Hokum Locum

Confidence Based Medicine

This is restricted to surgeons.

British homeopath suspended

The British General Medical Council (GMC) has found family practitioner Michelle Langdon guilty of serious professional misconduct and banned her from practising for three months. According to press reports, Langdon had advised a couple that the gastrointestinal symptoms of their 11-month-old were caused by “geopathic stress patterns” beneath their home and then “dowsed” for a remedy by swinging a crystal attached to a chain over a book of herbal remedies. A hospital emergency department subsequently found that the child had gastroenteritis. The GMC also examined evidence that another patient had been prescribed an herbal remedy for a sore throat after the doctor dowsed for the treatment.
http://www.homeowatch.org/reg/langdon.html

Bi-Digital O-Ring Test

This is what got Dr Gorringe into trouble with the Medical Practitioners Disciplinary Tribunal (MPDT). This test is part of the pseudoscience known as kinesiology. Dr Gorringe got the patient to pinch the thumb and forefinger together and then attempted to separate them. By introducing several homeopathic substances into an electrical “circuit” he claimed to be able to demonstrate a weakness of pinch-strength caused by “paraquat poisoning” and other equally ridiculous diagnoses. Dr Gorringe refused an offer to test his diagnostic method. Several patients suffered illhealth as a result of Dr Gorringe’s diagnostic methods and treatments and he has been struck off the Medical Practitioners Register and ordered to pay more than $100,000 in costs.

The full judgment is at www.mpdt.org.nz under Recent Events. It runs to 142 pages but makes fascinating reading. I often wonder how anybody can go through several years at medical school and then fall victim to these foolish and unscientific sidelines. Gulp! I just remembered that I did — acupuncture and spinal manipulation — but I was protected from getting too excited and committed to these modalities by a natural curiosity about how they worked. After all, curiosity or thoughtfulness is what scepticism is all about. Once I looked at the evidence and learned the significance of the placebo effect, I ceased these practices.

Gulf War Syndrome — the Continuing Quest for Compensation

Despite all of the evidence showing that there is no such thing as Gulf War Syndrome (GWS), the alleged victims are now suing the various corporations that supplied Iraq’s chemical weapons programme. This is to be expected and follows the same pattern that has been followed over nuclear test veterans and those exposed to Agent Orange. GWS is in reality a “post-war” syndrome, formerly called war neurosis or shell shock. The symptoms are presented in a context appropriate to the conflict. In the case of GWS the alleged list of causes includes chemical poisoning, immunisations, pollution, depleted uranium. Every conceivable cause has been investigated and scientists, whose naivety is exceeded only by their ignorance of history, continue to clamour for research funds to investigate ever more ludicrous theories.

For an excellent account read Hystories, by Elaine Showalter, Columbia University Press, 1997.

I can also forward by email an electronic copy of a paper I presented to a Military Medicine Conference.
Gulf War Syndrome — A Historical Context, 8th Asia Pacific Military Medicine Conference, 3-8 May 1998, Auckland.

Chemical Phobia?

Firemen had to wear breathing apparatus to clean up a hydrogen peroxide spill. This “toxic chemical” was described as “fizzing and bubbling” as it “reacted with the asphalt”. Of course it was fizzing and bubbling! The hydrogen peroxide was breaking down and releasing “toxic” oxygen and water. These emotively worded reports foster ignorance and hysteria about common chemicals. I recall a similar piece of ignorant journalism where a toxic spill was revealed to be the chemical equivalent of rust!
Dominion Post 6/8/03

Bee Products (Pollen-ate?)

These are currently popular with that segment of the NZ population who would eat sheep dropping sandwiches if they were properly advertised as benefiting health. That reminds me of the cruel jibe by Dame Edna Everidge (aka Barry Humphries) that NZ was a country of 60 million sheep, 3 million of which think they are people.

An advertisement in the Sunday Star Times, (20 July) contains the claim that “BIO BEE” is “the only Potentiated Pollen available that uses Dr Kelly Duncan’s (former Dean of Science, Canterbury) patented potentiation process”. Refer http://www.biobee.co.nz

I duly visited the website and some of the claims made for this product appear suspiciously close to health claims. I would welcome readers’ opinions.

I subjected Dr Duncan to a “google” which produced a number of interesting hits including him being a party to a complaint to the Advertising Standards Complaints Board. www.asa.co.nz/decisions/FULL/Fd0106.rtf

[Chair-entity’s note: A concerned member has been forced to tout bee products as part of his media-related job. We now have a new information flyer examining the case for various bee products available as a PDF here]

Herbal Medicine

“Kentucky Fried Medicine” is such an easy target but can always be counted on to provide material for your correspondent. As we all know, most, if not all such preparations are completely useless. The latest ploy is to illegally include effective prescription medicines, particularly in the area of erectile dysfunction. (New Ethical Journal, July 2003) It is perfectly obvious to a consumer when a product has not worked for erectile dysfunction so it makes perfect sense to cheat by adding a drug that does work. Such fraud invites a stiff fine.

Hua Fo VIGORMAX was withdrawn in Canada when it was found to contain tadalafil, marketed as the legitimate drug “Cialis” in New Zealand.

Likewise in the US, a product called Viga was withdrawn because it contained sildenafil, marketed in New Zealand as “Viagra”.

One possible benefit of these frauds is at least the Chinese might stop trafficking in endangered animal species in the preparation of these products.

An American study of 443 Web sites (reported in Manawatu Evening Standard, 24 September) found that most Web sites marketed herbal remedies with misleading or unproven health claims that violate US Law. I suspect that there would be similar findings in any survey of such sites in New Zealand.

Newsfront

Your Future is not in the Stars

Level-headed Virgos everywhere will not be surprised, but a 40-year study of astrology has found it doesn’t work (Dominion Post, August 19).

More than 2000 people, mostly born within minutes of each other, were tracked through the period of the study. According to astrology, the subjects should have had very similar traits. The researchers looked at more than 100 characteristics, including occupation, aggressiveness, sociability, IQ levels and ability in art, sport, maths and reading, but found the subjects no more similar than a randomly selected sample of the general population.

The babies were originally recruited as part of a medical study begun in London into how the circumstances of birth can affect future health. Former astrologer Dr Geoffrey Dean, who analysed the results, also found astrologers could do no better than chance in matching birth charts to the personality profile of a person among a random selection. Their success rate did not improve even when they were given all the information they sought. He said the consistency of the findings weighed heavily against astrology.

“It has no acceptable mechanism, its principles are invalid and it has failed hundreds of tests. But no hint of these problems will be found in astrology books which, in effect, are exercises in deception.”

Roy Gillett, president of the Astrological Association of Great Britain, said the study’s findings should be treated “with extreme caution” and accused Dr Dean of seeking to “discredit astrology”. Frank McGillion, a consultant to the Research Group for the Critical Study of Astrology, said: “It is simplistic and highly selective and does not cover all of the research.” He said he would lodge a complaint with the journal’s editors.

Ashburton Panther a Big Moggy?

A truck driver’s report of a panther not far from Ashburton came as no surprise to many people in the back blocks of the South Island (Rural News, October 20). Richard McNamara, of the Department of Conservation (DoC), says two English tourists reported a “mountain lion” about the size of a labrador at the top of the Lindis Pass, and this was not the first such sighting from the area. Christchurch teacher Marianne Daines also reported a labrador-sized cat, black like the Ashburton beast, from near Twizel.

According to Bendigo Station gamekeeper Steve Brown some of the feral cats in his area are huge — he has one weighing 6kg in his freezer, and says bigger ones are out there. DoC and Otago Regional Council confirm the existence of these big cats, many of which will completely fill a possum trap.

For that matter, this writer and Skeptic editor Annette Taylor saw a cat at Lewis Pass about 20 years ago which, if not as big as a labrador, would have been almost the size of our border collie (who is admittedly not the largest specimen of her breed).

Inaudible “Spooks”

Mysteriously snuffed out candles, weird sensations and shivers down the spine may not be due to ghosts but to low frequency sound inaudible to humans. Dr Richard Lord and his colleagues at the National Physical Laboratory in England have shown that extreme bass sound, known as infrasound, produces a range of bizarre effects in people, including anxiety, extreme sorrow and chills.

The team, who produced infrasound with a sevenmetre pipe and tested its impact on 750 people at a concert, said infrasound was also generated by natural phenomena.

Professor Richard Wiseman, a psychologist at the University of Hertfordshire, whose name often crops up in stories like this, says his findings support the idea that this level of sound may be present at some allegedly haunted sites and so cause people to have odd sensations that they attribute to a ghost.

Sex Abuse Counsellor Faces Tribunal

A tribunal in England has heard that John Eastgate, a consultant working mainly with adolescents, used counselling sessions to “lead” a “vulnerable and angry” 13-year-old girl into believing she had been indecently assaulted by a fellow doctor (Daily Telegraph, September 2).

Joanna Glynn, QC, representing the GMC, said it was “dangerous”, when dealing with a girl suffering from “adolescent difficulties”, to start from the premise that abuse did occur.

She said: “In this case the child was bright, angry and resentful, and it has to be said, a difficult adolescent, and the imposition of such preconceived ideas by the psychiatrist is likely to justify her anger in her own eyes and to colour most of the things she would say afterwards.”

The hearing in London was told that Mr Eastgate began treating the girl, known only as Miss A, at the Marlborough House adolescent unit in Swindon, in April 1996 after she was referred by teachers at her boarding school. He dismissed their fears that she was suffering from anorexia and claimed her lack of appetite was due to profound depression. He prescribed her antidepressants.

During a number of counselling sessions in June and July, he allegedly prompted the girl into believing she had been sexually abused by a doctor who had treated her when she was 9.

Professor X, an endocrinologist, had treated her in London for a growth disorder between January 1993 and August 1995 when she was growing unusually tall. He prescribed oestrogen to induce puberty early and limit her growth and, as part of his treatment, had to monitor her breast and pubic hair growth to assess her development. It was during these sessions that Miss A claimed that Professor X “fondled” her.

Three days later, without informing her parents, he contacted the local child protection team and the police. Miss A, who a month earlier had taken an overdose of antidepressants, was taken into care. The case against Professor X was dropped almost immediately after it emerged that her mother or grandmother attended all her visits to him. They did not see anything untoward. Giving evidence, Miss A’s mother described her reaction.

“I was completely in shock,” she said. “I thought, ‘How could anything have happened while I was there?”

But Miss A was not released from care for three years because during her stay she made further allegations of abuse against three other men, including her father, a businessman. Those charges were later dropped by Miss A, who is now reconciled with her family.

Mr Eastgate, who is in his 50s, denies four charges of misconduct, including failure to keep adequate notes, which if proved amount to serious professional misconduct.

Cell Phones Again

In last issue’s Newsfront, a Wellington School of Medicine study showed no link between tumours and cellphones. Now a doctor in Sweden has come up with a new way to scare cellphone users (Dominion Post, September 15).

Professor Leif Salford of Lund University has spent 15 years investigating whether microwaves could open the blood-brain barrier allowing a protein to pass into the brain and cause damage. The voluntary exposure of the brain to microwaves is, he says, “the largest human biological experiment ever.” No results from these studies were reported, however.

Doctor Found Guilty

A Hamilton doctor who prayed to cure illnesses diagnosed using wands and vials of chemicals has been found guilty of misconduct and disgraceful conduct (Dominion Post, August 13.

Richard Gorringe was found guilty by the Medical Practitioners Disciplinary Tribunal in relation to patients Yvonne Short and Ravaani Ghemmagamy whom he treated in 1998. The tribunal found he exploited Mrs Short for money, and knew, or should have known, that the diagnosis and treatments he gave her were wrong. It also found he did not give either woman enough information about their treatments for them to be able to give their informed consent.

The tribunal was told that Mrs Short’s eczema worsened under Gorringe’s care. Using the peak muscle resistance test, Gorringe asked Mrs Short to touch a metal wand to various vials of chemicals to see how her body “resonated” with them. He then diagnosed her with paraquat poisoning and prescribed homoeopathic injections and other remedies which he sold her.

Dr Gorringe diagnosed Ravaani Ghemmagamy with brucellosis, a rare and notifiable disease most commonly contracted from handling raw meat. After asking if she was open to “spiritual healing”, he raised his hands and prayed: “Lord God Almighty, strike the bacteria from this woman’s body.”

In the weeks since, there have been numerous letters to the Waikato Times from satisfied patients protesting Gorringe’s crucifixion by the medical establishment.

Complementary and Alternative Medicine Submission Now Out

The Word-based submission to the CAM discussion document which was sent out in our (NZCSICOP) name is now available for you to read at http://skeptics.org.nz/cam

My apologies for not being able to circulate this prior to sub-mission, but we only just finished the proof-read five minutes before submissions closed, with the much appreciated help of researchers world-wide (Stephen Barrett of Quackwatch has even sent his own submission in with a line-by-line critique of the proposals!).

I’ve tried to be as hardline as possible in those areas which are not negotiable. And I’ve tried to provide some grounds for cooperative, rational development in those areas where CAM may prove its utility, rather than rejecting it out of hand.

I hope that for the most part I have the mix about right, and that you consider it a reasonably representative view of our organisation.

Exhaustedly,
Vicki Hyde

The list below, taken from the submission’s introduction, covers the general recommendations it makes; each point is covered in detail in the remainder of the document.

Problems of Basic Focus

  • The basic question is whether CAM can help, not how;
  • Ministerial Advisory Committee on Complementary and Alternative Health (MACCAH) definition of CAM is too broad;
  • Better definitional analysis of CAM is required;
  • Categorisation and prioritisation necessary for evaluation, research and application;
  • Broader representation on MACCAH needs to be addressed for credibility of policy recommendations.

Regulation

  • Need to recognise public demand for regulation;
  • Does training imply competency? Disclosure and liability responsibilities must be enforced;
  • Regulations required against disproven and unsafe practices and products;
  • Need to ensure that apparent safeguards arising from regulation are not misleading to consumers;
  • Costs should be borne predominantly by CAM industry with independent monitoring;
  • Regulations need to recognise range of risks;
  • Lower standards for CAM harm its own credibility and should not be accepted;
  • Self-regulation is inadequate and inappropriate;
  • Issues of public accountability and enforcement have to be addressed;
  • Failure to regulate products leads to public harm;
  • Clear, consistent product regulation is vital and achievable;
  • Recommended response to ensure safety and efficacy.

Consumer Information Needs

  • Informed choice should be a primary requirement and must include totality of available evidence;
  • MOH database needs to be balanced, neutral to achieve credibility;
  • Vested sources can be inaccurate, misleading and potentially dangerous;
  • Publication bias has to be recognised and assessment provided.

Research, Evidence and Efficacy

  • Identify practices, products outside the scope of research;
  • CAM is big business and should contribute to research;
  • Credible research programmes can provide useful information;
  • Public research programmes need to prioritise promising approaches over questionable ones;
  • Public funding should be based on results and capped at appropriate levels;
  • All research programmes need to be robust and defensible;
  • Binding negotiated research protocols required;
  • Negative results need to be acknowledged, accepted and publicised;
  • Anecdotal evidence should be treated as an indicator for research, not a research result.

Integration

  • First, do no harm; second, do some good;
  • Education and training required: acknowledged where limited or conflicting;
  • Evidence of safety and efficacy vital prior to integration;
  • Integration efforts require monitoring and evaluation as current examples are inadequate;
  • Ethical standards necessary regarding declaration of commercial interests;
  • Cost-benefit analysis required prior to integration.

Hokum Locum

Nervousness based medicine

Fear of litigation is a powerful stimulus to over-investigation and over treatment. In an atmosphere of litigation phobia, the only bad test is the test you didn’t think of ordering.
NZ Medical Journal Nov 24 2000 p. 479

Magnet Quackery

While setting the VCR the other day I caught a segment on TV where a particularly slimy and irritating Australian was extolling the virtues of magnetic pillows and underlays. I was further reminded of this incident when Dr Keith Davidson of Blenheim, gave me a brochure on “Magnetic Energy”. Ever the humorist, Keith had scrawled across the bottom the words “doesn’t attract me!”

The web address is www.magneticenergy.com.au (shouldn’t that be ‘dot.con’?)

One of the great things about quackery is that it can be recycled after a period of time when people have forgotten the lessons of history. Charles Mackay — “Extraordinary Popular Delusions and the Madness of Crowds”, outlines the last great era of magnetic therapy in his book. Refer page 304.

When recycling an old fraud it is important to modernise it for a more sophisticated New Zealand audience (don’t laugh). It also helps to link it with other modalities such as acupressure and auricular acupuncture. Some highlights from the brochure: Magnetic water. Placing a jug of boiled water on top of the Mega Multi Magnet for 2-3 hours makes this. The daily use of “magnetised water may keep your negative and positive ions and pH levels balanced.”

What about an antinauseant magnet with the unfortunate acronym of “SCAT”. (Sea, Car, Air, Train). Scat is a North American term for animal sh*t which pretty much sums up these useless magnetic products.

Sexual abuse claims set to spiral

In Vol 62 I predicted that moves to allow lump sum compensation for sexual abuse claims would then be subjected to Welch’s Law. (Claims expand to take up the amount of compensation available).

Since the Government announced the reintroduction of lump-sum payments, 12,000 people have lodged “sensitive claims” and may be in line for $100K each regardless of whether police have investigated the complaint (they have been too busy collecting speeding fines) and claimants are not required to name the perpetrator.

I am very concerned that this absurdly unfair legislation excludes people who have really suffered through alien abduction. It should not matter that such claimants are unsure as to the identity of their abductor. In the half-light a Martian can resemble a Raelian. Unless the spaceship was speeding, it’s unlikely the event would come to the attention of the police. In passing, I wonder what the penalty is for doing Warp 9 in Taihape?
Marlborough Express 29 April, 2003

Work Stress

Employers have much to fear from proposed changes to the Health and Safety in Employment Act. Employers are about to become responsible for managing stress in the workplace. If this foolish proposal is implemented I predict that there will be a surge of complaints followed by requests for compensation as disaffected workers struggle to get their snouts into the ACC trough. Many already have by successfully claiming for spurious conditions such as chemical “poisoning”, multiple chemical sensitivity, and occupational overuse syndrome (OOS). These are all classical conversion disorders where personal stress and anxiety is manifest as physical complaints. Workers are now being given the opportunity to take their own personal worries to work and make them the responsibility of their employer and ACC.
Dominion Post May 5 2003-05-16

Food Supplements

These have been in the news lately and thanks to Alan Pickmere for sending me a range of what’s on offer in Whangarei. In an accompanying letter Alan recounted how his queries to various suppliers were met with a dose of “vehemence medicine”.

Zenith Corporation are promoting “Body Enhancer” and “Bee V Balm” via their website www.zenith.co.nz. Claims are made that their products are backed by research but none is evident, only the usual testimonials which are the hallmark of snake-oil salesmen. The language is very carefully chosen, for example: “Under NZ law and the Medicines Act 1981 we are prohibited from telling you how our products and the ingredients they contain will work for your benefit.” Wrong. They are prohibited by law from making claims for which they have no evidence.

Malcolm Harker’s website www.malcolmharker.co.nz tells us that he has been making traditional herbal medicines since 1981. The website is a bit “clunky” and lacks functionality but is worth a visit, if only to enjoy some of the product names. Troubled by “brain fatigue”? Try “E-sense”, a mixture of sage (geddit?), rosemary, gingko, kelp and fucus. That last ingredient sounds a trifle unpleasant.

I urge all readers to visit these websites and send in questions about these products. The alternative health literature is an endless source of whacky ideas and because so many of the people involved are scientifically illiterate, there are some wonderful howlers. Take this one for example:

“The activity (ie “hotness”) of the capsicum family is measured by British Thermal Units (BTU). Good quality cayenne capsules come in extra hot which is 100,000 BTU.”

One BTU is the energy required to raise the temperature of 1lb of water by 1°F. It has nothing to do with the perceived “hotness” of cayenne pepper. Consider a hot water cylinder containing 200lbs of water. 100,000 BTU by my calculations would raise the temperature of your cylinder by 500°F. I will leave you with Alan Pickmere’s comment: “rather a cheap way to heat your bathwater”.

Yoga for Sickness Beneficiaries

For many years I have been corresponding with various officials and bureaucrats about the continuing scandal of the sickness benefit. A short-term benefit for illness has been turned into a lifestyle and all that is required to gain this benefit is a signed certificate from a doctor. It is a matter of some regret to me that members of my own profession have been largely responsible for an increase of 3000 on the sickness benefit since July 2000. Over 4000 people have been on a sickness benefit for more than five years, 182 for more than 15 years and five for over 20 years.

At the expense of sounding like a redneck I get particularly annoyed when I read in the paper of professional criminals described as “sickness beneficiaries”. They are too sick to work but well enough to commit burglaries and serious criminal offences. All of my attempts to find out details of these cases have been thwarted by “privacy considerations”. This means that a third party (a doctor) can commit the state to providing a benefit with no independent means of auditing these decisions. The Government continues to express concerns as to why so many people are going on to sickness benefits. The answer is simple: because they can!

But wait … a novel solution has been found. Selected sickness beneficiaries are being offered “yogic breathing to help them get a job”. This has been described by critics as “unscientific, dangerous, and bullshit”.

However, let’s not write it off completely. If they also offered yogic “flying” this could offer the dual benefit of a return to work and a means of getting there. But what next? I predict language courses in Klingon?
Sunday Star Times May 18 2003

Chinese herbal specialists treat Hong Kong Sars patients

Traditional Chinese medical practitioners have given herbal remedies to Hong Kong Sars patients along with Western drugs, and public hospital officials said more patients might get similar treatment despite uncertainties about whether it helps.

The experts from mainland China visited 23 patients, and while two refused to take the herbs in conjunction with Western antiviral drugs and steroids, 21 received a combination of the two treatments.

Five of the patients have now been discharged and one died — numbers that are in line with Hong Kong’s broader experience with severe acute respiratory syndrome (Sars). So far, 1213 people have recovered from Sars in Hong Kong but 251 have died.

Professor Lin Lin and Professor Yang Zhimin, both from the Guangdong Provincial Hospital of Traditional Chinese Medicine, said the herbal treatments can work, although the rest of the patients are still hospitalised.

Western experts say there is no scientific proof that traditional remedies are effective and remain sceptical about any benefits. Meeting with local journalists, Lin and Yang declined to say which herbs they gave to the Sars patients.

Hong Kong’s hospital authority invited the herbalists to assist in the fight against Sars — the first time that public hospitals there have allowed traditional medicines to be part of their official treatment. Herbs have been used previously on a voluntary basis for some patients or in research by universities.

An executive manager of professional services at the Hospital Authority, Dr Choy Khai-meng, declined to say whether the herbs were helping anybody. But he said the mainland experts have been asked to stay for another three months so officials can learn more.

Some of the patients who received the combination Chinese-Western treatment did better, Choy said, but there is no evidence to explain why.

“I think we are not making any comment that it is Chinese medicine or Western medicine that has led to this result,” he said.

Going Grey with Colloidal Silver

The Skeptics flyer on colloidal silver (see the section on the Website) prompted this interesting correspondence from a doctor dealing with it.

Argyria and the whole food supplement issue is very controversial. There are almost no statistics available (that I know of anyway) since many of the people taking colloidal silver remain absolutely convinced that the silver will prevent almost any disease. This was the case with my patient. These patients often refuse to be photographed and continue to take, and even sell colloidal silver. It is disputble that the claims that colloidal silver cures AIDS, leukaemia etc are, at the very least unsubstantiated and certainly prey on the most vulnerable in society.

The risks of colloidal silver are great, as illustrated by the case I reported in “Clinical and Experimental Dermatology”. Unfortunately, the exact amount of silver required to cause these dramatic skin changes is shrounded in mystery, as these patients generally are very evasive about how much they have been taking and what concentration of silver used etc. I would certainly support any move to investigate further the toxicity of colloidal silver and to limit the sale of this dangerous chemical before the data become available.

Dummies Guide a Bit of a Parson’’s Egg

ALTERNATIVE MEDICINE FOR DUMMIES, by James Dillard and Terra Diane Ziporyn. Hungry Minds, Inc.

These books are all subtitled “A Reference for the Rest of Us!”. Perhaps I’m prejudiced but as far as I’m concerned, dummies is a better term for anyone who uses alternative medicine. Having said that, this book, written by a chiropractor and a science writer with a PhD in the history of medicine and science, is not as bad as I thought it was going to be.

I couldn’t be bothered grinding my way through the lot, but I did read the introduction, the chapter on chiropractic (because of the author) and those on homoeopathy and naturopathy. I then skimmed through various other chapters on Chinese and Indian traditional medicines, acupuncture, osteopathy, and aromatherapy. I guess the main problem with this book is that as part of a series, the objective is to sell books rather than to inform. In an effort to avoid offending anyone, including so-called conventional medical practitioners, it has a bob each way on just about everything.

The introduction is probably the worst example of this. Controlled, randomised, double-blind clinical trials are described as the “gold standard” of evidence. It makes the point that often alternative studies rely on anecdotal evidence or other less than perfect techniques. This is repeated in all the chapters that I studied, with the caution that if you have a serious physical illness, you should see an MD. Good sensible advice, which is then undercut in almost every chapter by saying that if you haven’t got a serious physical illness by all means go with what feels good, and that double-blind trials are not the be-all and end-all of medical evidence. Of course they’re not, necessarily, but in the section on acupuncture for instance; little evidence is offered other than the idea that “2500 years of History Can’t Be All Wrong”.

The section on chiropractic is the most interesting because one of the authors is both an MD and a chiropractor. It completely avoids the wild claims made in the past, explaining that it is only good for back pain and related problems, and then only for non-chronic types.

It goes on to explain that most back pain goes away no matter what you do, and that chiropractic is good for back pain largely because patients get “satisfaction” from it. (This satisfaction seems to be a major reason for indulging in almost any alternative therapy according to these authors, and in my mind shows one of the problems with conventional medicine, that perhaps not enough attention is paid to the emotional state of the patient.) Almost every treatment has a small section on possible complications, and in this case these are glossed over in that the problems associated with rapid neck twisting are not mentioned at all.

The authors are a little harder on most other types of treatment, for instance homoeopathy is called a science — in inverted commas. The points are made that it may delay or prevent treatment for serious illness, and that you are in fact taking nothing. To avoid offending the homeopaths too much, however, a couple of meta-analyses from the Lancet and British Medical Journal are thrown in which allegedly show effects more powerful than a placebo.

Naturopathy fares equally badly. To be fair though, the lifestyle changes promoted by naturopaths are represented as safe and good for you, and of course a healthy diet and regular exercise probably are.

One thing I do like about this book is that it invariably recommends seeing a conventional physician first to rule out a serious condition before you see an alternative medical practitioner. Alternative medicine in these cases is used as complementary therapy, and just involves extra expense.

Readers are also told to make sure they tell their physicians and their complementary therapists just what treatment they are receiving from each to avoid complications. Again sensible advice, but one wonders if it is done out of the sense of conviction or just to avoid litigation from the American market if someone reads the book, takes the advice, and has something horrible happen to them afterwards.

I must admit to being in two minds about this sort of book. On the one hand this is a series with some clout, I myself have used some of their sister publications, particularly those on computing, and I feel that this association gives it an authority it possibly doesn’t deserve. On the other hand it’s nice to see the book written by people who obviously support alternative treatments being relatively objective about them, and if I knew any dummies who were determined to seek out alternative therapies I would prefer them to read this book rather than any other.

Newsfront

Australians turn up the Heat on Pan

Breaking news as this issue goes to press (Waikato Times, April 30 and elsewhere) is the recall by Australia’s Therapeutic Goods Administration (TGA) of 219 products manufactured by Pan Pharmaceuticals. This is the biggest recall of medical products in Australia’s history; the TGA has also withdrawn Pan’s licence for six months.

Pan is Australia’s largest contract manufacturer of herbal, vitamin and nutritional supplements, representing 70 per cent of the Australian complementary medicine market and exporting to dozens of countries. It also makes some over-the-counter medicines including paracetamol, codeine, antihistamines and pseudo-ephedrine.

TGA principal medical adviser John McEwen said other products manufactured by Pan but sold under different brand names would be added to the list as they were discovered. Dr McEwen said Pan lost its licence following evidence of substitution of ingredients, manipulation of test results and substandard manufacturing pro-cesses.

Consumers have been warned not to take any vitamins or herbal supplements and even to check the label of headache pills.

The TGA said it was considering laying criminal charges as it continued the investigation.

Equipment at Pan’s headquarters in Sydney was not cleaned between batches, potentially contaminating products.

The investigation was sparked by a travel sickness pill, Travacalm, which the TGA said had sent 19 people to hospital and caused 87 adverse reactions.

“Some people were very, very ill. They tried to jump out of planes, off ships and things like that because of the hallucinatory effect,” federal parliamentary health secretary Trish Worth said. “I’ve been reliably informed it was fortunate nobody died.”

She said Pan’s vitamin A and natural remedy teething gels could be very harmful to pregnant women and children.

The Complementary Health-care Council said the entire health industry would be hurt by a loss of public confidence. The council’s technical director, Ian Crosthwaite, said manufacturers were holding crisis meetings and seeking an urgent meeting with the TGA to stop any further recalls. But the TGA’s Dr McEwen, said: “There is a clear risk with these products of serious injury … the longer we leave these products in the market the risk grows.

Pan recorded a $A13.6 million ($NZ15.30 million) profit last financial year, however founder James Selim saw his personal wealth of $A210 million collapse by $A26 million as shares plunged after the recall.

The Australian Stock Exchange is demanding answers as to why Pan failed to call for a trading halt in its shares as soon as it learned its licence had been suspended.

Sections of the market had the news of the licence suspension for 30 minutes before trading was halted.

A report by ECM Research on Pan Pharmaceuticals in September last year said about 40 per cent of its sales were exported and New Zealand was the most important destination, followed by Asia and Europe. The New Zealand market accounted for about a third of its market revenue.

The report also said Pan was supplying SAM-e, a natural antidepressant, into Australia and New Zealand. SAM-e is listed in advertisements for product recall. Other Pan products sold in New Zealand include libido enhancer Horny Goat Weed.

Great Balls of Fire

Thai scientists are to launch a probe into a famous fireball phenomenon occurring in the Mekong River once a year in the country’s north, (Sydney Morning Herald, April 14). Every year on the first full moon of the 11th lunar month, which coincides with the end of Buddhist Lent, hundreds of red, pink and orange fireballs soar up into the sky from the Mekong, drawing crowds of spectators.

The event known as Naga’s Fireballs, which has been reported by locals for generations, has long mystified scientists. Now nine experts are to start collecting soil and water samples from the areas where the fireballs appear to originate, deputy permanent secretary of the Ministry of Science and Technology, Saksit Tridech, told the Bangkok Post.

“We are quite sure the fireballs are a natural phenomena,” he reportedly said, adding that the team’s initial assumption was that the fireballs were caused by methane and nitrogen. Decomposition of accumulated plant and animal remains on the bottom of the Mekong could lead to the release of the gases, which rise to the surface of the water when the sun heats the water to a certain temperature, Saksit said.

Legend, however, says the flames come from a mythical Naga, or serpent, living in the Mekong river. “Society needs an explanation for this phenomenon,” said Saksit.

Claims by a television program last year that the fireballs were actually caused by tracer bullets fired by Laotian soldiers across the border caused uproar among locals, who called the suggestion insulting.

Abductees Stressed Out

People who claim to have been abducted by aliens suffer many of the same trauma symptoms as Vietnam veterans and World Trade Centre survivors, even though their memories are not real (Dominion Post, February 19).

A Harvard University team found that when recalling experiences they show many of the physical and psychological effects normally seen in post-traumatic stress disorder, including nightmares, anxiety, racing heartbeats and sweating palms.

The team suggests most abductees are not mentally ill and genuinely believe they have been kidnapped, but are experiencing false memories induced by sleep paralysis. This affects 30 per cent of the population at some stage in their lives, and occurs when a patient wakes during rapid eye movement sleep, when dreaming takes place and the entire body is paralysed with the exception of the eyes. It can often lead to frightening visions referred to as hypnopompic (upon awakening) hallucinations as elements of a dream impinge on wakefulness.

Sufferers usually report being unable to move while seeing shadowy figures around their beds, feeling electric currents coursing through their bodies, or levitating. The phenomenon probably explains the witch crazes of the 16th and 17th centuries, ghost sightings and other paranormal events, says Harvard psychology professor Richard McNally.

“Today, in Cambridge, Massachusetts, it’s interpreted as abduction by space aliens.”

All 10 abductees in the study recounted reasonably consistent details of their experiences, but these were almost certainly culturally determined. “Their memories were of being subjected to sexual and medical probing on spaceships. I certainly think we can say the X-Files probably helped with all that.”

Extraterrestrial Culture Day

The good folk in Roswell, New Mexico, who would no doubt dismiss the above item, can now celebrate every second Tuesday in February as “Extraterrestrial Culture Day”, after a local lawmaker’s proposal won House approval (Dominion Post, 25 March). Some scoffed at the idea, but memorial sponsor Republican Dan Foley said life on other planets — if you believe in it — surely has its own set of cultural beliefs. He claims aliens have contributed to recognition of New Mexico, and he wants a copy sent into space as a token of peace.

Calling All Spoon-benders

Mind readers, telepaths and anyone who attracts ghosts have been invited to participate in a new course at Griffith University in Australia (Dominion Post, February 21). Senior lecturer Martin Bridgstock says the subject, Scepticism, Science and the Paranormal, will give students the opportunity to study areas of science made famous by television shows such as The X-Files and The Twilight Zone.

Dr Bridgstock said he decided on the subject because he was impressed by the large number of people he encountered who believed in the paranormal. Opinion polls showed a majority of the population believed in psychic healing, while substantial minorities believed in astrology, mind-reading, UFOs and ghosts.

He said he would welcome anyone who approached the university claiming paranormal powers. “I would get the class together and I would invite this person to say exactly what he or she thinks they can do. Then we would try to devise an experiment which would enable that person to show if in fact they could do it under tightly controlled conditions.”

Hokum Locum

Providence based medicine

If the caring practitioner has no idea of what to do next, the decision may be best left in the hands of the Almighty. Too many clinicians, unfortunately, are unable to resist giving God a hand with the decision-making.
New Zealand Medical Journal Vol 113 No 1122 p479

Acupuncture and ACC

I am pleased to report that I received a reply from Dr David Rankin acknowledging the dearth of evidence for the widespread use of acupuncture. ACC are taking a responsible attitude and are commissioning a wide range of studies looking at current treatments in order to assess which of them are truly effective in speeding recovery and the return to work.

Saint Goncalo of the Immaculate Perineum?

Haemorrhoid sufferers are flocking to a church in Portugal in the belief that exposing their afflicted behinds to the statue of a local saint will cure them. I have named this pious act “anoflection”. However, the local Priest drew the line at allowing a young woman to pray naked in the hope that this would cure her severe acne. Given the revelations of widespread sexual abuse by priests, it would appear most unwise to expose oneself in this manner in a church.

Saint Goncalo, a 13th Century priest, also has a history of helping women find husbands. Every June, during a festival in his honour, unmarried men and women exchange penis-shaped cakes as tokens of their affection.

There is clearly no need for our organisation to attack or ridicule religious belief when the Catholic Church is doing it for us. I believe that we should sincerely welcome these quaint rituals into our culture. I look forward to a new range of phallic pastries at my local bakery.
Dominion Post 14/1/03

Placebos and homeopathy

The business of science is generating testable hypotheses. This is the classical approach espoused by Popper who put it in a negative sense in that he proposed that for something to fall within the realms of science, it had to be capable of being falsified (proved wrong). This approach has been criticised by Skrabanek in particular because he felt that nonsensical propositions should not be tested. In this respect Skrabanek raised the idea of having some kind of demarcation of the absurd which would avoid dignifying pseudoscience by testing it. For example, the Popperian approach requires us to test homeopathy in double-blind placebo controlled trials. Skrabanek’s approach would be to argue that homeopathy breaches so many scientific laws that it is already outside the tenure of science.

With respect to homeopathy, it is clear that placebo controlled trials of homeopathy are trials of one placebo against another. This explains the tendency for published trials to fluctuate around a midpoint with some showing a small positive effect and some no effect. The philosophy of David Hume teaches us to suspect either self-delusion or fraud if any published trial of homeopathy shows a dramatic effect of homeopathic solutions in any biological sense. The best example of this is the famous Benveniste study published in Nature. (Davenas et al., Nature, 1988, 333:816). This study could not be replicated by any other laboratory unless the experimental work was done under the supervision of Elizabeth Davenas.

After a team of skeptics (Randi et al) supervised a repeat of the work under their close scrutiny the original results were shown to be a delusion with implications of fraud and Benveniste was summarily sacked. People who believe in homeopathy are in the grip of an enduring delusion. Benveniste is a classic example of this and he has recently published a paper titled “Transatlantic transfer of digitised antigen signal by telephone link” (J. Allergy Clin. Immunol. 99:S175, 1997).

The claim is made that “ligands so dilute that no original molecule remained still retained biological activity”. The abstract is classically incomprehensible pseudoscience and Benveniste has the Gallic arrogance to quote his original discredited trial in the references!

Ginkgo flunks

Ginkgo is an herbal type product claimed to enhance and improve memory. Given what I have just written about placebo controlled trials it will come as no surprise that ginkgo provides no measurable benefit in memory or other related cognitive function. This will have absolutely no effect on the sales of this product because if people believe that it works then they will continue to buy it. Those people who sell the product will find endless reasons to defend their promotion of this useless remedy. I referred earlier to science involving the generation of a testable hypothesis. The practitioners and promoters of pseudoscience have become very skilled at generating endless secondary hypotheses to the point where further testing is impossible. Here are some examples:

  • The trial was too short/long
  • They should have used “x” and not “y” strength ginkgo
  • They should have used added vitamin C, selenium etc. etc

Ginkgo for memory enhancement: a randomised controlled trial. Solomon et al. JAMA. 21 Aug 2002. Vol. 288. No.7. p835-40

Chelation Fraud

A reader of the New Zealand Family Physician (Vol 29 Number 6, December 2002 p366) recently took issue with a review of a paper (Knudston et al., JAMA 23 Jan 2002, Vol 287 No. 4 pp481-6) which concluded “there is no evidence to support a beneficial effect of chelation therapy in patients with ischaemic heart disease, stable angina, and a positive treadmill test for ischaemia”. This was a placebo-controlled trial and the conclusions are the same as for similar published trials. The reader, however, objected to the use of an active placebo and claimed that this rendered the conclusions invalid. The debate raises several important issues.

  1. Chelation quackery is a worldwide growth industry worth millions of dollars. The hypothesis is that symptoms of coronary artery disease (CAD) will improve following the removal (by chelation) of calcium from atherosclerotic plaques in the coronary arteries. Despite an overly simplistic view of CAD it seems like this is a testable hypothesis but wait a minute. Chelation clinics exist all over New Zealand and as yet there are no, and I repeat no double blind placebo controlled trials proving that chelation is more than a placebo. In fact, the Knudston trial is further evidence that chelation is ineffective. There is a worrying trend here, seen also with acupuncture, where unproven therapies are introduced into practice and opponents of such quackery are then challenged to prove that the given therapy is ineffective. I object to this argument. It is up to the proponents of new therapies to prove that their treatments are superior to placebo. In other words, put up or shut up.
  2. The reader wrote in and objected that the Knudston trial used an active placebo. A placebo is by definition an inert substance. However, some drugs or treatments produce marked effects. For example, if the drug under test caused the patient’s skin to turn green it would be easy for both patient and doctor to determine who was receiving the drug or the placebo. The experiment has become “unblinded” and this is fatal to any conclusions that might be drawn. This problem is well recognized and some trials even invite participants to try and predict whether they received the test drug or the placebo. This is a sensible test of the blinding. Chelation mixtures are based around EDTA, which allegedly leaches calcium out of atherosclerotic plaques. Along with EDTA the preparations contain other drugs such as lignocaine, magnesium, vitamin C. Many of these are vasoactive and cause people to feel flushed or a little euphoric. If a true placebo was used it would not cause these effects and therefore the experiment would have become unblinded. It is therefore sometimes important to use active placebos whose side effects mimic those of the drug under evaluation. For example and I quote: “forty (59%) of 68 of the antidepressant studies published between 1968 and 1972 using an inert placebo control reported the antidepressant as effective, compared to only one (14%) of seven studies using an active placebo (atropine)”. (The Powerful Placebo, Shapiro, page 206). The antidepressants under test all caused a dry mouth and slightly blurred vision as does atropine. The use of an active placebo was clearly very important and shows once again how the expectations and optimism of researchers can lead to a serious overestimate of the efficacy of new drugs.
  3. Chelation mixtures are non-standard and contain a wide range of drugs in addition to the chelating agent EDTA. This allows quacks to get maximum effect from the generation of endless secondary hypotheses. Suppose we test just EDTA versus placebo and produce the expected result of no effect. The quacks will start bleating that we didn’t have Vitamin C, magnesium, rhubarb, senna pods (pick anything you like) so back to the laboratory. No sooner do you test one combination and they will come up with another. This is the generation of the endless secondary hypotheses and this is a sure sign of a pseudoscience. The hallmark of science is the generation of what Staudenmayer (Environmental Illness: Myth and Reality, Lewis 1999) calls a “hard core postulate” and he goes on to say: “When hard-core postulates cannot explain a phenomenon, auxiliary postulates (ie. Secondary hypotheses) are often invoked to protect them from refutation (ie. being proved wrong).

Good Company

What name do you give to a quirky bunch of people who are scientifically literate, who question fads, and who want their beliefs to rest on evidence from the material world — the sort of evidence that does not require one to ignore or reject all the laws of physics and other knowledge we have and that we rely on daily when flying, taking antibiotics or using the computer?

The group’s shortened name is the New Zealand Skeptics and in September in Christchurch they held their annual conference. What a delightful and idiosyncratic event this was, not least because there are so few lawyers in this group. I spend my professional life training would-be lawyers and writing articles for lawyers and other legal academics. You might think lawyers are instinctively sceptical. But actually, they’re not. They’re trained to take authorities — statutes, the decisions of judges — largely at face value. Yes, lawyers get very good at undermining certainty, at injecting doubt into the clearest of statutory provisions. But that is a different mindset than what one finds at the annual Skeptics conference.

This year, there was a host of interesting papers delivered. An academic from Canterbury University rubbished the trendy acceptance by some — under the false guise of being open-minded-of the possibility of psychic and paranormal knowledge. In fact, not one single police department in the US has found police psychics to be useful; only two or three out of nearly 500 National Enquirer predictions came true in the last dozen years or so; and not one single reproducible ESP phenomenon has ever been recorded, despite a huge reward being on offer to anyone who can demonstrate (that’s the key word) such powers.

Not really a surprise though, once you realise that if it were true, you’d have to jettison or re-write all we know about the physical laws underlying our understanding of the universe, knowledge that has doubled life expectancy in the past century, led to untold material advances and helped lift huge numbers of people out of poverty. The same sort of mindset was brought to bear in papers on organics (vastly over-rated), herbal medicine (how do you spell “placebo”?) and “biodynamic” approaches to eradicating the painted apple moth, just to name three. But two of the talks at the conference cry out for special mention, and praise.

The first was a talk on the Liam Williams-Holloway case. This included the chance to see the Australian 60 Minutes segment which broadcasters here have refused to televise. The most memorable line from that segment came from one of the alternative medicine practitioners: “All we care about is the wealth of our patients – I mean health.” That whole sorry and saddening episode casts a cloud over a good many people, and leads me to wonder why the parents of Liam have not been charged with a criminal offence.

Finally, I must mention the talk given at the conference by Lynley Hood, author of the prize-winning book A City Possessed: The Christchurch Civic Creche Case. If anyone out there thinks Peter Ellis should have been convicted, or still thinks he is undeserving of a pardon, that person should read this book. (See this month’s lead article –ed.)

I’d like to see a Commission of Inquiry headed by a tough-minded overseas judge — maybe the English judge who, in the height of a similar hysteria over there, acquitted two similarly placed crèche workers who have just won a big defamation case.

But if you think that’s likely to happen here in New Zealand, if you think the vested interests might break ranks, you need a good dose of scepticism.

Forum

Skeptics in the Greenhouse

I attended the recent Christchurch Conference and greatly enjoyed the excellent standard of presentation and discussion. One small item, however, left me wondering about the organisation that I had recently joined: the inclusion of global warming research in the list of core topics alongside biodynamic agriculture, alternative medicine and UFOs.

Global warming research is mainstream science. Many hundreds of ordinary scientists from dozens of countries have (with great difficulty!) reached a “consensus”. As a first step, I recommend the Intergovernmental Panel for Climate Change (IPCC) publication “Climate Change 2001 – Synthesis Report” published by Cambridge University Press. It is 400 pages long and is not easy reading, but what can you expect in a summary compiled by a large and diverse committee of technocrats?

A number of “Greenhouse Skeptics” vigorously oppose the findings of the IPCC. This is right and proper – science has always progressed by robust debate. These people – particularly those who have read the literature and can argue on the basis of evidence – are a distinct minority worldwide, but this does not necessarily mean they are wrong. They could be more perceptive than most, and history may prove them right. Alternatively, they could be misinformed or even eccentric. Many people react against any new idea that challenges their world-view. Many argue that there is an IPCC or environmentalist conspiracy.

The processes of science, through normal debate in the scientific media, will clarify the situation in the fullness of time. Is it the task of the Skeptics to wade into the fray? I have been disturbed by statements from well-known Skeptics, indicating that they have not read the mainstream Greenhouse literature, but are familiar with the “alternative” literature. This reminds me of people who are conversant with organic farming or homeopathy, but who are totally ignorant of conventional agriculture or medicine.

My message to Skeptics? Don’t pick a fight with bona fide scientists who are working on global warming, merely because some nutty environmentalists have sided with them. Be sceptical, by all means, but include the “Greenhouse Skeptics” in your scepticism. If you are interested enough in this topic to want to include it as a core area of activity, for Galileo’s sake find out more about it so you can form a balanced viewpoint.

Piers Maclaren

Alternative Veterinary Medicine

Some recent correspondence on the Skeptics’ committee mailing list led to John Welch writing to the Veterinary Council of New Zealand. This is their response.

Dear Dr Welch

You asked how the Veterinary Council deals with alternative animal medicine.

The council has established a Code of Professional Conduct that sets the principles of expertise, performance, behaviour, integrity and accountability expected of competent and reasonable veterinarians in New Zealand. Section 6.8 of this code refers to Alternative/complementary medicine and methods. I quote:

“Alternative or complementary therapies do not usually have the weight of scientific proof of their efficacy and therefore the use of these products and/or services must be considered a discretionary use. A veterinarian using an alternative or complementary therapy must do so in accordance with the NZVA Code of Practice for the Discretionary Use of Human and Veterinary Medicines by Registered Veterinarians.”

“In the event that alternative/complementary methods of diagnosis or treatment are requested by a client or are proposed by a veterinarian, the veterinarian must give a full explanation to the client, so that the client can make an informed decision. At all times the welfare of the animal is of paramount consideration.”

As in the US there are a number of veterinarians in New Zealand who are interested in alternative animal therapies. You may wish to contact the Holistic Veterinary Society, which is a special interest branch of the NZ Veterinary Association. The president of the Holistic Veterinary Society is Viv Harris, Tasman Street Veterinary Clinic, 23 Tasman St, Wellington. I know there has been healthy debate occurring amongst members of the NZ Veterinary Association. I have forwarded your letter to its CEO, Murray Gibb, and he may respond to you. There are also NZQA accredited courses in alternative forms of animal health taught at institutions in NZ such as the Bay of Plenty College of Homeopathy. The Veterinary Council is not in the business of promoting particular forms of veterinary training (apart from recognising the Massey Bachelor of Veterinary Science as the primary degree) but it has had communication with the College about such matters as the recording of qualifications attained on the Register of Veterinarians, and the restrictions on the use of the term “veterinary” or “veterinarian” or “specialist” in relation to training courses.

I hope the above gives you some idea of the council’s position in this regard.

Yours sincerely,
Julie Haggie
Secretary, Veterinary Council
of New Zealand

Writer’’s last book entertaining and moving

Snake Oil And Other Preoccupations, by John Diamond. Vintage, 2001, $29.95

I recently reviewed for NZ Skeptic this author’s previous book (C: Because Cowards Get Cancer Too), which described his experiences of his throat cancer and its treatment. That was written when he was still unsure whether it had been cured, and I admitted to moist eyes on reading of the gruelling time he had.

The success of that book, and his steadfast convictions about cancer treatments, led him to write another book, which was to be “an uncomplimentary look at the world of complementary medicine”. Unfortunately the cancer was not cured, and, in the middle of writing chapter six, he was taken to hospital for the last time. His brother-in-law describes how, the day after his death, they found his computer still switched on, the last words he had typed were “Let me explain why”. That he was never to do so brought on in your reviewer another attack of unmanliness.

Wisely, and luckily for the many who appreciate Diamond’s views and style, his executors have published the unfinished material, 82 pages, and filled out the book with a varied selection of his weekly columns in several magazines. Of the 60 or so of these, almost half are connected to the “Snake Oil” theme, and widen the coverage of “C”. Read about the role of the tongue in swallowing (you never miss it until you haven’t got it), and the problem of replying to a hearty friend’s enquiry after your health (“Oh, fine thanks…..well,actually, no. I’ve got cancer”).

The other items are light-hearted, entertaining pieces, remarkably so considering the pain he was in during the writing. Try “Does my bottom look too big?” (wise advice for those outside, and inside, the changing rooms in ladies’ dress shops). Diamond (of Jewish birth) confirms the view that Jewish jokes are invented by Jews; “The week before you know when”, is a spoof “The night before Christmas” bemoaning the way Jews are missing the commercial opportunities.

Diamond’s skill with words is matched by the Introduction contributed by Dawkins, another master. The light-hearted but erudite tone of his writing is the more remarkable considering what he was enduring. All who read and admired the earlier book will be both moved and amused by this one.