiring things like varicella vaccination for school/kindergarten in a different light.

I’ve left a comment on her blog (in moderation). Assuming it gets posted, will be interested to see what she says in response.”

Now, the story is quite true. We did get a letter. We don’t know precisely what prompted the school to sent it out, as they didn’t say, possibly for reasons of confidentiality. What we do know is that there is a kid in the school (who we know as he lives near us and uses the same playground), who has leukaemia and has been undergoing chemotherapy. He is almost certain to be  immunosuppressed. So it is an obvious inference that that is the reason for the letter.

I should say that I didn’t know then what the preferred “resolution” would be in this particular situation; Dr Synonymous responded some time later with:

I applaud Ohio for all the legislated vaccine mandates except the chicken pox, about which I agree with Dr Z as she previously posted on chicken pox (a whole blog post). Strategies for immuno-compromised children when exposed to vaccine-preventable diseases are included in the NHS Green Book about vaccines”

- the kind of information he referred to seems to be stuff like (e.g.) this and this; which would tend to indicate the child and his parents being tested for varicella immune status, and the parents then being vaccinated in the (unlikely) event that they were not already immune. Plus, if the child were then later exposed to chicken pox, the documents indicate he would need prophylaxis with antivirals or an immunoglobulin shot. Schools are also asked to be vigilant and report cases of chicken pox to parents, presumably partly so that in cases like this “contacts” with the disease can be identified (you can see a typical school policy here – NB PDF).

Now, all that is one approach, and the one the NHS seemingly takes. But you can easily understand why some other jurisdictions might prefer to simply ask for children to be vaccinated before they start school.

[Edit: more about this in the Addendum below]

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You LIE!

Anyway, this is by the by. It was the reaction to my remarks from the more anti-vaccine commenters on Dr Zilberberg’s blog that surprised me a little. Here is the first comment after mine

“Dr. Aust,

Maybe you have let your emotions get the best of you before you had evidence in your hand.

You post here that a little boy is being treated for cancer AND he is immunosuppressed.

Later on Respectful Insolence you posted that you received a letter from your daughter’s school “probably because there is a kid in the school under cancer treatment.”

It’s seems that you conjured up a scenario that angered you and filled in the conclusions yourself.

This is not what EBM is about.”

And it got worse: here is one of the inevitable Anonymous-es:

“Yes Dr. Aust, it seems you just made up a story about the kid with leukemia.”

And yet another Anonymous, in response to a different commenter who pointed out that what I had said was perfectly internally consistent:

“NO, [Dr Aust] went from a child has cancer to ‘probably’ has cancer. It’s as if he bluffed to one crowd and then went and bragged about it to another. It shows that he never was sure. He assumed it must be. But he felt the need to be more ‘honest’ to his friendly crowd. It shows the intention of deceit.”

*sigh*

As my mate James “jdc325″ commented on Twitter:

I like that, once it’s been explained, Anon carries on arguing. Of course *they* know what you meant – it’s *you* that doesn’t.

I think the point where you begin reiterating explanations to people who think they know better than you what you meant… …is the point where the head meets the keyboard and you should step away from the computer. Never gonna get through to them.”

True enough.

But what sticks out for me in all this is the double standard.

Anecdotes from people claiming some form of vaccine damage are always believed. Indeed, as I said earlier, when you express skepticism you are typically told “how can – how dare – you dismiss all this testimony?”

Meanwhile, anecdotes that in any way disagree with the anti-vax worldview are dismissed as deliberate falsifications.

As I put it, somewhat un-diplomatically, on Marya Zilberberg’s blog:

“Trying to discredit the messenger because you don’t want to tackle the substantive point is a wearyingly familiar tactic of anti-vaccine and other “Alternative Reality” folk.

In case anyone cares, I added a clarifying comment above. Sadly, the kid in question definitely has leukaemia. The “probably” was actually referring to the inference about why the school sent out the letter…

However, the Alt.Reality gang routinely accuse opponents and critics of deceit, or of being “Pharma Shills”, or of being part of some sinister organised group – you get this again and again if you puncture their bubble. I suspect they also default to such jibes so readily because it chimes with their own conspiracy fantasies and paranoia. For a look at this kind of tendency in its florid state one only has to take a quick look at a site like Age of Autism.”

Unfortunately, I suspect none of this sort of debating, and no amount of debunking, will influence the significant number of vaccine-averse “Mummy Warrior” types in our primary school here in Middle-Class-shire. The amount of ill-informed sh*t you hear in the playground about “the dangers of too many vaccinations” has to be heard to be believed.

And, though you may find it hard to believe, out of me and Mrs Dr Aust it is actually not me that gets the maddest at hearing this stuff. Though I do usually say something, I am not surprised by what I hear.  I have, sadly, become rather inured to the idea that some of our neighbours believe all kinds of daft nonsense about things scientific and medical, usually unencumbered by actually knowing anything.

Mrs Dr Aust, in contrast, despite all her years of dealing with the public, finds it harder just to let this stuff wash over her.

Perhaps, as I have mentioned before, it was things like treating seriously sick adult measles cases on the medical wards. Or seeing kids with Rubella syndrome as a medical student doing an elective in paediatrics.

Anyway, somehow she finds it hard to forget that stuff and “let it all wash over her” when people talk about homeopathy, or fish oils, or blackberry juice being a “natural antiviral” for little Johnny.

Or when they talk nonsense about vaccinations.


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Addendum: More on Chicken Pox

After I wrote the bulk of this post on Wednesday night, I was rummaging around on the Internet and found my way, via Respectful Insolence, to an article by the excellent American scientist-blogger Prometheus of A Photon in the Darkness, one of my favourite “mixed” science/pseudoscience blogs.

Prometheus’ excellent post is called “Three Popular Anti-vaccine Myths Deconstructed”. The third of Prometheus’ myths is “The chickenpox vaccine causes shingles!”

The particular reason why I found this interesting is that the NHS Choices page on “Why aren’t children in the UK vaccinated against chickenpox?” states:

“The chickenpox vaccine is not part of the UK childhood vaccination programme, because experts think that introducing a chickenpox vaccination for children could increase the risk of shingles in older people.”

Prometheus argues that the evidence from the use of the vaccination in the US shows that the vaccine strain of varicella is almost certainly not transmissible from children who have been vaccinated to healthy adults. So I guess NHS Choices does not mean “experts think adults could get shingles by catching the vaccine-strain virus from kids who have just been vaccinated”. I suspect that the idea is that in the UK adults regularly get a kind of “booster” to their varicella immunity every time they get near a kid with (wild-type) chicken pox. If the kids only get the (non-transmissable) vaccine strain virus, the adults around them will get no “booster exposure” to varicella, and their immunity may wane quicker; then if they later DO get exposed to a case of wild-type chicken pox, they may get a much worse case of shingles as their immunity will be less.

Of course, there are downsides to the UK policy. First, there is the risk of someone immunosuppressed who has not had chicken pox catching it (see my story above about our daughter’s school)  And second, there is the risk of someone older whose varicella immunity has run down being exposed to wild-type chicken pox and getting a nasty case of shingles.

In fact, I was interested to see there are currently proposals afoot to give people in Britain over 70 the varicella vaccination, the idea being to “top up” their immunity to the virus and thus prevent them getting shingles, either via viral re-activation (re-activation of varicella lurking in their sensory nerve cells, which is what the stuff does if your immunity gets low enough) or via exposure to an individual with chicken pox.

Now, I should say that the above is my interpretation of what I have read on the websites and on Prometheus’ blog. I am not a virologist of even a medical doctor, so there may be some inaccuracies in what O have written. Perhaps if DeeTee still reads the blog he can advise me whether I got all of this right.

The point, really, is that in mainstream medicine evidence is always developing, and policies based on the evidence are regularly under review. Currently, there is mass child vaccination with the varicella vaccine in many parts of the US, but not the UK. Does that imply disagreement? I don’t think so. They are simply different approaches to the problem of “managing” chicken pox/varicella in the population. And it is always possible that the policy in either country may change in the future. The reasons for the difference seem to hinge on the debate about how quickly the “lifelong immunity” conferred by childhood infection wanes, and the best way to manage the immune status of the community as a whole to make sure people are not exposed to the risk of shingles (or, more dangerously, chicken pox) late on in life. Which sounds like an interesting public health question, of the kind that public health doctors and epidemiology people would be found debating with their computer models.

In the meantime, though, one is still left with – mass varicella vaccination?  Or not?

To which the answer is – I don’t know, but it’s an interesting question.

Which is fine. Scientists, and doctors too, are generally comfortable with a bit of “don’t know” – with uncertainty. It is part of the business of science and medicine, because, as just mentioned, scientific and medical evidence is not a constant, but a changing body of information. Contrast Alt Med people – who, regardless of their mantra of “Let’s keep an open mind” usually aren’t happy with uncertainty and changes to what is known. After all, they already know they are right.  They are just waiting for the evidence to catch up with them.

Note: I’m not sure if those final two sentences were ironic or depressed.

Probably both.

Denouement for the MMR scare – updated

May 24, 2010

In which Dr Aust looks back over four years of commenting about MMR, and many more years of a modern tragedy

In just a few hours Dr Andrew Wakefield, of MMR infamy, will be facing the General Medical Council (GMC) for what is almost certainly the final time. The GMC Hearings calendar says:

“Update: It is now expected that on Monday 24th May 2010 at 9.30am the Fitness to Practise Panel will announce the final determinations on serious professional misconduct and, if necessary, sanction in the hearing of Dr Andrew Wakefield, Professor John Walker-Smith and Professor Simon Murch.”

It is widely believed, after the damning GMC findings released back in January, that Wakefield will be “struck off” – removed from the register of licensed medical practitioners. Even the man himself seems to think so, as publicity for his book – yes, he has written a book* – on Amazon says:

“In the pursuit of possible links between childhood vaccines, intestinal inflammation, and neurologic injury in children, Dr. Wakefield lost his job in the Department of Medicine at London’s Royal Free Hospital, his country, his career, and his medical license

Does he know, er, something we don’t? Anyway: today.  And if you want a preview and a bit of a retrospective, Brian Deer, the man above all responsible for exposing Wakefield, offers both in the Sunday Times.

Words, words…

Now, over the years I have been writing on the blogs and forums – it is roughly four years, since the early Summer of 2006 – I suspect I have typed in more actual words about the MMR farrago, and Andrew Wakefield, than about anything else. Indeed, he, and the press coverage of his work and its aftermath, probably did more to make me into a blogger than any other single instance of media misreporting of science.

You won’t find many of these words here, though.

I have, in fact, not done all that many actual blogposts on MMR. I have done most of this writing in comments threads. Sometimes I try and stick to correcting obvious misconceptions about things that are sort of scientific, or that I know a bit about – aluminium in vaccines, or formaldehyde in vaccines, or antibiotics in vaccines, or thimerosal in vaccines (which it usually isn’t). But I have also, against my better judgement, got involved in some long arguments with the anti-vaccine mafia, e.g. on autism blogs, or at the Guardian’s depressingly troll-infested Comment is Free, and at the now sadly disappeared NHS Blog Doctor blog.

These arguments have actually involved some of my most seminal internet commenting experiences. For instance:

- I have been denounced for being pseudonymous by several of the anti-vaccine zealots  (if you want to see one reason why I have a ‘nym, keep reading).

- I have had comments “deleted by a moderator” at Comment is Free –  the only place I have ever been deleted, apart from on some of the madder homeopathy blogs.  Apparently at CiF it is non-PC to call a conspiracy theorist a “conspiracy theorist”, something  I would argue is a simple statement of fact when it is demonstrably true.

- I have, in a rare bit of writing under my real name a few years back, been “trailed” back to my medical school website by an anti-vaccine campaigner. He then picked the names of a couple of pharmaceutical companies off the list of “organisations the Faculty have ties with” – note this usually means something like “funds a student prize in” – so that he could smear me on the thread where we were arguing with:

“I notice there is no response from Dr Aust of the Faculty of Science at the University of Snarkfield, corporate partners EvilPharma and BigPharma”

- yes, the  famous Pharma Shill Gambit, favourite opening salvo of conspiracy theorists and health crazies.

But nonetheless, despite all the commentary, there have been fairly few actual posts.

This is partly since all one could think of to say about MMR would typically already have been said much better. For the MMR saga has generated a vast amount of skeptical coverage, reflecting its status as the mother and father of all “bad science” stories.

Above all, the peerless Brian Deer has dug into Wakefield’s lies and evasions, doggedly and relentlessly, until ultimately the whole edifice of Wakefield’s carefully cultivated image as “the caring doctor” came tumbling down.

Ben Goldacre has documented, over many years and many articles, the laziness, conspiracy-theorising and scare-mongering of the media that helped give birth to, and sustain, the scare.

And other Badscience bloggers, like jdc325, Holfordwatch, and infectious disease doctor DeeTee have done their bit too.

Not to mention the many excellent autism sites that have covered each twist of the story in exhaustive detail, like Left Brain/Right Brain and Action for Autism

And there are many, many others, who I haven’t time to mention here.

So I have only rarely felt I had anything much to BLOG about on the MMR scare. But I like to feel I have done my bit in the comments department.

Indeed, the MMR scare was one of the first things I found myself commenting on over at Ben Goldacre’s Bad Science blog – see e.g. this thread about MMR from June 2006, where you will find me, er, holding forth.

And it was also one of the frst things I commented on over at the Bad Science forums. You can see a typical four-year old comment here.

I will quote one bit:

“People in science and medicine that I know find the determination of Melanie Phillips et al to see Wakefield as a “wronged crusader for the children” utterly barmy. That is as restrained as I can put it.”

Indeed, probably the thing I have written about most in commenting on the MMR scare was this idea that, given the trust parents had placed in Wakefield, and their belief that he was a caring and sympathetic doctor, he could not possibly be a “wrong ‘un”.

Another aspect of this is the belief, fervently-held among many of Wakefield’s followers, that he was a scientist of the highest class, and that his record of publications meant, again, that his scientific standing and integrity were beyond question.

Of course, this is nonsense, not even in any way specific to Wakefield, but simply because scientists – and doctors-turned-scientists – are human beings. They are not wholly dispassionate and logical. Anyone who works in science, like me, can tell you this, if it wasn’t already blindingly obvious. There is a thread talking about it over on the scientiists forum Nature Network right now.

Scientists are human.

They have pet theories. They have hobby horses.

Some even have idées fixes.

Andrew Wakefield, as was obvious long before his work on the children in the Lancet paper, had an idée fixe about the MMR vaccine. In particular, he had earlier tried to finger the vaccine as a cause of Crohn’s Disease in adults, an idea which got a little bit of attention in the literature and then sank without trace, as ideas which do not pan out tend to.

Plus: here is something else that anyone in the business can tell you. As human beings, researchers – whether, scientists or doctors, or doctors-turned scientists – face ethical challenges.

For instance:

- How much data editing is “making the true pattern emerge from nature’s noise?”

- How much is “making the data fit the hypothesis?”

- And how much is “research fraud”?

Now, these are real questions, and they are not a secret, and we debate them in PhD student training programmes. Indeed, I once even got to debate these things with Ben Goldacre at just that sort of forum. But they are everyday questions that scientists face. We wrestle with them, and we see our colleagues wrestle with them.

Most people are after the truth, and understand that they are fallible. So they try and watch themselves for “wishful thinking”.

Some are not so good at it.

And still others are so blinded by their pet theories, or their ambition, that they cross the line.

And some can’t even see that they crossed it.

Now, if you work in scientific research, you see all sorts.

You see some people who would no sooner “tweak ” the data than they would murder a bunch of people.

And you see others who are more “flexible”.

And just occasionally you may come across someone who is so convinced of their pet theory, and perhaps of their own brilliance, that people in the field will mention their papers with a special raised eyebrow that says “Don”t be too sure of anything coming out of this lab”

Which is, of course, one of the reasons why it is so important that science is a collective-but-also-competititve endeavour. Results get picked over. More spectacular or ground breaking results more so. Experiments get repeated. People compare their data with other peoples’ data. People look and say:

“Well if this is true, then we should be able to see this too, with our method”.

And so on, and so on.

And if, after all that, a result doesn’t stand up, people wonder how the result came out the way it did. Maybe it was an error. Maybe it was an artifact. Those are the common reasons.

Or maybe – just maybe – it was something a bit more sinister.

Considered, checked – and rejected

And that is what has happened with Wakefield’s work. It was published. People critiqued it. They looked carefully at the findings in the paper to see if they stood up. Other researchers tried to look for the relationship he suggested between autism and MMR vaccination in other kinds of studies. Or for the postulated relationship between autism and inflammatory disease in the bowel.

People also did the same with Wakefield’s subsequent work. His methods, particularly the “virus detection molecular biology”, were repeated in other labs.

Now, all of this was an entirely normal part of the scientific process, if rather more urgent because of the connection to the MMR vaccine.

And the answer? None of Wakefield’s work stood up. None of it.

But the more the evidence mounted up that the connection between MMR and autism was a mirage, the more Wakefield stuck to it. Right up until now.

At which point you essentially have two choices.

Either Wakefield is the saint his followers still insist he is, and all the evidence that contradicts his work is wrong, or fabricated, and this is a witch-trial.

Or…  the vast array of science that speak against Wakefield’s work is sound, and Wakefield is as we now see him – exposed as “callous, unethical … dishonest”, in the GMC’s words.

It comes down to the evidence, and how you see it. Two kinds of evidence, actually. First, the scientific evidence, in totality. And second, the evidence we now have of how Wakefield did his research, and reached his conclusions.

And it also comes down, of course, to how you see Wakefield.

As I frequently repeat when I am talking about this, and have repeated for the last several years,  I have never talked to a doctor or scientist about MMR – and I must have talked to hundreds – who doesn’t have a clear view on Wakefield. Universally, it is a view that does not cast him in a favourable light.

You can work the rest out for yourself.

Can this really be… the end?

So is this likely to be the end? If Wakefield is removed from the register? Will that be it for vaccine scares?

Somehow I doubt it. As others have observed, the furore over MMR was eerily reminscent of earlier vaccine scares, like that over Dip-Tet.

And there are sectors of the media that still find vaccine scares irrestible. The Daily Mail and Sunday Express coverage of the recent introduction of the HPV vaccine was, again, scarily reminscent of their “work” on MMR.

In fact, I fear that as long as anti-vaccine stories make headlines, and sell papers, the stories are not going to die. And they will always make headlines , and sell papers, because they play on fear. And that gives them power.

Looking at the old Bad Science Forum thread I linked to, I noticed another of my old comments,  this one rather melodramatically headed “Fear is the Key:

“Fear – even irrational fear with absolutely no basis in fact, like of Autism-from-vaccines – is incredibly powerful. You kind of have to take the decision to vaccinate despite some Id-type part of you wanting NOT to vaccinate because your fears have been aroused [i.e. by all the media scare stories]. What you know fights with your primal fear of the unknown, if that doesn’t sound too portentous…

People don’t just operate on higher reasoning. They operate on beliefs (rational or not) and Hollywood’s old favourite “gut instinct”. That is why it is often so hard to change peoples’ minds through reasoned argument, no matter how compelling.”

And that is also, of course, why the media coverage of MMR, keying on tragic families, and mothers’ fears, was so incredibly damaging.

Which brings me to a final point. The familiies’ tragedies are real. The anti-vaccine mob, like John Stone, make a habit of accusing those sceptical of their hero of  “callous disregard” for the suffering of the autistic children Wakefield was investigating, and of their families.

Which is a crock. Brian Deer has always been crystal clear about this, regardless of the mob baying for his blood outside the GMC:

Among the worst victims of the MMR scare were the parents who believed Wakefield’s findings — a few of whom will no doubt once again be shouting slogans tomorrow. I feel only compassion for them. Imagine how terrible it must be to believe that your son or daughter’s autism is your own fault, just because you had your child vaccinated.

“In a way, making the connection was worse for us,” said the mother of the youngster referred to as Child 12 in The Lancet. “We had convinced ourselves it was nothing we had done. Now we knew it was our fault.” ….”

As I said on another blog, the parents had to be “sold” the guilt in order to then be sold the conspiracy: “But you did it because they [i.e. the doctors and the Govt] lied to you!”

And I would call that selling them the guilt…  plain wicked. There is no other word.

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Update 1:  10:55 Monday

As predicted by everybody, including himself, Wakefield has been struck off.

So the old sceptical joke has come true:

“Disgraced ex-researcher Andrew Wakefield – or, to give him his full medical title…

…Andrew Wakefield.”

Update 2: 3.45 pm

Professor John Walker-Smith, the senior paediatric gastroenterologist at the Royal Free involved in the autism work, is also to be removed from the Medical Register – like Wakefield, he has been found guilty of “serious professional misconduct”. Walker-Smith is 73 and retired a decade ago.

The third of the doctors involved, Professor Simon Murch, has been found not guilty of serious professional misconduct and is free to continue in practise. Murch is currently Professor of Paediatrics at the University of Warwick.  The GMC’s press release discussing Murch’s role can be found here. It indicates that Murch had concerns at the time of the work about the ethical approval for the project, and had sought reassurance from senior colleagues. One of these was Professor Walker-Smith, under whom Murch had trained at the Royal Free. Murch also discontinued doing lumbar punctures on the children when he felt that they were revealing no clinically useful information. More on the story in the Guardian here.

The text of the GMC’s press release detailing the reasons for erasing Wakefield from the Medical Register can also now be found over at Left Brain Right Brain.

Update 3: 9.30 pm

Tom Chivers of the Daily Telegraph has a good post on Wakefield and the MMR saga here. The comments thread seems to be gradually filling up with anti-vaccine people. Of course, as anyone familiar with MMR-related threads will know, they tend to “out-last” other commenters. Anyway, Tom seems to be doing a good job of rebutting their dafter assertions, though he could perhaps do with some help.

An interesting aspect of the whole sorry saga is precisely how the 1998 Wakefield paper came to get published in The Lancet in the first place.

Well, they submitted it, it was peer-reviewed and then published… but of course, with journals at the “high-impact” end of science and medicine there often tends to be more to it than that. Anyway, over at the Guardian, clinical  epidemiologist Professor Christopher Butler has written a piece which talks about some of the likely behind-the-scenes stuff – and also points out some of the technical shortcomings in the paper that a referee with the right background might have picked up on.

Another of the murky stories from the start of the MMR scare is how his colleagues at the Royal Free Hospital Medical School regarded Andrew Wakefield and his work, something which probably had a significant influence on how events played out. I discussed this some time back in a comment here. Like many people, I am hoping that Brian Deer will one day write the definitive book on the whole saga.

Wakefield? Who he?

Finally, back in the Bad Science blogosphere, jdc325 has been noting the Daily Fail’s remarkable selective amnesia on their ex-hero Andrew Wakefield. They seem not to remember that he was once their poster boy of the “Brave Maverick Doctor”. You would think they would remember, given the vast amount of anti-vaccine guff they have printed over the last few years – see jdc’s post for the details.

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* The book is due to go on sale… today. May 24th. What an amazing co-incidence. Not.

You couldn’t make it up

March 10, 2009

A small round-up of what I have been reading.

The line “You couldn’t make it up” is a rather over-used one in the UK. Nonetheless, it often seem apposite when confronting enthusiasts for Alt.Reality.

Sometimes the line springs to mind when a particularly egregious example of Alt.Med abuse surfaces. One such of recent vintage comes from Gimpy’s brilliant coverage of the extraordinarily deluded Jeremy Sherr, the homeopathic guru who thinks that homeopathy can cure HIV/AIDS. More that that, Sherr is on a kind of Sacred Mission – I am oddly reminded of the Blues Brothers – to bring the joys of pure-water-plus-hocus-pocus to desperately unfortunate people in Tanzania who are both HIV-positive and in the grip of poverty.

Gimpy has done a tremendous job of exposing Sherr’s messianic delusions and ethical blind-spots – but the “You couldn’t make it up” moment does not stem just from Sherr himself. It also comes from the hordes of homeopaths who have lined up to defend – and heap praise on – Sherr, and from the homeopathic “trade bodies” which have been stunningly silent on what Sherr is up to. Behold the chorus of disciples on, for instance, Gimpy’s threads here and here.

AIDS is a deadly disease. It can be staved off with drug treatments. These antiretroviral drugs (ARVs), particularly the protease inhibitor cocktails, constitute one of the greatest recent achievements of the much maligned (often with considerable justification) ” Big Pharma”. Without ARV treatment, it is essentially inevitable that eventually your immune system will fail and an opportunistic infection will finish you off – as has sadly happened to most “It’s not HIV! ARVs are evil!” activists. With the triple cocktails, or similar ARV regimes, you have a good shot at living for many years. People with a grip on reality have campaigned tirelessly for HIV-positive people in the developing world to have access to ARV drugs at cost. These activists, like the Treatment Action Campaign in South Africa, are the real heroes.

But apparently, most lay homeopaths are quite convinced you should forego the anti-retrovirals and embrace their particular brand of “spiritual healing”.

You really, truly, couldn’t make it up.

And let’s not forget – Jeremy Sherr is widely regarded within homeopathy as a leader of the “discipline”, one of their key intellectuals and most revered teachers. Which says it all, really. You could hardly want for a more perfect demonstration of just what an extraordinary parallel reality homeopaths inhabit.

Did you call me a cult?

Also in the “You couldn’t make it up” category, but perhaps rather more predictable, the anti-vaccine cultists have resoundingly ignored the recent body-blows for the anti-vaccine cause. The first thing I am thinking of is the US Autism Omnibus decision, where the judges decisively rejected the idea that MMR vaccine could cause autism, and laid out in excruciating detail (excruciating for the anti-vaccine believers, that is) precisely how discredited, half-arsed, and nigh-on fraudulent is the so-called “research” and laughably useless “experts” on which the anti-vaxxers relie.

The second body-blow was the latest tranche of revelations from investigative journalist Brian Deer about Andrew Wakefield’s original work at the Royal Free that triggered the MMR scare. If even a fraction of what Deer alleges is true, then Wakefield stands revealed as a data-fabricator of the worst kind, and everything he has ever said turns irrevocably to dust.

However – none of this seems to have had the slightest effect on the True Believers. You can see this from a mammoth thread over at Kev Leitch’s Left Brain/Right Brain blog. A collection of the usual suspects from anti-vaccine group JABS – John Stone, Isabella Thomas, etc. – are clearly unshaken in their faith. They view the recent events, and the scientific revelations like Prof Steve Bustin’s devastating testimony on the stunning incompetence of Wakefield and O’Leary’s RT-PCR work, as a side issue. They are, predictably, more interested in trying to spread slurs and conspiracy theories about Brian Deer, and nitpicking over obscure legal decisions on what UK expert testimony was or wasn’t made available to the US courts.

If you can face the mega-thread, look particularly for the posts by “brian” (who identifies himself as a medical doctor and a molecular biologist), and see the responses they draw from John Stone and friends. The JABbies, as has been said before, are beyond reason. They are a cult.

Though they are a cult, sadly, that retains the odd friend in the media. Notably, the increasingly-out-of-touch-with-reality Melanie Phillips. Phillips  is still determined that Wakefield was right – though we don’t really know how she would know, given that she doesn’t understand the science – and that it is all a Dark Conspiracy.

Reading her latest post on this I was struck by the fact that there seemed to be almost no commenters apart from the hard-core Wakefield Groupies – John Stone, Clifford G Miller, Isabella Thomas, Seeonaid etc etc. Unsurprisingly, Melanie’s previous comment, a few days earlier, had echoed precisely the line taken by the JABS Mafia over at Left Brain/Right Brain by re-framing the whole thing as an attack on Brian Deer.

Among the dwindling band of normal people reading Melanie’s rant I was particularly struck by this comment from a poster styling himself “Valetinius” (7th comment on this thread):

“This is actually indicative of the new dogmatism that has deprived Melanie Phillips of the independence of mind that once made her a commentator of note. There is a lesson in discourse analysis on all of these recent pieces… …not that here is a journalist with an interesting, novel assessment of a controversial issue, but here is the definitive, conclusive, indisputable truth, sweeping away all contrary evidence and labelling opponents variously as knaves, liars or antisemites. Of all of the controversies [Phillips] has adopted as personal crusades, [MMR] is the most revealing. With infinitely more proof than global warming could ever hope to command, study after study has comprehensively refuted the Wakefield MMR-autism hypothesis, yet Melanie tastelessly maintains her contrarian position. She doesn’t seem to realise how revealing this is and how much damage it has inflicted on her defence of her other favourite causes. I agree with those who lament this personal and professional lapse of judgement. Instead of refreshingly adversarial, she now just looks silly.”

This summarised perfectly why it is that, for the last couple of years, I have been turning off BBC Radio 4’s The Moral Maze as soon as they announce that Melanie is on the panel. But perhaps it offers a clue as to the reasons for Phillips’ unwavering support of Wakefield, even as the scientific underpinnings of his ideas and his credibility have crumbled.

It is our old Alt.Reality friend the Galileo Gambit – an unshakeable belief that you must be right, precisely because everyone else is telling you that you are wrong.

Alternatively, of course, you could just be wrong.

How DARE you not take me seriously?

Something that comes across strongly in long argumentative threads on Alt.Medicine themes is a sense of just how seriously Alt.Reality folk take themselves. They also have thin skins. This is particularly marked, I have been finding recently, with Chiropractors.

Now, chiropractors are institutionally, as well as individually, thin-skinned – as the BCA vs. Simon Singh libel case, and recent events in New Zealand, show. They also seem to be rather humourless. I started to get this latter idea while reading a recent Economist thread on Alternative Medicine. Here you will find a Dr Robinson – a “Doctor of Chiropractic” (DC), to be precise – defending Alt.Reality and getting a bit huffy when anyone appears not to be taking her as seriously as she takes herself. Rather scarily – from my point of view – it turns out she works for this bit of the World Health Organisation (more about them here).

I casually (or possibly mischievously) posted a link to the Economist thread over at Respectful Insolence, thereby inadvertently triggering another “discussion” about Chiropractic and its relationship (or not) to reality.

The Respectful Insolence thread makes for an interesting demonstration of how many Alt.Reality types see their own professions, including those of their fellow “practitioners” who are at the wackier end of the spectrum:

Chiropractors who advise against vaccination? Just a few bad apples.

Chiropractors who push chiropractic for things that it is demonstrably useless for? Exercising their clinical judgement.

Chiropractors who wrench peoples necks around? There’s no stroke risk, the people who caution that there is, like Edzard Ernst, MUST be liars.

Chiropractors who call themselves “Doctor” and don’t make clear they are not conventional physicians? Well, why not, Chiropractors are fully trained clinicians, with all the expertise to resuscitate you if you keel over. (Seriously, some of them believe this).

Ben Goldacre once wrote somewhere that the most defining characteristic of CAM was its hard-wired inability to critique itself in any meaningful way. Threads like this show you exactly what he meant. And remember, a US “Doctor of Chiropractic” with the DC degree is the absolute top of the training tree in terms of a CAM practitioner, at least with regard to length of training. As Dr (of Chiropractic) Robinson pointed out to me, they do a postgraduate degree taking 4 years to become a DC, just like a conventional US medical degree which takes four postgraduate years.

Having said which, if I rocked up in an American ER with a chest pain, I would not want to see a DC. I would want an MD. And personally I would feel the same about a bad back. If I had back pain, and shooting pains down my leg, I would want a medical doctor to assess me. If I had uncomplicated lower back pain, and wanted spinal manipulation, I would go to a manipulative physiotherapist. A chiropractor might know slightly more background about spinal ailments than the latter, but I would have zero confidence in the clinical judgement of someone who believes that chiropractic spine-bashing is a useful way to treat a small child’s asthma.

[In the interests of balance, it should be said that there ARE some people in chiropractic who would like to make it evidence-based, and who campaign for chiropractic to remove the quasi-religious overtones, fact-free 19th century hocus-pocus, anti-vaccine propaganda, and general nuttiness. However, if recent surveys of what practising UK chiropractors actually believe are to be trusted, these reformers are going to have their work cut out. Needless to say, their ideas have not really caught on in the chiropractic community]

No logic please – we’re intuitively crazy

Last of all, and by far the best from a surrealist point of view, here is an example of Alt.Reality that provokes laughter and “you couldn’t make it up” in equal measure. Andrew Taylor of the “Apathy Sketchpad” blog tells us that he has been banned from the earnestly reality-free Homeopathy4Health blog.

The reason? He has been guilty of dangerous use of logic. Apparently logic is frowned upon when discussing homeopathy. Though I suppose one shouldn’t be surprised.

The blog owner, the homeopath who goes by “Homeopathy for health”, starts it off.  Another old friend of ours then chips in:

————————————————————————

Andrew’s comments are no longer allowed on this blog. This is because he has a tendency to write opinions based on logic and not from experience or facts. He is a programmer by profession.

Comment by homeopathy4health — 7 March 2009 @ 10:45 am

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h4h, that’s the funniest thing you’ve ever written. Am I to assume that only illogical arguments based on experience and facts are allowed?

I had a bad egg this morning, therefore it rained.

Comment by gimpy — 7 March 2009 @ 1:55 pm

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You can’t present opinion on logic alone.

Comment by homeopathy4health — 7 March 2009 @ 2:31 pm

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To which there is really no answer, apart from rolling on the floor helpless with despairing laughter.

Or – as they say – “You couldn’t make it up”

Which is, of course, where we came in.

Goodnight. And – as the late, great, Dave Allen might have put it –

“May your Personal Alternate Reality go with you.”

[BPSDB]


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