Archive for the ‘history’ Category

Measles – spot the worrying trend (Updated)

January 14, 2009


Widely reported in the media, the latest figures show that cases of measles are up again in the UK. The BBC has the story here, including a graph:

bbcs-hpa-graph

…while blogging GP Euan the Northern Doctor offers some analysis here. The story has also been well covered in the Bad Science Blogosphere by both jdc and by Martin the Lay Scientist.

As if by some sort of serendipity, yesterday also marked the re-start of the General Medical Council’s protracted “Fitness to Practise” (misconduct) hearings into Dr Andrew Wakefield, one of the key originators of the UK anti-MMR panic. If there is anyone reading not familiar with the media ”manufactroversy” over MMR, Ben Goldacre offers an introduction here, while journalist Brian Deer gives a magisterial, if lengthy, summary of his investigations into Wakefield and his work on his blog.

One interesting aspect of the new measles figures, highlighted by the Northern Doctor, is that the rates of measles infections seem to vary for different parts of the country. Which got me to wondering why. Of course there are many, many possible reasons, but one variable might be the extent, and kind, of pro-vaccination information that people see.

So what material does the NHS put out?

Pretty anodyne stuff, is the answer.

If you go to the NHS immunisation information site, you can find the current NHS MMR vaccination poster:

nhs-measles-poster

– the big red blob with smaller blobs around it presumably represent a virus particle, or perhaps new virus particles budding from an infected cell, although you would possibly have to be a scientist (or at least have done GCSE science) to work this out.

To me, the whole poster seems… well, boring. It is a pretty enough piece of graphic design, and has the key verbal message, but it has no “What?” value. Just a bunch of words.

The only NHS vaccination poster which appears to have any kind of “Warning” element is the one for the winter ‘flu jab:

uk-flu_jab-pic

This one has a few scary saber-toothed gremlin-type thingies, presumably again representing nasty ‘flu viruses, and a finger-wag. But, again, nothing to really stop you short.

Im Vaterland schaffen wir das anders…

In contrast, a couple of months back my German friend “Sceptic Eric” sent me some pictures of two German posters promoting vaccination that had appeared where he lives:

german-pro-vax-ad-no1-crop

The caption says:

Lisa, aged 9, is blind because of Rubella

(The smaller writing on the red backgrounds says “Vaccinate Now!”)

And the second poster:

german-pro-vax-ad-no1-crop-2

Daniel, aged 12 – left mentally handicapped by Measles.

These appeared, note, on big advertising bill-boards – not hidden away on the wall of the GP’s waiting room. They seem to me to be much more shocking – and thus memorable – posters than the UK ones. Instead of vague exhortations, they focus on the tragic consequences that can follow infectious diseases which people commonly view as harmless.

Ah yes. “Harmless childhood illnesses”.

An argument one often hears, typically from parents who do not have their children vaccinated is

“Illnesses like measles and mumps were a normal part of childhood. Loads of older people we know had them, and they were fine.”

Well, the German campaign gives some context for this statement. Some children who catch diseases like measles are emphatically NOT fine. Some get very ill, but get better, like the child whose story is described here. Some get even sicker, with things like pneumonia and encephalitis. And unvaccinated adults can get measles, and the nasty consequences, too. As I said in an earlier post, Mrs Dr Aust treated a few seriously ill adult cases like this in her days in hospital acute medicine and Intensive care.

And for Rubella, children with the disease give it to other people. Possibly including pregnant women. After all, pregnant women often have children, including nursery- and school-age children. Schools and nurseries are the best places you can think of for children to catch bugs from one another. This is, I suspect, even truer in the UK than in some other countries. If Governments and schools bang on relentlessly about high levels of attendance; if both parents work, and employers frown on time off for family reasons; if kids are almost universally in nursery from the age of six months up – then it stands to reason that there will be plenty of children at school and nursery who are clearly sickening for something, if not frankly ill. The UK, you might notice, fulfils all the above conditions.

If a woman in early pregnancy catches Rubella, she has about a 20% chance of miscarrying spontaneously. And if her pregnancy goes to term her child has a significant chance – 20-50% depending on precisely when in pregnancy the mother caught Rubella – of being born with Congenital rubella syndrome, which can mean serious physical and developmental problems, like blindness, deafness and mental retardation – as the first German poster indicates.

So why, I wonder, do we not have similar ram-the-vaccination-message-home poster campaigns here in the UK?

Do we think it is too graphic?

Or do we think that, because of all the media’s credulous reporting of the anti-MMR and anti-vaccine scare, people will look at posters like this and see “scare tactics and thought control”?

Or do they say “well, you can get them things just from getting vaccinated, innit?”

[ Err… not. The reported rate of “serious reactions” to MMR is about 3 in 100,000. In contrast, acute measles hospitalizes roughly one child in ten and kills one in every two to five thousand]

The tricks of memory

The flawed argument about “harmless childhood illnesses” is easy to understand. Most people have never seen a case of serious illness following measles. Ergo, measles must be harmless. They are blinded by their own personal experiences, and cannot seem to grasp the statistics.

I can understand this to an extent. I am a child of the 60s, pre the measles vaccination, and I had measles. I was OK. Others, of course, were not. But not anyone I knew.

The problem (from the POV of anti-vaccine scares) is that my experience is more common than the other – getting really ill, or knowing someone closely who did. So people in my age group commonly tend to know people that had measles (them and all their friends) but who got better with no serious, or at least lasting, consequences. They in turn tell their children and friends this.

Of course, the memory may not even be accurate. Even if a cousin or friend was in hospital as a child for a week, would you remember this after thirty years? If it was a classmate? If you too were a child at the time?

Personally, I have only one lasting memory before the age of about seven, and that is that the cake for my fifth birthday was shaped like Thunderbird One and had a Walnut Whip covered in red icing for a nose-cone. And I probably only remember that because there is an old family photo of it somewhere.

So – memory is unreliable. With the benefit of years that wipe away the memory of how lousy you would have felt when you had measles, your bout of measles gets recalled as “I must have had measles, so did everyone I know, we were all fine” (which may, or may not, be accurate) and then translated on into “measles is a totally harmless childhood illness” (which of course is rubbish, as we have already seen).

Heroes in the struggle for reality-over-scares

There is a great article on this, and the underlying statistics, here, written by a retired CDC epidemiologist who survived a life-threatening bout of serious measles complications as a kid in the late 50s. The author blogs as “EpiWonk”. Over the last year or so he has done a great job on his blog of the same name deconstructing the inaccurate and spurious arguments of the MMR-equals-horrors nitwits, specifically when they misuse and abuse epidemiology

And talking of measles, vaccination, and Dr Aust’s patch in the North-west of England, an honourable “local hero” mention should go to Dr Peter Flegg, an Infectious Disease consultant from Blackpool who spends a fair amount of his time online patiently explaining risk-benefit (and related topics) to do with vaccination.

Of course, a lot of the people he is trying to explain it to are figuratively sat with their fingers stuck permanently in their ears while shouting “nyeeah nyeeah nee nyeeah nyeeah, I can’t hear you”. But he keeps trying.

For a fairly recent example of both of these, try the British Medical Journal thread here, where you will find him discussing the relative risks and benefits of vaccination (versus actually catching measles). As you would expect, the real numbers are overwhelmingly in favour of vaccination. Even more remarkable is that Dr Flegg, with heroic restraint, manages not to lose his rag with Jackie Fletcher of JABS and her equally crackers friends.

Yet another person who deserves a lot of kudos for his tireless exposition of the nonsense of the anti-MMR lobby (and anti-vaccine nuts generally) is Dr Anthony Cox, proprietor of the BlackTriangle blog.  Cox has often been found over the years taking on the thankless task of debunking the anti-science ravings of media Wakefield Über-fan Melanie Phillips, and of various inhabitants of that stew of ignorance and prejudice known as “the JABS forums”. For this Cox regularly gets abused in personal terms by the JABS crew, who of course insist endlessly that they “don’t do ad hominem attacks”

So what to do?

So what do we take from the rise in measles rates?  We conclude, I think, that it is worrying, though not as worrying as the prospect of a further rise if vaccination rates don’t increase again. And we conclude that more effort is needed to get the vaccination message out.  And to educate people on the real rates of complications of measles, rather than of vaccines.

Perhaps it is time we spent some of the money the Government likes to spend paying celebs to appear in health campaigns on a pro-vaccination campaign (with or without celeb). Or on some German-style posters. Or both. We certainly need to do something.

Euan the Northern Doctor tells us he has managed more than a decade of practicing medicine in hospital, and latterly as a GP, without seeing a single confirmed case of measles – thanks, of course, to mass childhood vaccination:


“I don’t recall having ever seen a case of measles and I am hopeful it will stay that way.”

I hope so too. Though I am not all that confident.

[bpsdb]

——————————————————————————————–

Update:  Saturday  Feb 7th. Jeni Barnett is a mother and an ex-actress. So she knows all about vaccination. ..err…?

Since this post was written, the MMR vaccine has rocketed back into the news again in the UK (at least in the blogosphere) with the furore about actress turned rent-a-quote presenter Jeni Barnett and her spectacularly awful phone-in on vaccination. I have never, I think, seen an issue which has united the BadScience bloggers and the medical bloggers (like my e-friends Dr Crippen, Dr Grumble, the Jobbing Doctor and Euan the Northern Doctor) in such unanimous fashion. Indeed, it seems like Dr Aust is probably the only BadScience blogger NOT to have covered the issue (mainly because so far I can’t think of anything new or distinctive to say). Anyway, Holfordwatch has an excellent roll-call of the blogs which, in a predictable but gratifying “Streisand Effect”, have covered the issue.

Jeni Barnett’s astonishingly ill-informed comments, petulant on-air behaviour, and dismissive attitude to anyone – notably actual healthcare folks – that rang in to correct her demonstrate, yet again, just how idiotic – not to mention dangerously deluded -“personalities” can be when they comment on stuff they know F-All about.  Holfordwatch has links to all the transcripts if you haven’t already read them, or heard the programme.

It all reminded me oddly of  a depressing TV debate I saw, just a bit more than five years ago, that followed on from Channel 5’s airing of the notorious 2003 TV Play “Hear the Silence”, about a mother convinced her child had been damaged by the MMR vaccine. The play – Guardian TV review here – featured Juliet Stevenson as the mother, and had a ludicrously saintly version of Andrew Wakefield (glossily impersonated by actor Hugh Bonneville) as its main hero. It was a powerful and compelling piece of drama…

…except that everything in it relating to MMR was farcically inaccurate, and utterly wrong.

What got me, however, was not so much the play as the studio debate afterwards – in which Juliet Stevenson, a fine actor but with no scientific or medical knowledge or training, harangued the medical and scientific types about the (imaginary) risks of MMR vaccination. Embodying the role is one thing, but deciding you now know enough to harangue people about the science on national TV? As so often, the phrase “The Arrogance of Ignorance” springs to mind – see also Jeni Barnett, or Jenny McCarthy in the US.

You can read what the British Medical Journal’s commentators – child health experts David Elliman and Helen Bedford, and GP, author, and Channel 5 debate participant Mike Fitzpatrick – thought of Hear the Silence here and here. Sadly, you won’t be able to get to the full text versions unless you have BMA, University or Athens login privileges, though you will be unsurprised to hear that they were not impressed. However, you can read, for free, the Rapid Responses (e-Letters)  that the BMJ received about the articles. The thread following Fitzpatrick’s article is notable for some sane responses from another doctor-turned-author, Neville Goodman. You will be unsurprised that the thread following the other BMJ piece eventually ends up with anti-vaccine über-obsessive John Stone of JABS talking to himself (as usual) long after everyone else has left (as usual).

Meanwhile, more measles – and a death

Finally, just a couple of days ago, as the shit hit the fan over Jeni Barnett’s dismal programme, I got an e-Mail from my German-language correspondent Sceptic Eric, directing me here. This is a piece about a recent Swiss measles epidemic, including the death of a 12 year old girl from measles encephalitis (1).

Perhaps Jeni Barnett would care to read it before putting up any more ill-informed self-justification on her blog.

(1) Sorry, Google machine translation, so a bit incoherent, though you can get the gist. If you can read a bit of German, the original is here.

The same case (I think) is reported in the French-language Swiss press, e.g. here (a thank-you to Svetlana for pointing this out) – and English machine-translation is here.

—————————————————————————

Postscript

While I was writing the original lengthy ramble Californian blogger Liz Ditz drew my attention to a talk given by American scientist and “skeptic” Dr. Steven Salzberg a couple of months back in the States, and now up on youtube. If anyone needs a concise video introduction to the MMR anti-vaccine scare, it is a good place to start. Prof S thinks we should all be doing more to combat the still-bubbling anti-vaccine hysteria:

“Scientists and skeptics need to act to quell the rumors and educate the public, so that vaccines, one of the greatest medical successes in history, remain an effective tool in our fight against disease.”

The talk may be a bit US-focussed for UK listeners, but it is a good introduction to the whole story. It is in five parts – if you haven’t got the patience for the whole lot, and/or are already familiar with the main bits, you could skip to parts four and five to see the kind of things that American defenders of vaccination like Dr Paul Offit are up against (more on Offit here).

Part One,  8:31 min – Intro to autism & Wakefield’s paper.

Part Two, 7:54 – Brian Deer’s revelation of Wakefield’s misdeeds and Wakefield’s responses.

Part Three 6:34– Mostly on the thimerosal (vaccine preservative) – autism scare so beloved of ex-travel writer David Kirby

Part Four 8:54– Why Is Autism Ripe for Quacks to Exploit? segueing into “What does science say about autism?”

Part Five 8:49 – Continued discussion of increased incidence of vaccine preventable disease with fall in vaccination levels, plus a discussion of “Is there an autism epidemic?” and “What is really known about the causes of autism”. Finishes with US lawyers’ attacks on vaccines and courting of public opinion by anti-vaccine groups.

Advertisements

It’s quiet…. Too quiet

December 23, 2008

carry_on_up_the_kyber_4

As the year draws towards its end, what has become of one of the big Alt.Reality stories of the year in the UK – the back-crackers Chiropractors vs. Simon Singh libel action?

Well, legal blogger Jack of Kent has been keeping a weather eye on the procedural bubblings-under of this case, in which the British Chiropractic Association (or BCA) are suing noted science writer Simon Singh for being mean about them.

As those who have been following the case will know, it all stems from a short Opinion piece Singh wrote in the Guardian back in April. In the article he repeated what he and Edzard Ernst had said in their excellent book Trick or Treatment; namely that there is no credible scientific or medical evidence that chiropractic can treat lots of things wholly unrelated to your spine, such as asthma in children, colic in babies, sleeping problems in babies, feeding problems and so on.

All of which claims appear on the British Chiropractic Association’s website here (NB – PDF).

The BCA promptly sued. Which ensured them the undying derision of the Bad Science Blogosphere –see e.g. Holfordwatch’s summary here – and also promulgated knowledge of Singh’s claims, and the BCA’s rather thin-skinned response, across the Interwebs – the so-called “Streisand Effect” or “Spartacus Effect”. Much online discussion ensued, including my own extended (not to say downright longwinded) amateur legal analysis of the ways in which Singh might defend the suit.

Subsequently, all went quiet until about a month ago, when Jack of Kent reported that the BCA’s lawyers had finally detailed how they felt Singh had libelled their clients, and that subsequently Singh and his lawyers had filed their defence, i.e. had outlined the basis on which Singh would seek to defend the action. I was pleased to note, if I may be allowed a bit of self-congratulation, that my analysis of both the libel and of the likely defences had been reasonably close.

One of the most interesting aspects of Singh’s outlined defence is that he does not appear to be proposing to use a simple defence of “fair comment” (in effect, to say that the allegedly libellous bits of what he wrote were his honestly held opinion based on the facts). The filed papers strongly suggest that Singh and his legal team are prepared to “go the distance” and argue justification, i.e. to argue that the remarks Singh made debunking the Chiropractors’ claims were materially true and accurate.

This is interesting, because it is a much more nail-your-colours-to-the-mast position – especially under the plaintiff-friendly British libel laws – than “fair comment”.

As I discussed at length before, a straight “fair comment” defence would probably be the standard newspaper “get-out clause” for defending this kind of libel action. Indeed, in my earlier post I suggested that the BCA might actually be banking on Singh filing a “fair comment” defence:

“I suppose it could be that the BCA are taking the action specifically in the hope that Singh will file a “fair comment defence”, the idea being that they can then issue a ringing public statement arguing that Singh has admitted his comments about the BCA are “opinions rather than facts, by his own admission”. Of course, that would not dispute the facts on which the opinions are based.”

Now, if this was an accurate reading of the mindset of the BCA, then Singh’s filed defence has rather called their bluff. Jack of Kent quotes from the defence brief:

Further or alternatively, insofar as necessary the Defendant will justify the article in the following meanings:

(a) The Claimant [BCA] is …  promoting chiropractic as a treatment for infants and young children with colic or sleeping and feeding problems or frequent ear infections or asthma or prolonged crying [even though]  (as it should be aware):


(i) that there is reliable scientific evidence that this would be ineffective in respect of children with asthma, and/or


(ii) that there is no/no reliable scientific evidence supporting the effectiveness of such treatment for each of those conditions/symptoms, and/or


(iii) that in the circumstances chiropractic treatment for none of those conditions /symptoms is worth the risk of adverse side-effects,


and such treatment is to that extent bogus.”

(one or two minor edits to hopefully reduce the risk of my being sued – you can see Jack of Kent’s blog for the unexpurgated version)


Jack comments:

”As the onus will be on Simon Singh to demonstrate these factual justifications, again the trial will deal fully with expert evidence and cross examination as to the efficacy of Chiropractic.”

Later, Jack spells it out again:

“For the BCA to fully meet Simon Singh’s defence means that the efficacy of Chiropractic in respect of six children’s ailments will require scrutiny by the court, cross-examination of experts, and the testing of the validity of the “scientific evidence” which the BCA cites in support of the efficacy of Chiropractic.

As I said above, the real effect may be to put Chiropractic on trial before the English High Court.

This offers the tantalizing prospect of a series of eminent scientific and medical figures, like Directors of the Cochrane Collaboration, Professor Edzard Ernst, Professor David Colquhoun, and Professor Michael Baum, all trooping into the High Court. Firstly to explain the nature of scientific evidence, and how it is assessed and synthesized, and secondly to set out why the state of the scientific and medical evidence does not support many of the claims made by chiropractors for chiropractic.

Would the BCA, one wonders, really want to have a libel case defended on this basis heard, doubtless over many days, in the High Court in the full glare of the media?

Well, at the moment we don’t really know – because:

It has all gone quiet – very quiet.

In particular, Jack of Kent notes that the BCA and their lawyers have not filed a “Reply” to Singh’s defence. As I am not a lawyer, I am a bit hazy as to the precise point of this “Reply”. However, one possible use of such a Reply, I surmise, could be to allow the BCA’s legal team to dispute whether any of Singh’s proposed modes of defending the action are allowable, or arguable, in law. Again speculating, it could allow them to argue the legal niceties of whether what Singh says he meant (which interpretation makes his words less libellous in law) is less plausible than what they (the BCA) contend his words would usually be taken to mean.

If that sounds a bit convoluted, then it is probably because I’m not explaining it very well. But essentially, a lot of the case might conceivably reduce to what the word “evidence” is commonly taken to mean in the context of a discussion of the “evidence” supporting a treatment. Singh will almost certainly argue that when someone says “evidence” this way – when he said it – it means “the balance of the scientific evidence, scientifically assessed for believability and combined by techniques like scientific review and meta-analysis – which is the way scientists and doctors would do it”

The BCA are likely to argue that evidence means “any evidence, including equivocal or poorly done trials, case reports, customer testimonials, and other evidence which scientists and doctors regard as wholly unreliable.”

Now, if you were the BCA, you might wish to dig out a lot of legal precedents – assuming you could find some – that said that the courts take “evidence” to mean de facto “absolutely any sort of evidence at all” rather than “the balance of scientific evidence”. And you might want to put these arguments in the “Reply” to head off Singh’s defence in advance – sort of:

“You can’t argue the word “evidence” commonly means what you wish it to mean here, because it’s meaning in this context is already well established in law, and it’s what we have been saying it means – so you cannot mount your defence on this point.”

Now, as I am not a lawyer, all of this last bit could be a load of utter nonsense. If so, hopefully Jack of Kent or someone else better informed will come along and put me right.

However: whatever the precise legal purpose of the “Reply”, to date a ”Reply” has not appeared. Jack of Kent’s piece makes clear that this is rather unusual for a case of this type. Jack runs through some possible reasons for the missing “Reply” here.

Will they… Won’t they… Will they… Won’t they…

I have always doubted myself that the BCA would really want this one to go the distance. If I were the BCA’s spin doctor, I would probably be telling them to try and think of a way of staging a tactical retreat, whilst simultaneously claiming that they had been vindicated. However, murmurings emerging from Chiro-world, as briefly chronicled by Jack of Kent, seem to suggest that some voices at least within the BCA think they have to carry on to the bitter end in order to “defend the reputation of the profession”.

To which one might respond – “Err…?”

Now, one could perhaps usefully ask at this point what the general view on chiropractic is among practicing health-care folk, as opposed to among the academic ninjas of evidence-based medicine like Ernst and Colquhoun.

Well, among the medical doctors I know well, the consensus view on chiropractic seems to be roughly that summarized by American physician (and noted medical blogger) PalMD here:

“I am often asked my opinion of chiropractic care. My usual answer (based on evidence) is that it can be somewhat helpful in the treatment of low back pain. That’s it. Any further claims are complete and utter …”

see Pal MD’s post for the rest. It is well worth a read.

It also bears repeating that Professor Edzard Ernst himself, co-author with Simon Singh of the book from which Singh’s disputed claims arise, is not just one of the world’s foremost experts on the assessment of evidence for and against “Complementary Therapies”. He also has long had a special interest in “spinal manipulation therapies”, of which Chiropractic is one. This almost certainly reflects Ernst’s background as a rehabilitation physician. Prior to taking up the Complementary Medicine Chair in Exeter in the mid-90s, Ernst was the Head of the Department of Physical and Rehabilitation Medicine in the University of Vienna’s Medical Faculty. This would mean he is very familiar with physical therapies, probably including spinal manipulation therapies. He may even have trained to carry out spinal manipulation on patients.

It must be highly doubtful, to put it mildly, whether the BCA will be able to find anyone with a matching level of expertise and credibility to argue that Ernst’s damning assessment of the scientific evidence regarding their more outlandish claims is incorrect.

So who thought up all this back-cracking business?

Another thing that might not help Chiropractic is that a high-profile court case would be expected to trigger some media stories exploring their beliefs. It is a fair assumption, I think, that a setting out of the origins, history and philosophy of Chiropractic would not help the BCA’s credibility, either in court or on the wider world. A neat and amusing summary of some of this history was given by Private Eye, which covered the Singh libel case earlier this month:

chiro-extract

All hardly likely to cast Chiropractic in a flattering light,  I would say.

A further intriguing point is that this is all happening at a time when spinal manipulation for lower back pain (something practised by several different groups of practitioners, including chiropractors) is fairly widely available, and viewed as a reasonably mainstream intervention.  If I were the back-crackers, this is just the time when I would be keeping a low profile and trying desperately not to look like a bunch of quacks, cranks, and loonies.

Hence my doubts that the case will go the distance.

But…but…

But – it is a predictable part of the mindset of many Alternative Practitioners, and of their “professional organizations” too, that they have little or no self-insight in certain key respects.  Specifically, they have no insight into either the intrinsic silliness and implausibility of their beliefs, or the central sticking point of their repeated refusal to engage with actual evidence on the key question of efficacy.

It seems constitutionally beyond them to understand that the basic reasoning in healthcare has to be:

“Well, the evidence that [insert your therapy of choice] works for X is reasonable… but the evidence that it works for Y is much dodgier, and near to non-existent, and it is pretty clear-cut that it doesn’t work at all for Z, and might even be harmful… so we should stick to offering it for X, and should discourage our wackier practitioner brethren from offering it for Y and definitely for Z.”

Don’t, though, expect to get this kind of logic from full-on Alt.Reality merchants like the homeopaths. The vast majority of them simply cannot get their heads round this kind of thinking, whatever soothing noises they may make for public consumption.

To repeat for the umpteenth time: They believe it works.

Evidence, schmevidence. They believe. They know.

And as a corollary, many of them seem to believe their therapy of choice will work for nigh-on everything, from asthma, to a bad back, to a blocked nose, to depression, to pre-menstrual tension.

Again, careful sifting of evidence, condition by condition – who needs it?  We just know.

And finally…

Chiropractors are regulated by professional bodies. They are a registered healthcare profession. That, it seems to me, is part of why they are suing Singh.  Their sense of their own gravitas has been offended.

But: judging from these claims the BCA make for chiropractic “treating” all sorts of things that have nothing whatsoever to do with your back – and if one takes it that many of their members will be offering these treatments –  it would not appear a stretch to argue that many chiropractors seem to struggle to recognize where the limits of effectiveness of chiropractic lie.

And if anyone points this out? They sue.

Now, I would expect a “registered healthcare profession” to argue claims about their therapy, and the evidence supporting it, in the scientific and medical literature.

To quote (again) the Editor of the New Zealand Medical Journal, Prof Frank Frizelle, when the New Zealand Chiropractic Association recently threatened to sue him, his journal, and his authors:

“Let’s see your evidence. Not your legal muscle”.

However… given their sense of wounded dignity, we may yet see the BCA’s lawyers and Simon Singh’s lawyers facing off in the High Court. In which case we stand to get both “legal muscle”, and evidence.

Personally, I shall be looking forward to it.

[BPSDB]

The Tragic Human Cost of Political Idiocy and AIDS Pseudoscience

December 13, 2008

In which Dr Aust ruminates somewhat unoriginally on the desperate consequences of delusional thinking about medicine… when the deluded are the people running the country.

Somewhat submerged under the media storm over the Bombay terrorist attacks, last month saw the publication of a sobering estimate of the true human cost of the Mbeki government’s decade of incomprehensible HIV denialism in South Africa. The Guardian covered the story here.

The basic history is no doubt well known to most readers in the Badscience blogosphere; as the millenium dawned, South Africa faced an unprecendented AIDS crisis, with 10% of the population infected with HIV. However, seemingly enchanted by the claims of maverick scientists like Peter Duesberg, President Thabo Mbeki and his government decided to pursue a policy based on the view that HIV was not the cause of AIDS. They therefore failed to implement programmes of treatment with antiretroviral drugs – the drugs that had transformed the prognosis of HIV-positive patients in other parts of the world in the late 90s.

They continued with this policy as yet more scientific evidence accumulated that HIV was the cause of AIDS.

They continued as HIV-positive people in many other countries had their death sentences stayed by antiretroviral therapy.

They continued even when the cost of the antiretroviral drugs tumbled, and when global schemes were set up to fund the treatment programmes.

They continued even though studies showed antiretroviral treatment was cost effective in South Africa.

And they continued even when South Africa’s poorer regional neighbours, like Botswana and Namibia, managed to implement treatment programmes.

The authors of the recent estimate summarise some of the timeline in a handy diagram:

hiv-timeline

To see the original,  go to the paper, click the “Full text” link, then “Fig. 1”, and finally click the figure itself to get an enlarged version – or, when you reach the full version of the paper, click “View full-size inline images”.

Among the things the Mbeki government failed to do was implement programmes to treat HIV-positive pregnant women. An untreated HIV-positive woman has around a 25% chance of passing HIV on to her child during childbirth. With antiretroviral therapy, that transmission risk can be reduced to around 10% in developing world settings with vaginal delivery, or even to only a few per cent in some recent studies (for a medical review of some recent trials see here, or the Cochrane summary here). This is not enough on its own, sadly, as breast feeding can also pass on the virus – but it is a start. Around half to two-thirds of children who acquire HIV from their mothers in the developing world do so during delivery.


Estimating the true cost in lives

The stories that appeared last month centred round a new analysis, by a group of workers from the Harvard School of Public Health, that estimated how many lives the Mbeki regime’s failure had cost. They did this by assuming that South Africa could have achieved something approaching the kind of treatment coverage and results that proved possible in neighbouring Botswana and Namibia, countries with similar social and infrastructure “contexts”.

The authors estimate – and they make clear that their estimates are “conservative”, so likely to be on the low side – that each year from 2000 to 2005, about 7000 HIV-positive babies were born in South Africa who could have been born virus-free had their mothers been treated.

They also estimate that around a third of a million people in all died unnecessarily over these five years. People who might have lived had they got timely treatment with antiretroviral medication.

The terrible effects of this death toll, of course, go beyond the lives of those lost. In the Introduction of their paper, the authors note that:

Approximately 1.2 million children [in South Africa] younger than 17 years have lost one or both parents due to the [HIV/AIDS] epidemic”.

So what caused the Mbeki Government’s disastrousfailure? The authors of the study discuss one salient issue, that of the cost of the antiretroviral drugs, and conclude that this cannot account for the South African government’s actions. They could have afforded the programme, as their poorer neighbours ultimately did. The cost of the drugs has dropped dramatically over the last decade, largely due to pressure on the pharmaceutical companies from activists and campaigners – the real heroes of the hour – as well as from governments, NGOs and charities. So cost alone was unlikely to have been the decisive issue.

The South African government also chose to convince itself that the scientific consensus that HIV caused AIDS was uncertain.

One vehicle for this was Mbeki’s notorious Presidential Advisory Panel on AIDS in 2000. The Panel included Peter Duesberg and a bunch of other “HIV sceptics”, like Harvey Bialy and David Rasnick (the latter now seems to have fetched up working for the Dr Rath Health Foundation in South Africa).

As the British Medical Journal noted at the time:

“At least half of the Presidential Advisory Panel on AIDS, as the group is now known, are scientists and doctors who have disputed the orthodox views on AIDS. Many of these do not believe HIV causes AIDS.”

Unsurprisingly, the Panel rapidly split into two distinct groups; those who believed HIV was the cause of AIDS, and recommended rapid institution of retroviral treatment programmes along with public health measures; and those, like Duesberg, who denounced the HIV hypothesis and recommended (largely) public health measures alone. The Panel’s report, which can still be found online in full here (warning! – 1 MB PDF), makes bizarre reading; it is really two reports in one.

What appears nowhere in the report is any hint that the HIV sceptics, who were well represented and even in a majority on the Panel, were representative of a tiny – if vocal – minority of the scientists and doctors studying AIDS worldwide.

In a recent editorial, entitled “The Cost of Silence?” Nature suggests that the mainstream scientists and doctors might have done better to have refused to serve on the Mbeki Advisory Panel at all. Their participation, Nature says, led to the appearance in the Panel’s deliberations that there was a real scientific issue to be argued. The Panel’s report, in turn, presented this “dichotomy of views” – when really there was a massive preponderance of evidence, and expert views, on one side, and a lot of evidence-free fringe theorizing on the other. This appearance of an undecided issue gave the Mbeki government the fig-leaf it needed to state that the issue was still contested, and to stall on antiretroviral therapy programmes. While Nature does not state outright that it thinks the South African government had already made up its mind when it set up the Panel, the implication is clear.

Reading the Advisory Panel report, one can perhaps catch glimpses of why the “HIV is not the cause” case might chime with the thinking of some populist politicians. Since they had decided HIV was not the agent causing the AIDS epidemic, the “HIV sceptics” could instead call for progress on a long list of the kinds of things dear to politicians’ hearts:

———————————————————————————————–

The recommendations listed below were proposed as necessary and sufficient to combat all the risk factors that are the real cause of AIDS:

1. Improving sanitation and public health measures to decrease water-borne diseases.

2. Strengthening health infrastructure.

3. Reduction of poverty and improving general nutrition and implementing nutritional education and supplements for the general population.

4. Improving screening for and treatment of sexually transmitted diseases.

5. Promoting sex education based on the premise that many sexually transmitted diseases and pregnancies could be avoided.

6. Implementing public education campaigns to destigmatise AIDS and reduce public hysteria surrounding the disease.

9. Treating infections vigorously and timeously (sic – possibly meaning “in a timely fashion”).

10. Increased support for and promotion of research into the development of drugs against AIDS, its cofactors and risk factors.

12. Implementing aggressive programmes to empower women and change the power relations between men and women.

13. Reducing the vulnerability of communities by improving access to health care.

14. Improving literacy.

[Presidential AIDS Advisory Panel Report: March 2001: pp 86-87].

—————————————————————————————–

Now, none of these is a bad thing – far from it. Who could argue with any of it? All good stuff, and the “HIV causes AIDS” group on the panel said many of the same things in their recommendations.

But – and it is a very, VERY big “But”- these laudable measure were, sadly, just not what was needed as a first priority in the face of an unprecedented epidemic of a deadly but slow-acting viral disease. Or, at least, they were not enough, and never would be. They would do some good – but not nearly as much good as if they had been combined with an immediate and vigorous campaign of treatment with antiretroviral drugs.

There is also another side to the catastrophe, as noted by many commentators, including Bad Science’s own Ben Goldacre, and also the Harvard authors:

The South African government, through the Health Minister Manto Tshabalala-Msimang, …continued… to divert attention from ARV drugs to non-tested alternative remedies, such as lemon juice, beetroot, and garlic, sometimes even promoted as better alternatives and not supplements for AIDS treatment

Tshabalala-Msimang scores high on the infamy scales for me because she is, almost unbelievably, a medical doctor who trained in obstetrics and gynecology and later in public health. I am truly dumbstruck that a person with her professional background could have participated in such an orgy of delusion. Though if some of the stuff that newspapers in South Africa have printed about her is true (see e.g. here and here) it is pretty scary that she was a Minister in the first place.

Anyway, the quackery was doubtless not just Tshablala-Msimang’s idea; the promotion of alternative therapies was prominent in the recommendations of the HIV denier half of the Advisory Panel. The keen-eyed reader will have noted the omission of several numbered points from the list above. The missing ones are as follows:

———————————————————————————————–

7. Investigating the use of immune-boosting medications, such as interferons, growth factors, B-complex vitamins and herbs (such as ginseng, Chinese cucumber, curcumin, aloe vera, garlic and echinacea).

8. Encouraging the detoxification of the body through several inexpensive interventions, such as massage therapy, music therapy, yoga, spiritual care, homeopathy, Indian ayurvedic medicine, light therapy and many other methods.

11. Encouraging the involvement of complementary medical and health practitioners, including indigenous healers, in research and clinical fields.

(Italics mine)

——————————————————————————————–

Following the embracing of this menu of delusion by the Mbeki government, Tshablala-Msmang enthusiastically promoted it – no doubt applauded by plausible nitwits, sorry, “Nutritionists”,  like Patrick Holford, and by the “Pope of Vitamins”, Dr med Matthias Rath. Both Holford and Rath have spent a lot of time in, and promotional effort on, South Africa these last eight years or so.

It does not take a genius to surmise that they would have seen a large market, full of often poorly-educated people, where their seductive nutritional remedies (“no nasty toxic drug side effects!”) would appear almost officially sanctioned.

Admittedly, the role of AIDS deniers, of alternative medicine idiots, and of vitamin pushers like Rath and Holford, are minor compared to the overwhelming responsibility of Mbeki, his Health Minister, and the rest of the President’s deluded inner cabal. But there is an obvious element of “toxic enabling” at work.Which suggests:

—————————————————————————————-

A BadScience Formula:

Self-deluding scientifically illiterate politicians

+ vocal “skeptics of the scientific orthodoxy”

+ “traditional healing practices” enthusiasts

+ vitamin salesmen and Nutritionistas

+ endless ill-informed media reportage, especially of the previous three groups

= possibly catastrophic consequences

———————————————————————————–

Anyway, I would like to think that the next time dear old Patrick Holford says something mind-bogglingly dim like:

“[The retroviral drug] AZT is… proving less effective than vitamin C” [ in treating HIV]

– or the next time that Matthias Rath claims that modern medicine is a Pharma conspiracy to keep people sick – that someone will be there to remind them of just where their preferred nostrums and delusions can lead.

You might, for instance, like to ask Patrick:

“So can Vitamin C prevent mother-to-child transmission of HIV, the way that anti-retrovirals do?”

I would love to know what his answer would be.

Getting back to the paper, the authors’ conclusion is chilling:

“Access to appropriate public health practice is often determined by a small number of political leaders. In the case of South Africa, many lives were lost because of a failure to accept the use of available [antiretrovirals] to prevent and treat HIV/Aids in a timely manner.”

One can only hope that political leaders elsewhere have proper scientific and medical advisers. And that they can keep their minds free of the soothing claptrap peddled by the fans of Alternative Reality.

Although looking at the way that politicians in the UK these days persist in regarding CAM as purely an issue of consumer choice, with no health implications… sometimes I am not so confident

—————————————————————————————

Notes:

This post is not very original, and obviously owes a lot to Ben Goldacre’s coverage of the issue. Talking of which, word in the bookosphere has it that the revised edition of Ben’s Bad Science book, due out next Spring, will have an extra chapter devoted to Herr Dr Med Matthias Rath, in which the learned Herr Doktor’s South African activities can presumably be expected to feature prominently.

Another good guide to the history of the South African HIV denialism catastrophe is the Skeptical Inquirer article by South African economics Professor Nicoli Natrass.

Finally, a longer and more scholarly article written earlier this year by Prof Nattrass for the journal African Affairs, can be found here. It includes an earlier estimate of the human cost of Mbeki’s policies, broadly similar to the Harvard study’s conclusions. This article also has a section (pp 169-171) dealing with Rath and other peddlers of “nutritional solutions”, and their relationships with Tshabalala-Msimang.

[BPSDB]


Some history: double-blind trials are a hundred years old (give or take a year)

November 15, 2008

Sorry, no bad science trashing this week – a bit of scientific historical rambling instead, reflecting another of my part-time interests. Probably too serious, too. I blame the clocks going back – pesky SAD.

The recent plethora of (often rather good) TV and radio programmes commemorating the 90th anniversary of the end of World War One set me to thinking this week.

What is the link between the WW1 trenches, a best-selling modern novel and a pretty good film, and the history of double-blind trials?

The answer is a man – William Halse Rivers FRS (1864-1922), Gold Medallist and Croonian Lecturer of the Royal Society, scientist, ethnographer, founding father of British anthropology, psychology and psychotherapy, Cambridge don, physician, wartime Royal Army Medical Corps doctor and author of a key early account [1] of treating ”war neurosis” – shell shock as they might have said then, post-traumatic stress disorder (PTSD) as we would say now.

Rivers died comparatively young (58), from an acutely ischaemic bowel. He fell ill while alone, and by the time he was discovered it was too late to operate. He was much mourned by his scientific colleagues – for instance, the then President of the Royal Society, the Nobel Laureate Charles Sherrington, referred to Rivers’ death as “cutting short in the fullness of his activity and powers a psychologist and ethnologist of exceptional significance”. Rivers was also mourned by the many young officers with “war neurosis” who he had helped at the Craiglockhart War Hospital near Edinburgh, notable among them the writer and poet Siegfried Sassoon. It is this episode in Rivers’ and Sassoon’s lives that has made Rivers famous again. Their relationship as doctor and patient features centrally in Pat Barker’s novel Regeneration.(1991) and the 1997 film of the same name, aired again recently on the BBC digital channels, in which Jonathan Pryce portrays Rivers.

[The book and film also portray Sassoon’s friendship with another Craiglockhart patient, the war poet Wilfred_Owen. There is a good interview with Pat Barker which discusses her work here]

wartime-riversPryce as Rivers

Caffeine, alcohol, and double-blind trials

As already noted above, Rivers’ career took in an amazing range of disciplines. His role in the instigation of double-blind trials comes from one of the less well-known bits, his researches into the effects of caffeine and alcohol on muscle fatigue. This work was carried out around 1906-7 in Cambridge, and is described in a 1907 paper in the Journal of Physiology [2] and in Rivers’ 1908 Croonian Lectures to the Royal Society [3]. Rivers had been appointed to a Cambridge University lectureship in ‘physiological and experimental psychology’ in 1897, and worked in Cambridge for the rest of his career, barring anthropological expeditions and his wartime work. As the job title suggests, Rivers’ interest was in the interplay of the physiological and the psychological. This can be seen in his interest in the effects of alcohol, where the measured “physiological” changes in a subject’s exercise performance were clearly heavily influenced by his psychological state and reactions. In addition, there was a possible psychological effect on the experimenter, who might bias the results by, for instance, being more encouraging and enthusiastic if he knew the experiment was using the drug rather than the control.

The placebo and blinding techniques Rivers and Webber used were an attempt to minimize these psychological influences. In the 1907 paper they describe the method for the caffeine experiments:

“Each experiment was prolonged over a number of days, on some of which a dose of caffeine was taken, and on others a dose of the control. Both the caffeine and control mixtures were in most cases prepared for us by Dr W. E. Dixon for whose kind help in this respect we are very greatly indebted.

We took the caffeine in the form of the citrate, and the control consisted of a mixture of gentian and citric acid … it was not till the end of the whole experiment that we acquainted ourselves with the nature of the dose on any given day.’

Walter.E. Dixon FRS (1871-1931) was a famous early British pharmacologist who you can read about here. Dixon shared River’s interest in disentangling the psychological and physiological aspects of the effects of things like alcohol. Gentian was presumably used because it has a strong bitter taste, mimicking the bitterness of caffeine; Gentian is one of the main flavours in Angostura Bitters, a fairly loathsome herbal concoction used to this day in making cocktails. For enthusiasts of British Imperial Tradition, Angostura is one of the ingredients in the British Naval officer’s traditional Pink Gin.

Rivers and Webber’s experiments with alcohol used a similar double-blind placebo design, with the alcohol, or (placebo) control, again prepared by a third person and with the experimenter and subject (Rivers and Webber alternated in these roles) not knowing which was which. Disguising the taste of alcohol required a more complex concoction containing capsicum, (hot chilli pepper extract), cardamoms, chloroform and peppermint. What this would have tasted like I cannot imagine, but it must have been quite something.

“Ancient wisdom”, belief, and medicine

Rivers was clearly regarded in his time as a significant scientific figure. Though many of his ideas have inevitably been superseded or disproved, his place as a key founder of British psychology and anthropology, is secure. Indeed, in the age of vanishing habitats, languages, tribal customs and indeed entire ways of life, many of his remarks about primitive peoples, and their endangerment by the actions of Western society, seem prophetic. Rivers studied the social structures of the tribal people of Melanesia – he is said to have felt that his History of Melanesian Society, published in 1914, was his finest work – as well as their traditional healing practises [4]:

I hope that the facts brought forward in these lectures are sufficient to show that in the department of his activity by which he endeavours to cope with disease, ”savage” man is no illogical or prelogical creature, but that his actions are guided by reasoning as definite as that which we can claim for our own medical practices.”

– Rivers, second Fitzpatrick lecture, 1915

So does this mean Rivers would have been a fan of modern alternative medicine, with its enthusiasm for “Ancient Healing Wisdom”? Personally I think not. Rivers was clear that in all his many activities he tried to apply the best of the scientific method as it stood at the time. In the passage above he is saying that “ancient healing wisdom” is based on a clear and structured set of beliefs. He is not saying that these beliefs are true, or that the practises work. Indeed, I suspect Rivers would have believed that any effectiveness of these methods depended on suggestibility, and particularly the patient’s and healer’s shared belief. This shared belief is culturally specific; a traditional healing practise would have a psychological effect dependent on its setting and culture, not due to any “intrinsic power” of the actual healing method.  So what Rivers is saying here is nothing like the “it is traditional and therefore it is just as good as the modern scientific stuff” view popular with modern Alternative Reality types.

Rivers’ treatments of the shell-shocked officers were psychotherapeutic in nature – “talking therapy” – and Rivers was clearly aware of, and fascinated by, the interplay between the physiological and psychological side of medicine and treatment. In this his thinking somewhat puts me in mind of modern medical social scientists who emphasise ”Health_Beliefs” as part of understanding the process of treatment, and the perception of how well it is working.

“As medicine has progressed and has been differentiated from magic and religion, [the] play of psychological factors has not ceased.

Few can now be found who will deny that the success which attended [many remedies and treatment regimes] of the last generation was due mainly, if not entirely, to the play of faith and suggestion. The salient feature of the medicine of today is that these psychical factors are no longer allowed to play their part unwittingly, but are themselves becoming the subject of study, so that the present age is seeing the growth of a rational system of psychotherapeutics.”

– Rivers, final Fitzpatrick lecture, 1917.

Rivers would doubtless have found modern psychological therapies, like Cognitive behavioral therapy (CBT), fascinating. A bit fancifully, I would guess that a Rivers re-born in the modern age would also be fascinated by contemporary research into the placebo effect, in all its different manifestations. I like to think that, faced by modern Alternative Therapy, Rivers would want to insist on a clear-headed scientific discussion of the role played by beliefs and suggestion. He would certainly have insisted on the need to design experiments and trials rigorously to take account of, and where necessary exclude, such effects. After all, before one can study where physiology and psychology interact, one needs to make the effort to be able, as far as possible, to tell them apart. This is as true now as it was when Rivers was doing his caffeine and alcohol experiments a century ago.

Memorials

Rivers is not much remembered these days for his pioneering use of the double-blind experimental design, though he does get an honourable mention for it over at the James Lind Library site. And while Rivers’ role as a founder of modern British psychology and ethnology is well-known in academic circles, it probably does not go far beyond that.

Perhaps fittingly, given the affection in which Rivers was held by so many of those he came into contact with, the aspect of his life that has given him his most lasting memorial was the wise and concerned doctor and therapist, helping his Craiglockhart patients cope with their war nightmares and flashbacks. Apart from Pat Barker’s fictionalized account, Sassoon and his friend Robert Graves both wrote about Rivers in their respective memoirs [5], and Sassoon made clear that he felt Rivers had saved his life –as the poem below, written many years after the war, attests. It is not a terribly good poem, but the last couple of lines of each stanza give a sense of the debt Sassoon felt he owed Rivers. Finally, in a discussion a few years back in the British Medical Journal about “portrayals of doctors in fiction that would be good role models”, the Rivers character portrayed in Regeneration was mentioned several times. Which strikes me as a pretty good way to be remembered.

Revisitation 1934 – Dr W H R Rivers – Siegfried Sassoon

What voice revisits me this night? What face

To my heart’s room returns?

From that perpetual silence where the grace

Of human sainthood burns

Hastes he once more to harmonise and heal?

I know not. Only I feel

His influence undiminished.

And his life’s work, in me and many unfinished.

————————————-

O fathering friend and scientist of good

Who in solitude, one bygone summer’s day,

And in throes of bodily anguish, passed away

From dream and conflict and research-lit lands

Of ethnological learning, – even as you stood

Selfless and ardent, resolute and gay,

So in this hour, in strange survival stands

Your ghost, whom I am powerless to repay.

1. Rivers WHR “The Repression of War Experience” Lancet, XCVI., pp. 513-33, 1918. The article can be found on the net here.

2. Rivers WHR and Webber HN. The action of caffeine on the capacity for muscular work” Journal of Physiology 36: 33-47: 1907 (August).

3. Rivers WHR. “The influence of alcohol and other drugs on fatigue”: Croonian lectures 1906” London: Arnold, 1908 Some pages from the lectures can be read.here.

4. Rivers WHR. “Medicine, Magic and Religion” Fitzpatrick Lectures 1915, 1917.. Lancet 1916; i: 59-65, 117-123; 1917;2: 919-23, 959-64.

5 Sassoon writes about Craiglockhart and Rivers in Sherstons Progress, the third and final part of his memoirs of WW1; Graves mentions Rivers in his famous memoir Goodbye To All That

[BPSDB]