At last year’s conference, John Scott spoke on the problems of mixing misinformation and medicine.
Early in my medical career I became aware of the enormous distorting forces which operate upon science in the real world. In my field the forces were those of Quaker Oats, Kellogg, Sanitarium, the diary industry, the AMA, elements within the cardiology camp, and the tobacco giants. I became an interested observer of some enormous investments in dubious research projects, many of which could only be termed con-jobs. More particularly, I realised that we scientists were very human creatures.
Together with many of my colleagues I plodded along trying to inculcate into oncoming generations of medical students a genuine understanding of scientific principles and methods. To be frank, my generation of teachers has failed, certainly as far as the bulk of medical graduates is concerned. Events over the past year in England, Europe and New Zealand have rammed that point home, often in painful ways, as far as I am concerned.
I do not wish to be seen to disparage many of the achievements of scientific and technological medicine over the past thirty to forty years. They have been massive. However, other huge investments in the health-disease industry deserved to be challenged and remain in that situation.
The central message so far is not news to this society. Bill Morris gave a paper at the Palmerston North meeting challenging much of the classical diet-coronary heart disease hypothesis. His voice was about as lonely as mine at that time. Science ultimately makes advances by gaining improved understanding of mechanisms. There is nothing wrong in doing one’s best with available knowledge until one obtains comprehensive understanding of a particular situation.
Coronary artery disease and arterial disease generally present very complicated problems. Fortunately and unfortunately, in an exquisite paradox, arterial disease is a very general phenomenon and becoming more so as countries become steadily more affluent.
There is enough knowledge to make a reasonably firm statement of dogma, that the causation is multifactorial and represents an interplay between environment and one’s genetic endowment. This statement doesn’t help a great deal about developing techniques for elucidating mechanisms. It does, however, provide wonderful protection for less competent scientists and technologists, and certainly, for industry generally.
The cholesterol-saturated fat-diet-arterial disease hypothesis really took off when the 19th century concepts concerning the potential of computers were made possible through the development of transistors and printed circuits. In turn, epidemiology was provided with a tool it had needed. The autoanalyser had also been invented and thus mass biochemistry was now possible.
What amounts to an industry with a turnover through the decades of trillions of dollars was really set alight by a gentleman called Ancel Keys. He undertook studies in Europe linking what amounted to death certification and some relatively crude morbidity data with the local diet and estimates of cholesterol levels.
Here we get into what I term the “global messenger hoax”. On a simple arithmetical biaxial plot, Ancel Keys’ data, from his various countries, was the traditional dog’s breakfast. Subsequently one of his senior technicians, who was extremely troubled by what happened, published the truth.
In turn the technician’s article was immediately suppressed pretty effectively by the scientific juggernaut which had developed around this particular health-disease industry. Ancel Keys had selected a series of points which produced a straight line on a semilogarithmic plot or a gentle smooth curve on semilogarithmic axes.
I was aware of this at the time but didn’t get very far in quoting it, although, to his credit, the later Sir Edward Sayers accepted that Ancel Keys had at least been naughty. However, eventually a very prominent American nutritionist and professor of medicine, Dr Feinstein, published the original material plus Ancel Keys’ simplified extrapolated data which had set the whole bandwagon rolling. Feinstein came into the scene too late. He was too big a Don Quixote to be rubbished, so he was therefore largely ignored.
Now there is nothing particularly unusual about all that. As is eminently predictable, history is catching up with the epidemiologists who have continually reinvented the Ancel Keys wheel. Basic scientists, particularly anatomists, pathologists and immunologists, with their analysers and biochemistry, have begun to get at the common pathways upon which genetics and a complex environment interact to produce arterial disease. The gross simplifications have been exposed. Interestingly, however, the process continues of twisting results of recent research to fit the theory at each stage of the wheel reincarnation.
Most of you will know about the statin drugs which are very powerful reducers of cholesterol levels. Probably a majority of my colleagues believe that the advent of these drugs and their testing on a massive scale by people, including me, has vindicated the cholesterol hypothesis.
However, it might interest you to know that Brown and Goldstein, now working in Southwestern University of Texas, have a huge group of scientists and technologists exploring alternative interpretations.
If it was possible for physicians and epidemiologists to remove their dogma spattered spectacles, they would see what is obvious from most of the large statin trials, particularly the much hailed 4S or Simvastatin study. The effects of morbidity and mortality were proportionally just as great for the group at the bottom end of the scale of cholesterol elevation as they were for the top end.
If one thinks that through carefully and reanalyses the evidence, something else is going on than mere lowering of cholesterol and low density lipoprotein. There is no real surprise in that, when one looks at the nature of the intervention in the cholesterol synthesis pathway, and links that to the ubiquity of cholesterol as an essential structure which holds many biologically important molecules in a particular spatial pattern.
Cholesterol is involved in many biochemical processes and synthetic pathways. The statin drugs do many more things than just lower elevated cholesterol. But the message proclaiming the dogma is out there, and the messengers are not going to change their message in a hurry without carefully considering the shareholders’ interests. After all, the drugs do have a demonstrable effect and are eminently marketable even on the basis of partial evidence.
That brings us up against the real problem and my choice for the title of this talk. We live in an age of misinformation. Politicians seem oblivious to that as they play gleefully with the bubbly toy of the knowledge society concept.
Political games not withstanding, we are all in on this mass-deception exercise. When I thought about applying to the then Mr, now Sir Douglas Graham for legal aid to support the skeptics in a crusade against the pervading partial truths and cunning deceptions, I realised that he probably would remove his pipe temporarily and mumble something about the stability of societal constructs and the impoverishment of lawyers generally.
When more recently I wondered about approaching the Hon Tony Ryall, I realised that I might receive a lecture on fundamentalist thinking. He might use the biblical quote, “You who are not for us are against us.” Moreover, if I took my protests elsewhere I would be rapidly caught up with various religion-based aphorisms. You seek to be a prophet in your own country, haven’t you read the bible?
Shooting the Messenger
These musings sent me off on another trial as the green lipped mussel saga developed. I happen to know a lot about these tasty beasties, because work on them was undertaken in the Department of Medicine in Auckland during the time that Derek North and I were HODs.
Once again, it’s the messenger business that interests me. I happen to believe that Susan Wood is a more astute and intelligent anchor girl than Holmes, allowing for gender-bending bias. However, it rankled me that she and the editor of the New Zealand Herald both came out with the all-innocent line – “Why attack me, I’m only the messenger,” to paraphrase things. A spokesperson for the Ministry of Health understood that he was being snowed by Susan Wood but didn’t quite get his counter-attack launched correctly. The Herald seems to have got away with it more or less completely.
However, there is a huge message within that message. The media are not just the messengers. They are an integral part of the process of the misinformation economy. New Zealand is, for at least half its population, a comfortable consumer society, seemingly happy to buy more than it can afford. The United States is going the same way as evidenced by this month’s trade deficit.
If we analyse that situation further, it becomes pretty obvious that what might be termed scientific truth, in itself certainly not an absolute or a constant quality, is now a debased commodity. The concept of quality of information which members of the Skeptics believe to be an essential prerequisite for intelligent human advancement, is held in contempt by key players in the global economy.
Evidence of Efficacy
It is all very well for the Medical Council of New Zealand to pronounce that there is no difference between orthodox and traditional or nonorthodox therapies, their common attribute being that any claims they make shall be based upon evidence of efficacy.
That sounds fine but it flies in the face of reality. Unfortunately, the failure of people like me as medical educators receives poignant testimony from the increasing use of acupuncture, homeopathy and so forth, by so many of our graduates.
Moreover, the status of a critic of these mixed practice habits is weakened by the continuing paucity of sound justification for many so-called orthodox practices. However, thanks to the financial seduction of the messengers, downgrading of science is now a fashionable global activity.
Occasionally I tune in before the 6pm TV1 news and there is the lady representing Blackmores coaxing me into upsetting my gastrointestinal system with slippery elm and to exposing my nervous and renal systems to potential chaos as I ingest mixtures of herbs, some of which contain quite toxic compounds.
I have carefully avoided quoting from the genetic engineering debate but you all know that I am heavily involved in that as president of the Royal Society and in defending science and technology. In particular that society is trying to ensure that information across the spectrum of opinion is made available to the New Zealand public.
We have done a bad job in this, because we failed to estimate the strength, political nouse, and financial capacity of the opposition, that is, of the anti-biotechnology anti-genetic engineering lobbyists, particularly in Europe, England and now New Zealand.
Is this little diatribe of any relevance? I believe there are two important aspects to the great global messenger hoax and the misinformation economy. A lot of harm is being done to people who are not in a position to understand what is happening.
As soon as I make such a statement, I am immediately assailed by the various groups which benefit financially, or in terms of personal status and so forth, because I am becoming paternalistic in a traditional manner and seeking to impose my restrictions on their freedom of choice. However, let’s take that a wee bit further.
To me it is heartening to see Sandra Coney and Robyn Stent opposing one another publicly over the issue of patients’ rights in relation to Lyprinol. I further applaud Dr Pippa MacKay in joining the fray in the New Zealand Herald. I suspect that newspaper does feel guilty about its part in the $2 million one-day killing, but that guilt won’t last for long. Why then are these issues important?
In 1998 reports began to circulate that measles, mumps and rubella (MMR) vaccination might cause autism, possibly through a mechanisim involving changes in bowel function.
There were immediate notes of caution sounded but they were largely ignored. It was pointed out that the reported cases might have been due to what is termed temporal coincidence. There was certainly no convincing laboratory evidence for the contention. A specially convened United Kingdom Medical Research Council committee found the so-called clinical evidence unconvincing.
However, the media messengers got into gear and there was a definite drop in acceptance of MMR vaccination in the United Kingdom. That has spilled over into New Zealand and added fuel to the anti-vaccination campaign here.
This is what I mean by people being harmed by what I have termed the global hoax of purveying partial or pseudo scientific information, to gain readership or viewing numbers for the profit of the moment or for political advantage. Infants and children are in no position to give informed consent, their parents are well placed to be misled.
I use this particular example because the press internationally ignored information available at the time of the initial sensational reports, which indicated that the measles virus was not the mechanism for the observed cases of inflammatory bowel disease (IBD). There was thus selective reporting for purposes of gaining sensation.
I believe that in June 1999 The Lancet laid the matter to rest with the advent of further information. The Lancet also says in its edition of June 12, page 1988 that:
Will the scientifically sound and essentially ‘negative’ results published this week garner the same media and public attention as the initial report of the MMR-autism hypothesis? It is unlikely, as evidenced by the renewed media frenzy last week in response to another report by the group that proposed the hypothesis. This report was of an increased risk of inflammatory bowel disease among individuals who had naturally acquired measles and mumps within one year of each other. The study had no data on MMR vaccine and the investigators specifically stated that they did not find a significant relation between monovalent measles vaccination alone and later IBD. Yet the popular media trumpeted the study as providing evidence that MMR vaccination may cause IBD. In such an environment it is critical to strengthen vaccine safety monitoring systems and risk-communication strategies to maintain public confidence in immunisation.
Lancet Editorial Comment, by F De Stefano and RT Chen, 1999, Vol 353, pp 1987-1988
Thus I believe the first important aspect of all this is that the misinformation distribution process can be harmful.
The second important aspect relates to what the whole process tells us about ourselves as a collective society. In a New Zealand which is seemingly increasingly non-numerate to an effective degree, and increasingly less literate in the classical sense, we do face a problem and may need more than legal aid to save our society from contemporary ridicule emanating from better educated international competitors, or worst fate of all, transformation into a nation dominated by a media worshipping cult.
I don’t blame the media for what is happening – I blame ourselves for our failure to anticipate the consequences which automatically ensue when the information technology explosion hits an unprepared, untutored, non-critical society.
We skeptics do have a role – we need to decide how to change the pattern of which I am, I believe, justifiably critical, such that New Zealand can reach democratic decisions on a basis of roundly presented, soundly analysed, best available information.
Can we, the skeptics, help disprove the hypothesis of HG Wells who wrote in 1920:
Human history becomes more and more a race between education and catastrophe.