The (bad) science behind the MMR hoax

The world-wide panic over the MMR vaccine was sparked by the actions of one doctor who breached several standards of scientific practice. This article is based on a presentation to the 2010 NZ Skeptics conference.

Every few years, the World Health Organisation (WHO) publishes a series of ‘death tables’, a summary of how many people died in a given year and the causes of death. The tables make interesting reading. The figures published for 2004 show that a third of all deaths worldwide were due to infectious diseases, a staggering 15.1 million people1. Of these, four million may have been prevented by vaccination.

As a microbiologist, I am staggered by the growing anti-vaccination movement. Vaccination has to be the success story of ‘modern’ medicine. Just look at the benefits: vaccination can provide lifelong protection, does not rely on correct diagnosis or treatment being available and can avoid some forms of auto-immune disease that can be triggered by infection. As the saying goes, prevention is better than a cure. While it is true that vaccines are not 100 percent risk-free, the benefits to both the vaccinated individual and the wider community (through ‘herd immunity’) far outweigh the risks.

What is fascinating about vaccination ‘hysteria’ is that different countries have different scares, even though they are using the same vaccines. One such scare, which has resulted in a resurgence of measles in a number of countries, relates to the MMR vaccine. This is a freeze-dried preparation of three living but disabled viruses: measles, mumps and rubella. In the 1990s, a British doctor by the name of Andrew Wakefield claimed there was a link between MMR vaccination and autism. He claimed to have discovered a new syndrome, which he called autistic colitis, in which autistic children were found to have a particular kind of gut disease.

He also claimed to have found that the appearance of symptoms of autism coincided with MMR vaccination, and children with autistic colitis had measles virus in their guts. His findings were based on a study of 12 children with developmental and intestinal problems, published in the Lancet medical journal in 19982. Nine of the children were diagnosed with autism. The children were believed to have been developing normally and then suddenly regressed, and parents were asked to recall how close to the time of MMR vaccination the symptoms appeared.

The study suffers from a number of crucial flaws, not least the lack of blinding or control groups, or potential for parents to incorrectly recall the appearance of symptoms. It also turned out that Andrew Wakefield had numerous conflicts of interest: he was receiving money from lawyers looking to build a case against a vaccine manufacturer, had submitted a patent on an alternative measles vaccine, breached ethics compliances and even paid children at a birthday party for donating blood.

The journalist Brian Deer was instrumental in bringing all of these conflicts to the public’s attention and has maintained a website (briandeer.com/mmr-lancet.htm) summarising his investigations into Wakefield and the MMR debacle. Recently, the British Medical Journal (BMJ) commissioned Deer to write a series of articles summarising his findings3-5. In 2010, Andrew Wakefield was found guilty of misconduct and struck off the medical register in the UK and the Lancet finally retracted his paper.

In an editorial accompanying one of Deer’s articles, the BMJ’s editors asked:

“What of Wakefield’s other publications? In light of this new information their veracity must be questioned. Past experience tells us that research misconduct is rarely isolated behaviour.”

What of his other work? Indeed, the Lancet paper was just the first in a series of papers by Wakefield attempting to link autism with measles. One of the things he showed was that measles virus could be detected in the guts of autistic children using a technique called the polymerase chain reaction (PCR). PCR is a fantastic technique used to amplify very small amounts of target genetic material to generate over a billion copies. In a nutshell this means PCR can take something that is undetectable and make it detectable. However, one of the downsides of such a sensitive technique is that it is very easy to contaminate, so proper controls are really important. For those who want to know how PCR works, there are some very nice videos online (youtube/eEcy9k_KsDI).
One of the crucial things needed to carry out PCR is a set of very specific ‘primers’ which recognise the region of genetic material that you want to amplify (Fig 1). You need primers to each end of the region of interest and then PCR amplifies the bit between the primers. So if the primers match the wrong region, you will end up with a large amount of the wrong thing, a classic case of garbage in, garbage out. So the important things to remember are:

  1. The primers need to be specific so that they only amplify what you are targeting and nothing else.
  2. You have to be very, very careful not to contaminate the reaction.

To make sure the primers are specific and nothing has been contaminated, it is crucial to include a number of controls alongside the samples being tested:

  1. A negative control which has water in place of any target genetic material which will tell you whether you have had a contamination problem or not.
  2. A negative control which has control genetic material that does not contain any of the target sequence which will tell you if your primers are specific enough.
  3. A positive control which has genetic material that does contain the target sequence which will tell you if your reaction has worked.

So, you have your samples and your controls, the PCR machine has done its dash and you are left with a little tube filled with billions of copies of the target sequence (or none if the sample was negative…). This can then be visualised by gel electrophoresis and you are left with something like the picture in Fig 2.
Lane 1 contains a size standard, lane 2 is the negative control containing no genetic material, lane 3 is the negative control containing no target sequence (the very faint band is just the background genetic material), lane 4 is the positive control containing the target sequence and lanes 5 and 6 are our unknown samples (which in this case are all positive). It is important to say here that very rarely would you see an actual gel published in a paper. Most results are just described as the number of positive or negative samples. This is important as it leaves the reader assuming the correct controls were done. But it doesn’t end with gel electrophoresis. To make absolutely certain, the amplified genetic material can be sequenced to confirm it is the correct thing. And if the claims you are making are wide-reaching and/or controversial then sequencing is exactly what should be done.

Andrew Wakefield hypothesised that exposure to the measles virus in the MMR vaccine was a factor in the emergence of his so-called ‘autistic colitis’ and that genetic material from the measles virus would be found in patients with the disease but not healthy controls. He supervised PhD student Nick Chadwick to investigate. The first paper they published (in January 1998) was in the Journal of Virological Methods, reporting a “rapid, sensitive and robust procedure” for amplifying measles RNA6. In August 1998 they published a second paper describing the use of the procedure to look for measles virus in samples from patients with inflammatory bowel disease (IBD)7. They state:

“These results show that either measles virus RNA was not present in the samples, or was present below the sensitivity limits known to have been achieved”.

They then went on to look at the children reported in the, now retracted, Lancet paper (that is, the ones with ‘autistic colitis’). Wakefield never published these results but Nick Chadwick did write up his PhD thesis in 1998. Brian Deer has put the relevant information from the thesis on his website (briandeer.com/wakefield/nick-chadwick.htm). Nick Chadwick concludes: “None of the samples tested positive for measles, mumps or rubella RNA, although viral RNA was successfully amplified in positive control samples”. Despite this negative result from 1998, Wakefield then appears as senior author alongside a team of Japanese researchers in a paper published in April 2000 in the journal Digestive Diseases and Sciences8 where they report the detection of measles virus:

“One of eight patients with Crohn disease, one of three patients with ulcerative colitis, and three of nine children with autism, were positive. Controls were all negative. The sequences obtained from the patients with Crohn’s disease shared the characteristics with wild-strain virus. The sequences obtained from the patients with ulcerative colitis and children with autism were consistent with being vaccine strains.”

In 2002 Wakefield then published another, bigger study of children suffering ‘autistic colitis’ with a team from Ireland9. They reported:

“Seventy five of 91 patients with a histologically confirmed diagnosis of ileal lymphonodular hyperplasia and enterocolitis were positive for measles virus in their intestinal tissue compared with five of 70 control patients.”

Yasmin D’Souza and colleagues at McGill University in Canada published a very nice study in 2007 in which they compared the primers used by both the Japanese and Irish groups with their own primers for the measles virus on a range of IBD and control intestinal biopsy samples10. Any positive samples were verified by sequencing.

And the results? The primers used by Wakefield and colleagues weren’t specific for measles virus. In fact, the amplified fragments were found to be of mammalian origin. What this means is that human samples should all be positive. Unsurprisingly, when D’Souza tried using genuine measles specific primers they “failed to demonstrate the presence of MV [measles virus] nucleic acids in intestinal biopsy samples from either patients with IBD or controls”. They also failed to find any measles virus in samples taken from over 50 autistic children11. This does suggest that Andrew Wakefield’s research conduct does not stop with the Lancet study.

There is now a huge body of evidence indicating that there is no link between vaccination and autism. Despite this, Andrew Wakefield is held up by many as a hero, fighting a corrupt system with the ‘evil’ pharmaceutical industry at its centre. Wakefield has recently published a book entitled Callous Disregard: Autism and Vaccines – The Truth Behind a Tragedy. One reviewer wrote:

“Dr. Wakefield sets the record straight. It was not he who showed callous disregard towards vulnerable, sick children with autism. It was the British medical establishment, the General Medical Council, the media and the pharmaceutical industry that threw the children under the bus to protect the vaccine program. This is a book for everyone who cares about our future”.

Who needs evidence, hey?

References

  1. WHO website. www.who.int/healthinfo/global_burden_disease/en/
  2. Wakefield AJ, Murch SH, Anthony A, et al. (1998). Lancet 351(9103): 637-41. RETRACTED.
  3. Deer B (2011). BMJ. 342:c5347. doi: 10.1136/bmj.c5347.
  4. Deer B (2011). BMJ. 342:c5258. doi: 10.1136/bmj.c5258.
  5. Deer B (2011). Secrets of the MMR scare. The Lancet’s two days to bury bad news. BMJ. 342:c7001. doi: 10.1136/bmj.c7001.
  6. Chadwick N, Bruce I, Davies M, van Gemen B, Schukkink R, Khan K, Pounder R, Wakefield AJ (1998). Virol Methods. 70(1):59-70.
  7. Chadwick N, Bruce IJ, Schepelmann S, Pounder RE, Wakefield AJ (1998). J Med Virol. 55(4):305-11.
  8. 8. Kawashima H, Mori T, Kashiwagi Y, Takekuma K, Hoshika A, Wakefield A (2000). Dig Dis Sci. 45(4):723-9.
  9. 9. Uhlmann V, Martin CM, Sheils O, Pilkington L, Silva I, Killalea A, Murch SB, Walker-Smith J, Thomson M, Wakefield AJ, O’Leary JJ (2002). Mol Pathol. 55(2):84-90.
  10. D’Souza Y, Dionne S, Seidman EG, Bitton A, Ward BJ (2007). Gut 56(6): 886-888.
  11. D’Souza Y, Eric Fombonne E, Ward BJ (2006). Pediatrics 118(4): 1664-1675.

Manipulation, chiropractic, and the idols of Francis Bacon

Chiropractic has had a colourful history since its invention in the 19th Century.

Chiropractic has had an extraordinary history, but the vehement response of its practitioners to criticisms of its claims is nothing if not human. These unwelcome aspects of human behaviour – a readiness to believe and a violent reaction to well-founded criticism – were recognised and categorised by Francis Bacon 400 years ago.

Chiropractic has been defined as “a system of treating bodily disorders by manipulation of the spine and other parts”.1 The Oxford English Dictionary gives a number of meanings for manipulation, including “The act of operating upon or managing persons or things with dexterity, especially with disparaging implications, unfair management or treatment”. Manipulate, among other meanings, is “to manage by dexterous contrivance or influence, especially to treat unfairly or insidiously for one’s own advantage”.

[Until 1818 English dictionaries gave only one meaning for manipulation: the method of digging for silver ore.]

The practice of chiropractic began in the US in 1885. It is one of a number of strange behaviours and belief systems which have had their origins in that country, including osteopathy, craniosacral manipulation, applied kinesiology, scientology, creationism science, Christian Science, and Mormon beliefs. It was in that country too that homeopathy received its greatest support after its invention in Europe. Why this should have happened is an interesting question. An American friend says that it springs from an overwhelming desire to avoid the perceived errors of Europe with its suppression of religious freedom.

David Daniel Palmer was born in Ontario in 1845, and brought his family to the US where by 1865 they were living in Davenport, Iowa. He was a grocer, and a bee-keeper, and had a deep interest in spiritualism. He practised ‘magnetic healing’ and called himself ‘Doctor’. 2, 3, 4

He later said that the idea of chiropractic came to him as ‘received wisdom’ at a séance in 1885, from a certain Dr. Jim Atkinson, deceased at that time. Shortly after this, on 18 September, 1885, he treated a man who had been deaf for 17 years. He said: “I examined him and found a vertebra racked from its normal position – I racked it into position by using the spinous process as a lever, and soon the man could hear as before.” He went on: “There was nothing crude about this adjustment; it was specific, so much so that no chiropractor has equalled it”.

Palmer called the spinal irregularity he had found a “subluxation”, a term borrowed from orthodox medicine where it means a partial dislocation of a joint. Only chiropractors can find, feel, or see their patients’ abnormalities, which they proceed to correct.

Palmer decided there must be a single cause for all diseases: “I then began a systematic investigation for the cause of all diseases and have been amply rewarded.” He had a friend coin the word ‘chiropractic’ from the Greek ‘cheir’, hand, and ‘praxis’, action. He said that the free flow of the body’s ‘innate intelligence’ (or ‘psychic energy’) to all parts of the body was interrupted by spinal vertebral subluxations, and this was the cause of 95 percent of all illnesses.

He said: “I occupy in chiropractic a similar position to Mrs [Mary Baker] Eddy in Christian Science. Mrs Eddy claimed to receive her ideas from the other world and so do I. I am the fountainhead.”

Palmer was hugely successful. In 1897 he opened the ‘Palmer School of Care’ in Davenport. Admission was by payment of tuition fees and no other qualification. In 1905 it was renamed ‘The Palmer School of Chiropractic’ and it has gone on to occupy a large campus on what is now called Palmer’s Hill, in Davenport.

His son, Bartlett Joshua (‘BJ’), took over the business in 1906, while his father was in prison for practising osteopathy and medicine without a licence. DD and BJ fell out and DD opened a rival school.

By 6 August 1908, the US congress was considering a bill to regulate the practice of chiropractic and to licence chiropractors.

David Daniel Palmer died in 1916 a short while after being run over by BJ in an automobile. The death certificate said ‘typhoid fever’.

Bartlett Joshua Palmer made a fortune, and promoted chiropractic in Canada, Australia, and the United Kingdom. He stressed salesmanship as he taught, and his classrooms were decorated with such slogans as:

“The world is your cow, but you must do the milking”

and

“Early to bed and early to rise, work like hell and advertise”.

BJ marketed a patented machine called the Neurocalometer which he said could detect subluxations, whether or not the patient had symptoms. It is still sold today as the Nervoscope and costs about $US799.

BJ founded a radio station, WOC (Wonders of Chiropractic) in 1924.

In 1926, HJ Jones in Healing by Manipulation stated there were more than 8000 chiropractors in the US and Canada.

BJ died a multimillionaire in 1961.

This story is one of extremely successful entrepreneurship in the best tradition of American showmanship. It has nothing to do with science, and a lot to do with evangelical know-how.

In 2007 there were 19 colleges of chiropractic in the US, two in the UK, at least one in Australia and one in New Zealand.

Repeated examinations of x-rays, MRI scans and autopsy material have failed to show any evidence for existence of the ‘subluxation complex’. The American Association of Chiropractic Colleges states that “the subluxations are evaluated, diagnosed, and managed through the use of chiropractic procedures”.

Because of Palmer’s initial dogma, many chiropractors reject the role of infectious agents in disease and hence deny the value of vaccination.5 Chiropractic neck manipulation is associated with an increased risk of vertebro- basilar vessel damage.6 Chiropractors insist on spine x- rays even when the risk of unnecessary exposure to radiation is raised, and this despite the absence of x- ray changes consistent with a ‘subluxation’.

A careful examination of all the scientific evidence7 has resulted in the conclusion that chiropractic offers some help for low back pain but otherwise has no more effect than that of a placebo for any other complaint.

In 1999 an American chiropractor, Samuel Homola, published Inside Chiropractic: a Patient’s Guide8. He supported manipulation for back pain, but rejected what he described as chiropractic dogma. He confirmed that the chiropractic profession had little tolerance of dissent.

“Its nonsense remains unchallenged by its leaders, and has not been denounced in its journals. Although progress has been made, the profession still has one foot planted lightly in science, and the other firmly rooted in cultism.”

He was labelled a ‘heretic’ by his colleagues.

Some commentators divide chiropractors into ‘straight’ dogmatists and ‘mixers’ who will use some science.

Chiropractors and defense by legal action: the American Medical Association Saga

In the US, doctors encouraged the arrest of chiropractors for practising medicine without a licence. By 1940 it is said that 15,000 prosecutions had been brought. However 80 percent of these had failed, with the United Chiropractors’ Association, encouraged by BJ Palmer, giving financial support to the defendants.

The AMA Committee on Quackery lobbied in 1963 to have chiropractors relegated to a non- medical status. The committee argued that chiropractic should not be recognised by the US Office of Education, citing the lack of scientific evidence, the denial of germ theory, the claim to be able to treat 95 percent of all diseases, and the use of the ‘E- meter’.

In 1976 the Chiropractors’ Association, having become aware of further action planned by the AMA, brought a suit against the association on the grounds that it planned to limit chiropractors’ practice, and this was in breach of anti- trust legislation as it was anti-competitive.

In 1987 the Court found in favour of the chiropractors, and an appeal by the AMA in 1990 failed.

The chiropractors had shifted the issue from science to rights of commercial practice. This was totally in keeping with their history of astute business acumen – and lack of scientific evidence.

The 1978 NZ Royal Commission of Inquiry into Chiropractic

In a context of legal and political mechanisms, the NZ Chiropractors’ Association with its supporters, and the NZ Medical Association and its supporters, battled for and against official recognition of chiropractic as a national health resource, and the access of its practitioners to the rewards from the Accident Compensation scheme.

The chiropractors bolstered their position with hundreds of letters to the commission from satisfied customers, and the NZMA responded by scathing and dismissive comments as to the worth of such letters, and by decrying the lack of science in the practice of chiropractic.

Kevin Dew9 suggests that the result was a negotiated settlement exchanging a proposal by chiropractors to restrict their practice to musculoskeletal conditions, in return for official Government recognition, and the addition of chiropractic to New Zealand’s health resources.

The controversy was resolved without any resolution as to the scientific validity of the claims of chiropractic. It was thought there were only 100 chiropractors in New Zealand at that time.

Recent publications6show that the majority of chiropractors in the English- speaking world continue to make claims for their treatment which extend well beyond the realm of musculo- skeletal disorders.

There were 391 chiropractors advertising in the Yellow Pages in New Zealand in August, 2010.

Simon Singh and the British Chiropractors’ Association

In 2008, Simon Singh and Edzard Ernst published a book called Trick or Treatment.7

On 19 April 2008, Singh wrote an article in The Guardian, pursuing the topic canvassed in the book, that chiropractic was alternative medicine and there was no evidence for any effect except on lower back pain.

“The British Chiropractors’ Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections and prolonged crying even though there is not a jot of evidence. This organisation is the respectable face of the chiropractic profession, yet it happily promotes bogus treatments”.

The BCA quickly sued him for libel, and on 7 May 2009 the court handed down a verdict in favour of the chiropractors.

Meanwhile in New Zealand

On 25 July 2008, the NZ Medical Journal published a paper by Andrew Gilbey reporting evidence that some chiropractors in NZ were using the title ‘Doctor’ in a manner which could mislead the public. In the same issue an editorial by David Colquhoun appeared, critical of chiropractic, and the qualifications of its practitioners. He wrote:

“For most forms of alternative medicine, including chiropractic and acupuncture the evidence is now in. There is now better reason than ever before to believe that they are mostly elaborate placebos, and at best are no better than conventional treatment.”

In the next issue of the NZMJ the editor published a letter from a lawyer, Paul Radich, representing the NZ Chiropractors’ Association, threatening legal action under the NZ Defamation Act, against the journal, Gilbey, and Colquhoun. The letter demanded apologies from all parties, and outlined the financial penalties for all.10 The tone was intimidatory.

In his comments about the position of the NZMJ as a scientific publication, the editor, Frank Frizelle, invited the chiropractors to an evidence- based debate with these words: “Let’s hear your evidence, not your legal muscle”.

The NZMJ published an invited response from the NZ College of Chiropractic in its next issue11 and I understand there has been no further correspondence from the lawyer (personal communication from the editor, NZMJ, September 2010).

Back to London

A month after the initial court procedure in London, Simon Singh announced his intention to appeal the finding in favour of the BCA.

On 1 April 2010 the Appeal Court handed down its verdict. The Lord Chief Justice of England and Wales, The Master of the Rolls, and Lord Justice Sedley stated that Singh(s comments were not libellous, and that they were matters of opinion backed by evidence. They went on to quote an American judge, Judge Easterbrook, now Chief Justice of the US 7th Circuit Court of Appeals.

In Underwager v Salter 22 Fed.3d 730 (1994):

“Plaintiffs cannot, by simply filing suit and crying ‘character assassination’ silence those who hold divergent views, no matter how adverse those views may be to the plaintiff’s interests. Scientific controversies must be settled by the methods of science, rather than by the methods of litigation. More papers, more discussion, and more satisfactory models – not larger awards of damages – mark the path toward superior understanding of the world around us.”

Back to New Zealand

As it happens, nine days after Singh’s appeal was upheld, Ernst and Gilbey authored a paper in the NZMJ: “Chiropractors’ Claims in the English-speaking World”.5 They examined 200 individual chiropractors’ websites and nine chiropractic association sites in Australia, Canada, New Zealand, the UK and the US. They concluded:

“The majority of chiropractors and their associations in the English-speaking world seem to make claims which are not supported by sound evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue.”

On 11 June 2010, Shaun Holt and Andrew Gilbey wrote a letter to the editor of the NZMJ12 drawing attention to the wider public scrutiny of chiropractic claims and nature following the success of Simon Singh’s appeal.

Francis Bacon and his ‘idols’

Francis Bacon (1561-1626) lived at a time when the new empiricism was disturbing the security and comfort taken in accepting the opinions of established authorities. He was a lawyer, a legal theorist, a judge, and a writer. He became Lord Chancellor, but was charged by Parliament with corruption, and having taken bribes from those appearing before him in court. He pleaded guilty and wrote: “I was the justest judge that was in England these fifty years, but it was the justest censure in Parliament these two hundred years.”13

Bacon wrote a series of ‘Axioms’ towards the end of his life. I would like to use some of these to examine aspects of human behaviour that the history of chiropractic reveals. It has been a considerable surprise to me to realise the prescience of this man.

He used the term ‘idols’ to list aspects of human behaviour.

Axiom 41: “The Idols of the Tribe”

These have their foundation in human nature itself.

“For it is a false assertion that the sense of man is the measure of things. On the contrary, all perceptions, as well of the sense as of the mind, are according to the measure of the individual, and not according to the measure of the universe.”

We are all subject to our nature, and seek security and certainty, and believe the evidence of our eyes. If we get better after manipulation, then clearly the manipulation made us better. Emma Young says: “We are causal determinists – we assume that outcomes are caused by preceding events”.14

Axiom 42: “The Idols of the Cave”

These are the idols of the individual man, due to our own peculiar natures, our education, our own experiences, or to reading from authorities we admire. “The spirit of man is in fact a thing variable and full of perturbation”. If we are told by our parents or teachers that someone else is better after manipulation, then we will believe that it is a ‘true’ relationship.

Axiom 43: “The Idols of the Marketplace”

“Formed by the intercourse and association of men with each other. For it is by discourse that men associate, and words are imposed according to the apprehension of the common understanding. The ill and unfit choice of words wonderfully obstructs the understanding. Words plainly force and overrule the understanding, and throw all into confusion and lead men away into numberless empty controversies and idle fancies.”

The choice of the word ‘subluxation’ for example, to describe an undemonstrable change! Or the claim for the existence of ‘psychic energy’. A radio station extolling the “Wonders of Chiropractic” is a wonderful Idol of the marketplace.

To take legal action and gain the publicity which is sure to follow with extensive argument about the meaning of, for example, ‘happily’ has great appeal in the marketplace.

Axiom 44: “The Idols of the Theatre”

“Which have migrated into men’s minds from various dogmas, and the wrong laws of demonstration. All the received systems are but so many stage plays – many more plays of the same kind may yet be composed.”

How well aware of this human trait are all showmen and charlatans. The Palmers, father and son, exploited this behaviour. To claim that new knowledge has come from beyond the grave is wonderful ‘theatre’, full of drama and mystery. To maintain the dogma of the wonderful in the face of evidence to the contrary is so much easier than to examine the evidence.

All these human behaviours can be seen in the history of chiropractic, and in so many other catastrophes such as the anti- vaccination campaign, the Peter Ellis trial, the Cartwright affair, the anti- fluoridation campaign and so on and on.

The history of chiropractic, and the response of chiropractors to criticism about the absence of science in their beliefs, illustrate the profound insights of Francis Bacon about our nature. It is our nature which results in the persistence of the perverse, and which resists the truth.

The responses of those without objective evidence for their personal beliefs often include ad hominem attacks, threat of legal action and financial injury, professional ridicule, and public invective. All these are seen in the chiropractors’ responses.

References

  1. Collins’ Concise Dictionary of the English Language (1988).
  2. Shapiro, R 2009: Suckers: How Alternative Medicine Makes Fools of Us All. Vintage Press, London.
  3. Carroll, RT 2003: The Skeptics’ Dictionary; A Collection of Strange Beliefs, Amazing Deceptions and Dangerous Delusions. John Wiley & Sons, NJ.
  4. Goldacre, B 2008: Bad Science. Fourth Estate, London.
  5. Ernst, E; Gilbey, A 2010: NZMJ, 123(1312) 36-44.
  6. Ernst, E 2007: J. R. Soc. Med. 100(7) 330-338.
  7. Singh, S; Ernst, E. 2008: Trick or Treatment: Alternative Medicine on Trial. Transworld Publishers, London.
  8. Homola, S 1999: Inside Chiropractic: A Patient’s Guide.
  9. Dew, K 2000: Sociology of Health & Illness, 22(3) 310-330.
  10. Editorial, 2008: NZMJ, 121(1279) 16-18.
  11. Roughan, S 2008: NZMJ, 121 (1280)72-74.
  12. Gilbey, A 2010: NZMJ, 123(1316) 126-127.
  13. Hollander, J; Kermode, F 1973: Oxford Anthology of English Literature. OUP, London & New York.
  14. Young, E 2010: New Scientist 2720.

Truth is the daughter of time, and not of authority: Aspects of the Cartwright Affair

The ‘Unfortunate Experiment’ at National Women’s Hospital has entered the national folklore as a notorious case of medical misconduct. But there is still disagreement about what actually happened.

It is 22 years since the Cartwright Inquiry published its findings. Arguments about the whole affair persist, with repeated public support from those who say it was a valuable and proper exposure of damaging improprieties by the medical profession, and from those who say that the inquiry and the events which led to it are based on an erroneous interpretation of a scientific paper, and selective evidence gathering at the Inquiry.

If indeed an error has been made, then the vilification of the medical people involved, which has occurred and which still goes on, must be redressed.

I want to consider two aspects of this affair, and if the evidence shows a miscarriage of justice, to offer reasons as to why this might have happened.

I shall:

  • consider the contention that an unethical experiment was performed at National Women’s Hospital (NWH) by Professor Green and his associates, and whether or not the Inquiry made a fair and just assessment of the current (1988) internationally accepted management of carcinoma-in-situ of the cervix (CIN3);
  • discuss what factors in our scientific literary world might be contributing to error.
  • describe unwelcome aspects of our human behaviour which allow an issue of this magnitude to survive in our society, unresolved for 22 years, and how writers have described these for many centuries. I have chosen as my title a quotation from Aulus Gellius in his Attic Nights, written in c.150 CE to emphasise the long-standing nature of the problem.

It is important to have a clear outline of the sequence of events over time at NWH and here is a timeline for reference:

1966: Green proposed to the NWH Medical Committee that CIN3 should be managed by cone biopsy if indicated and regular review. This was in response to considerable doubt worldwide about the natural history of the condition, for which many advocated hysterectomy. The committee agreed.

1973: Editorial in the British Medical Journal, “Uncertainties of Cervical Cytology.”1

1974: Article in New Zealand Medical Journal (NZMJ) by Green showing evidence that “The proportion progressing to invasion must be small.”2

1975: The NWH Medical Committee reviewed the management protocol and agreed it should continue.

1982: Professor Green retired.

1984: “The Invasive Potential of Carcinoma-in-situ of the cervix” was published.3 This was the paper on which Sandra Coney and Phillida Bunkle based their Metro article.

1985: A letter to the NZMJ by Skrabanek and Jamieson was critical of a national cervical screening programme for CIN3 as a detection and treatment method for carcinoma of the cervix (14 August).

1986: A letter from David Skegg was published in the NZMJ supporting a cervical screening programme. “The case for the effectiveness of screening does not rest on the unfortunate experiment at NWH in which women with abnormal smears were treated conservatively and a proportion have developed invasive cancer” (22 January).

1987: “An Unfortunate Experiment at National Women’s” appeared in the June issue of an Auckland magazine,Metro. Within 10 days the Minister of Health (Michael Bassett) has announced the inquiry, and that it was to be chaired by Sylvia Cartwright.

1987/1988: The inquiry sat, and published its report in 1988.

1988: A book, An Unfortunate Experiment, by Sandra Coney was published.

1990: Jan Corbett, a journalist, wrote an article in the July issue of Metro reviewing the errors in the Coney and Bunkle paper, and the way in which the data in the 1984 paper had been distorted.

2008: A conference was held to commemorate the Cartwright Inquiry. A number of papers including Charlotte Paul (a medical adviser to the inquiry), and Sandra Coney, were presented endorsing the inquiry findings.

2009: A book, A History of the ‘Unfortunate Experiment’ at National Women’s Hospital, by Linda Bryder, a professional historian, was published.

2009: A book, The Cartwright Papers, published by participants in the 2008 conference, and now including a vehement criticism of Linda Bryder and of her book.

2010: The NZMJ publishes a letter from Dr Helen Overton, “In defence of Linda Bryder’s Book.”4

The 1984 paper

“The Invasive Potential of Carcinoma-in-situ of the Cervix” was written by two gynaecologists from NWH (McIndoe and Jones), a pathologist from NWH (McLean) and a statistician (Mullins).

I have read this carefully, and made a summary of its contents. It described the follow-up data for 948 women with carcinoma-in-situ of the cervix. The women were followed for five-28 years by repeated smears and observation according to the 1966 proposal, unless they showed evidence for spreading cancer. The women were seen at three, six, and 12 months after presentation, and yearly after that. The women’s records showed that at 24 months after presentation, 131 continued to have an abnormal smear. (Of course, the other 817 had normal smears, or had had removal of the cervix by hysterectomy or other treatment.) There was no difference in age or parity between those in either group.

The division into the two groups was made retrospectively by the authors on the evidence for the presence or absence of an abnormal smear at 24 months.

They compared the outcomes in the two groups in terms of the development of invasive cancer (22.1 percent in the group with positive smears at 24 months, 1.5 percent in the larger group). They also compared the number of deaths in each group at the end of the observation period (June 1983). Four women who had had normal smears at 24 months had died (0.5 percent) and eight women had died who had had abnormal smears at 24 months (6 percent).

Treatment

There was no withholding of treatment in that group with the persistently abnormal smears – see Table 1.

Initial treatment Eventual treatment
Total hysterectomy Cone biopsy or amputation Total hysterectomy Cone biopsy or amputation
Group 1 (n=817) 217 (26.6%) 576 (70.9%)
Group 2 (n=131) 33 (25.2%) 88 (67.2%) 62 (47.3%) 166 (126.7%)

Table 1. Initial and eventual treatment of patients with normal smears, or who had cervixes removed by hysterectomy or other treatment (Group 1), and of patients with persistent abnormal smears (Group 2). Percentages exceeding 100 percent reflect the need for two cervical procedures in some women.
The authors said in the paper’s discussion, “the almost universal acceptance of the malign potential of this lesion has made prospective investigation into the natural progression of CIS ethically impossible”. That would require an experiment where women had no treatment. This is quite clearly not the case in this reported series.

It is clear that in this report of the management of CIS there is no evidence of withholding of treatment, nor of an experiment.

Three years after this paper was published, it was used by Sandra Coney and Phillida Bunkle as evidence for gross wrongdoing by the medical staff at NWH. Here is what they wrote:

“The study divided the women into two groups – 817 who had normal smears after treatment by conventional techniques, and a second group of 131 women who continued to produce persistently abnormal smears. This group is called in the study the conservative treatment group. Some had only biopsies to establish the presence of disease and no further treatment.”

Later in the article the authors refer to “group two women who had little or no treatment”.

This paper in a popular magazine was used by the Cartwright Inquiry as some of the evidence which led to its conclusions.

In 1990, Liggins said, “The famous 1984 article which emanated from the National Women’s Hospital and on which the Metro article which stimulated the cervical cancer inquiry was based, was misinterpreted by the authors of the Metro article and by the judge”.5

Was the management of cervical carcinoma-in-situ unethical?

This is the second aspect of the Cartwright affair that I wish to examine. In June 2010 the statement was made that “treatment with curative intent was withheld in an unethical study” at NWH from 1965 to 1974.6

It is important to make clear what we understand by ‘ethical’, ‘unethical’ and ‘conventional’, or we shall be reduced to the state of the Looking-Glass world: “‘When I use a word,’ Humpty Dumpty said in a rather scornful tone, ‘it means just what I choose it to mean – neither more nor less.'”7

Ethical: “In accordance with principles of conduct that are considered correct, especially those of a given profession or group”. (Collins Concise Dictionary, 1988.)

Unethical: Not in accordance with these principles.

Conventional: Relating to convention or general agreement. (OED)

Convention is a general agreement or consent. (OED)

Was the protocol for the management of CIN3 by Prof Green and his colleagues at NWH an unethical experiment? If he had proposed to divide the women as they presented into two groups, one of which was treated and the other not, then that would have been unethical. Although uncertainty existed as to what proportion of women with an abnormal cervical smear developed an invasive cancer, it was agreed that an abnormal smear meant that the woman was more likely to develop cancer than if she had a normal smear.

His protocol did not deny women treatment.

There was widespread international uncertainty as to the best form of management. If Prof Green had withheld an acknowledged proven treatment that was agreed to by the majority of workers in the field, and replaced it with an unproven treatment, then that would indeed have been unethical.

He didn’t do that.

During 1966-1984 there was no international agreed conventional treatment for this condition. As Iain Chalmers of the James Lind Library in Oxford points out, 8 Linda Bryder in her book has made a thorough review of the contemporary medical literature on this subject which makes it clear that there was no worldwide, generally accepted treatment of CIN3. The evidence called by the Cartwright Inquiry did not reflect the lack of an international consensus. It was indicative of only one aspect of the issue. It has all the attributes of ‘cherry-picking’.

The accusation that Green and his colleagues behaved unethically in these matters is not sustainable. Unless his detractors can show that there was a single international conventional treatment which he ignored, then repeated accusations of “unethical behaviour” are wrong. These accusations continue to be made, as recently as 1 June, 2010.6

Why do manifestly false beliefs persist over time?

There are features of our human behaviour which are conducive to the persistence of untruths, and they include a desire for uniformity in the interest of the maintenance of a coherent and more easily managed society.

Once a decision has been made, it is easier for all of us to go along with it, and not to ‘rock the boat’.

There have been trenchant criticisms of the Cartwright affair and its outcomes, often met with strident objections and not much logic. To accuse the whistle blower of “intransigence and arrogance” rather than meet the questions fairly is shameful.

Another feature of the last 22 years is the increasing number of papers published in the medical literature which on close examination are of poor quality. An example of this is the paper published on 1 June, 2010.

This was published as an abstract online. The authors include a medical adviser to the Cartwright Inquiry, a medical witness at the inquiry, and one of the authors of the 1984 paper. There is the old accusation that “treatment with curative intent was withheld in an unethical clinical study of the natural history of CIS at NWH in the years 1965-1974.” But in the results it is stated that 51 percent of these women had treatment with curative intent! The group treated with the diagnosis made in 1975-1976 had curative intent treatment in 85 percent. Prof Green retired in 1982; his proposal for the management of carcinoma in situ was approved in 1966.

Treatment with curative intent was not defined in the abstract.

The results include P values of 0.0005 for the significance of differences between groups, for a difference which defines the grouping.

The number of new patients in the year 1975-1976 was half that in each of the two previous decades. There is no explanation for this in the abstract. This group was not included in the comparison of risk for cancer of the cervix or vaginal vault. There is no explanation for this.

The medical science literature shares with all scientific paper publishing a current deterioration in standards. This contributes to the persistence of error. This issue has been recently addressed in an editorial in The European Journal of Clinical Investigation.9

“Why would scientists publish junk? Apparently the current system does not penalise its publication. Conversely, it rewards productivity.
Nowadays, some authors have been co-authoring more than 100 papers annually. Some of these researchers only published three or four papers per year until their mid-forties and fifties. Then suddenly they developed this agonising writing incontinence.”

Another factor in our society which feeds our appetite for orthodoxy is the popular press. Truth is often submerged in the sensational. An example of this occurred in the NZ Herald on 1 June, when their health reporter wrote a report of the on-line article6 with the headline:

“Otago research backs cancer inquiry findings: Unfortunate experiment at National Women’s not imagined, says report”

There followed 40 column centimetres supporting the headline, including two which stated: “The cancer death rate differences between the periods and sub-groups are not significantly different”. This information is not included in the on-line published paper. The reporter’s statement is not correct in his summary of the report. In addition he cites information which suggests he has access to the complete (as yet unpublished on June 1st) paper.

The television ‘press’ included that morning an interview with Charlotte Paul, one of the authors, and that evening, an interview with Clare Matheson, the woman named as ‘Ruth’ in the original Metro article. There was no reference to the valid criticisms of the Cartwright affair which have been made over the years.

It is not my case that the medical profession to which I belong is without fault, and I accept that since 1988 more attention has been paid by doctors to issues such as informed consent. But the means, by this miscarriage of justice, do not justify the ends.

Our human desire not to alter our beliefs in the face of contrary evidence, the willingness of the popular press not to disturb established ‘truth’, the current deterioration in the standards of the world medical press, and an unquestioning respect for ‘authority’ are factors recognisably active in the persistence of the myths surrounding the Cartwright affair. These behaviours are not new, and their effects on the emergence of truth have been recognised for centuries. Francis Bacon (1561-1626) in his Axioms wrote, in number 46:

“The human understanding when it has once adopted an opinion (either as being the received opinion, or as being agreeable to itself) draws all things else to support and agree with it. And though here be a greater number and weight of instances to be found on the other side, yet these it either neglects and despises, or else by some distinction sets aside and rejects; in order that by this great and pernicious predetermination the authority of its former conclusions may remain inviolate.”

References

  1. Editorial. 1974: BMJ, 5891, 561-2.
  2. Green, GH. 1974: NZMJ 80, 279-287.
  3. McIndoe, WA; McLean, MA; Jones, RW; Mullins, PR. 1984: Obstetrics and Gynecology 64, 451-458.
  4. Overton, H. 2010: NZMJ 123, 95-96.
  5. Liggins, CC. 1991: Australia and New Zealand J. Surgery 61, 169-172.
  6. McCredie, MRE; Paul, C; Sharples KJ; Baranyai, J; Medley, G; Skegg, DCG; Jones, RW. 2010: Australia and New Zealand J Obstetrics and Gynaecology, ‘earlyview’ on-line 1 June.
  7. Carroll, L. 1871: Through the Looking-Glass. Chapter 6.
  8. Chalmers, I. 2010: NZMJ Letters to the Editor. 30 July.
  9. Editorial. 2010: European J Clinical Investigation 40(4), 285-7.

Slops the latest Health Threat

The World Health Organisation has issued a new warning against non-essential travel to the entire Western Hemisphere following renewed concerns about the spread of Severe Loss of Perspective Syndrome (Slops).

Officials are warning travellers not to visit western Europe and North America where outbreaks of the disease have led to mass panic among the media, and increased profits from DIY stores as the gullible public rush to bulk-buy face masks and boiler suits.

A WHO spokesman said, “You’d be much better going to somewhere like Thailand or China, because all you’ve got to worry about there is Sars, and let’s face it, you’re about as likely to die from that as you are to get kicked to death by a gang of zombie nuns.”

The Sars virus has now claimed a staggering 500 lives in only six months, which makes it considerably more deadly than, say, malaria, which only kills around 3000 people every single day. Malaria, however, mainly affects only natives what speak foreign, whereas SARS has made at least one English person feel a bit iffy for a couple of days, and is therefore considered much more serious.

The spread of Slops has now reached pandemic proportions, with many high-level politicians seemingly affected by the disease. Its rapid spread has been linked to the end of the war in Iraq and the need for western leaders to give the public something to worry about. Otherwise, they might start asking uncomfortable questions about domestic issues.

Newsfront

“Dr Jaz” Dies

Dr Neil McKenzie, better known to music lovers as Dr Jaz, died in May following a long battle against a brain tumour (Bay of Plenty Times, May 15 2003).

Neil McKenzie was also a long-time member of the NZ Skeptics, and wrote the “Skepsis” column on medical issues for this magazine from 1997 to 1999.

Born in Edinburgh, Scotland, he was raised in Surrey and attended medical school in Charing Cross hospital. He first came to New Zealand in 1974 and subsequently took up a post as a GP in Tokoroa. He settled in Tauranga in 1985.

Neil McKenzie first formed a skiffle band at age 16 in England and took up the banjo – an instrument which became his trademark. In 1980 his band, ‘Dr Jaz’ was born, and has been a regular feature of the local music scene here and overseas ever since.

Equally comfortable in the worlds of music and medicine, he will be greatly missed in both.

ACC Investigates Acupuncturists

ACC is investigating 20 acupuncture providers after discovering they were getting half its annual funding for the treatment (Nelson Mail, Dominion Post, May 21).

More than $2 million was going to only 20 of almost 200 registered acupuncturists, ACC Healthwise division general manager David Rankin said. Some were claiming for 12 hours a day for every day of the week.

Acupuncturists will now have to consult ACC clinical advisers after 10 treatments, rather than the previous 24, before further treatments will be authorised. ACC spends about $4.6 million a year on acupuncture treatments.

Register of Acupuncturists president Kevin Plaisted said the new limit was unlikely to stop further sessions going ahead.

“There is no reason why ACC will not approve further treatment … it’s certainly not designed to stop treatment at 10 but simply that we’re accountable for the treatment we’re providing,” he said.

Dr Rankin said injuries like sprains were treated with acupuncture but it required more sessions than other treatments.

Who Would Have Predicted This?

T Bromley, of Greymouth, takes the Press to task in a letter to the Editor (May 22) over the accuracy of the paper’s Christmas “clairvoyants” Maureen Rose and Rosina Bond.

Neither were able to predict the main stories early in the New Year, which included the Australian bushfires, Sydney’s train disaster, and even the space shuttle crash.

Rosina Bond’s prediction for the war in Iraq read, “While Iraq has become the US’s New Russia it’s predicted the two countries will not go to war in 2003 … When conflict comes to a head it will be late September-early October, Bush will be stopped in his tracks.”

No mention either of the power crisis, nor (and this, says T Bromley, is the grand-daddy of them all) the Sars virus. Like shooting fish in a barrel, really.

Watch Out for Those Ladders

Joanne Black’s Blackchat column (Dominion Post, April 28) had a novel perspective on the Sars epidemic. Pointing out that 110 people dying of the disease in China in one month was equivalent to four New Zealanders dying in a year, she took a look at the statistics to see what types of things kill four, and only four, New Zealanders in a year.

In 1998, the “latest” year for which mortality figures are available, three people died from cystitis, from varicose veins in the legs and from male breast cancer. Eight died from falling in holes, two from acute tonsillitis, four from curvature of the spine, three from genital prolapse, five from falling off ladders or scaffolding, and 14 from being hit by rolling stock (which Black thinks is to do with trains rather than sheep tumbling down hillsides).

Investigating Sars has taught her plenty, she says. She wouldn’t hesitate to travel to China, but from now on, she’ll certainly be more vigilant when crossing railway lines, take more care on ladders, and particularly watch out for those lethal holes in the ground.

Psychics “See” Missing Woman

Psychics have told police they know what happened to missing Hauraki Plains woman Sara Niethe (Dominion Post, June 16).

Several psychics have called police since investigators announced a $20,000 reward for information which would help them find the woman they now believe may have been a victim of foul play.

“They have had visions of where Sara is and where her car is. If they are specific enough we will check them out,” a spokesman said. Most, however, have not been specific.

Ms Niethe vanished on March 30 after drinking in Kaihere with a friend. Wide police searches of the plains, rivers and an irrigation ditch found no sign of her or her light blue-green late 1980s Honda Civic. Her family say it is out of character for her to leave her children, and her bank accounts have not been touched.

We Suspected As Much

The incidence of cancerous tumours in the brain, neck and head has not risen since the arrival of mobile phones, according to the Wellington School of Medicine (Dominion Post, June 16).

Researchers collected data on men and women aged 20 to 69 from the cancer registry between 1987 and 1998, as well as data on cellphone use. Professor Alistair Woodward said the findings, published in the New Zealand Medical Journal, should provide users with some reassurance. He said the study’s weakness was that it looked at the overall population rather than particularly at those who used mobile phones, meaning it was not known whether those developing tumours were using cellphones or not. But the research still showed there was not a strong link between cellphone use and cancer. The findings backed up a similar study in Denmark.

A study of tumour rates among cellphone users compared to non-users would be completed next year.

And on a Similar Note… British researchers have cast further doubt on fears of a link between overhead power lines and childhood leukaemia (Dominion Post, June 16). A study published in the British Journal of Cancer found no evidence to support such concerns from laboratory experiments. Researchers used blood cells from a donor to test the effect of mag-netic fields on the normal repair process and found cells exposed to strong magnetic fields repaired themselves naturally.

Funds Raised for Alternative Treatment

A former Hawkes Bay goal-kicker and member of the Blues Super 12 rugby team will use more than $100,000 raised at charity functions to fight his motor neurone disease with alternative medicine (Dominion Post, June 2).

Jarrod Cunningham, who was diagnosed with the disease last year, said $45,000 was raised at a Hawkes Bay auction on May 31, and up to $70,000 at a rugby game the following day, featuring All Blacks Norm Hewitt and Bull Allen. This would go toward research and education on the natural supplements which had “cured” him.

Cunningham, 34, said he was on the road to a full recovery from amyotrophic lateral sclerosis, a form of motor neurone disease, after taking a course of 20 capsules of astragalus, from the root of the astragalus plant, over five days, and says it has put him into full remission.

After his Christchurch-based Chinese “healer” told him that chicken parasites caused the symptoms of his disease, he has vowed to use money raised to prove this and help others with the disease seek herbal remedies to treat it.

The money raised at the weekend would be fed into a trust to be administered by the healer Cunningham has been working with.

Before taking the herb he was unable to get out of the bath without help. Three weeks after the dose he was able to do so on his own. “If that’s not remission of symptoms I don’t know what is,” he said.

Cunningham was also prescribed a dose of cayenne pepper to help unblock his lymph nodes, which he says worked. He based this on his armpits smelling like curry.

He no longer visits his doctor in Britain where he has been based, saying the doctor was closed-minded and negative. However when his muscles grow back in three to six months, as he predicts, he will tell his neurologist how he did it.

Never Mind That White Powder, Just Pass Me a Face Mask

These are nervous times. By an astounding coincidence, as I wrote that line and paused to think of what to put next, I had a call from a friend to tell me there was a Sars case at the Waikato Hospital and to ask whether, in my other role as a subeditor at the Waikato Times, I would want to pass that on.

Astounding because I was about to add that the Sars panic seems to have taken over from the terrorism panic (although just the other day someone caused an alert after discovering “white powder” – almost certainly crystallised sugar – on his chewing gum) as the concern of the month.

True, it’s early days, but Sars doesn’t seem to have what it takes to be a true pandemic. It’s just not contagious enough – if a country with resources as limited as Vietnam’s can control and eliminate it, the rest of the world should be able to handle it too. It’s hard not to conclude that there has been a substantial over-reaction to the outbreak.

Now alright, I’m not that old, but I’m sure it never used to be like this. Death and disease used to be all part of life. People got, say, tuberculosis, went to the Sanatorium, and if they were lucky they came out again a few months later. If not, the rest of the community would gather around the bereaved family. Miners died of foul lung diseases and that’s just the way things were.

In one sense, then, the current panics are a good thing. They show that human life is more highly valued than it was in the past. They are perhaps also a symptom of the secularisation of society. At one time the bulk of the population would have believed that physical death was only the beginning of an immortal life in the hereafter, and therefore not a cause for prolonged grief. With that certainty gone for most of us, we are acutely aware that this life is all we have, and are terrified at the prospect of having it snatched away from us.

The sophistication of our modern, secular society, then, is only skin deep. As Carl Sagan said, “…the candle flickers, and the darkness gathers, the demons begin to stir.”

No doubt some would have predicted that following the decline of religious beliefs we would enter a brave new world of rational thought as a species. The hysteria over Sars, white powder and cellphone towers show this is not the case. Human nature remains the same as it ever was.

Annette's signature

The Price of Water

Insecurities about water quality have led to a boom in sales of bottled water. But the health benefits of the phenomenon are probably minimal.

We were surprised to hear recently that sales of drinking water are now the fifth largest earner of overseas currency for Fiji. A little investigation suggested that that figure may well be correct, but threw up further surprises.

Much of Fiji has high rainfall, but water is in short supply in some areas. Villagers can easily dig shallow wells, and Aid agencies have dug deep wells for some villages. But deep water is often mineralised. We have stayed on islands were rain is the only supply of drinking water. As populations have grown, water extraction has allowed intrusion of salt water, and the well water is brackish. After weeks of washing in brackish water, a fresh shower is a great luxury. Tourist resorts build de-salination plants but that is not an option for villagers.

According to the Australian Financial Review, Aid money was used to develop a mountain spring as a source of export water. The main market is the USA where Fiji water is now the 6th highest-selling bottled water after advertising endorsements from Tiger Woods and Elle Macpherson. Good luck to the entrepreneurs, but I wonder if the contributors realised the destination of their charitable dollars.

Something is odd about a third world country exporting drinking water to the USA. Fifty years ago American travellers had one main grumble about Europe; the tap water was unsafe to drink. This implied that the tap water was drinkable back home where the only people refusing US tap water were right-wing conspiracy theorists who claimed that somebody (either the government or the commies) were adding chemicals to damage the mental health of citizens.

Bottled water was then almost entirely ‘mineral water’, either naturally carbonated water from a few famous springs or the much cheaper alternative invented by Schweppes. Scandals about contamination of some famous springs damaged the market, but some genius discovered that bottled drinking water did not need to be carbonated and any source of clean water would do.

Until that time the manufacturers of soft drinks were regarded as the epitome of value improvers; the addition of carbon dioxide and a few drops of syrup converted water at low cost to a marketable product. But the drinking water industry changed this perception. All the costs are in bottling and transport, the cost of the water in the bottle is as near zero as makes no difference.

The industry started in the USA but then took Europe by storm, 15 years ago British sales of bottled water had reached £216 million and London restaurants were charging £1 per glass. It took longer to reach Australia and NZ but the sight of all those tourists clutching their bottles had an effect.

Have a look in your local supermarket, there are a variety of brands and unless you buy it in very large containers it is more expensive than petrol. Marketing has been closely targeted, using magazines and radio stations rather than TV. The sales people know their main clientele, young, affluent travellers.

By a strange bit of timing the tap water in Europe had become safe to drink just before bottled water became popular. In fact one of the priorities of government has been the provision of safe tap water (it is even safe to drink on the main Fiji island), but as it became safe, tourists stopped drinking it.

So what is the motive? At least partly it is fashion, backpackers have been seen furtively refilling their bottles at the tap so later they can be seen with the right brand. But most clearly believe it is healthier to drink ‘natural spring water’. Some brands will tell you they are ‘fat free’! Ironically the quality standards on most tap water is probably higher than those on much bottled water. But backpackers are all aware of the high incidence of ‘traveller’s diarrhoea’, one estimate is 20 million cases per year world-wide, though it could be much higher.

Herbert DuPont is Chief of Internal Medicine at St Luke’s Episcopal Hospital Houston Texas and an expert in diseases of the alimentary tract. His opinion is that although “Most people think it (diarrhoea) is caused by the water”, it is not. “Bad food is responsible for 90% of traveller’s diarrhoea.”

Even in the USA, eating out is twice as dangerous as eating at home. Scientific American July 2000 contained some amazing statistics. A large percentage of outbreaks of food poisoning could not be traced to a particular source, however of those that could be so traced, the most dangerous foods were not those I would have suspected:

Food that caused a problem % of outbreaks
Salads 12.4
Fruit and vegetables 6.0
Beef 2.3
Chicken 2.1
Fish (including shellfish) 1.3
Milk and eggs 1.0
Pork 0.4

Vegetarians beware; the most dangerous items are those generally considered the most healthy! However going back to Professor DuPont, he warned that the really dangerous items were sauces and condiments, particularly if they were not properly refrigerated. I suspect (without any evidence) that this may be the case here.

It seems obvious that these percentages would be quite different in other countries, but if you cannot trust the salads in the USA, those bought from street vendors in Asia must be pretty dodgy.

In the past, epidemics of the great water-born diseases, typhoid and cholera, killed millions- and they were a threat to the traveller. But in countries were most of the bottled water is being drunk, this is no longer the case. The last major outbreak of cholera from a public water supply was in a South American country where activists had opposed chlorination. Chlorine of course is a chemical, and a poison, and they should not be putting it in our drinking water! I suspect that if travellers were questioned, many would give ‘chlorination’ as a reason for not drinking tap water. I just wonder, how safe is bottled water?

Forum

Alternative Child Healthcare

The following correspondence between nursing lecturer Sue Gasquoine and Skeptics’ chairentity Vicki Hyde is reproduced with the permission of the participants -ed.

Hello Vicki,

I heard you talking to Wayne Mowat on National Radio yesterday. I have a theory for you to consider as you wonder why New Zealanders view with such skepticism “religious” reasons for denying children treatment (epitomised by the death of baby Caleb Moorhead) when there seemed to be significant support for Liam Williams-Holloway’s parents when they decided to “hide” him and seek “alternative” therapy.

There is a world of difference between diagnosis with and death from a vitamin deficiency and diagnosis with and death from cancer.

Vitamin deficiency is entirely avoidable even with very strict diets. Cancer in children is not. Treatment of vitamin deficiency is generally uncomplicated, entirely successful and has few side effects. Treatments for cancers such as radiotherapy and chemotherapy are by no means uncomplicated and are often associated with distressing side effects. They vary in their effectiveness depending on the type and location of the cancer and are by no means a guarantee that the child will survive.

There are few if any useful parallels that can be drawn between parents trying to act in the best interests of their child with cancer, who may in the process decline treatments offered by western medicine and parents who do not recognise the ‘necessaries of life’.

I think New Zealanders recognise this critical difference which has been absent in most media coverage of these tragic events. They do well to be skeptical of religious fanaticism, alternative therapy AND western medicine which also makes false claims – the “safety” of HRT and the rate of caesarian births being the most recent examples!

Sue Gasquoine, Lecturer – Nursing
School of Health Science, Unitech

Vicki responded with:

Thanks for the feedback — always appreciated.

I certainly agree there is a world of difference between diagnosis with and death from a vitamin deficiency and diagnosis with and death from cancer, and it may well have been a contributing factor though not, I would suggest, a major distinction made by people in looking at the various cases.

I say that because of the Tovia case just before Liam’s one, which also involved refusal of cancer treatment for a child (albeit a 14-year-old), but this time on religious grounds.

In that case, there was, as with the Moreheads, a much more critical view taken of the parents and their role in refusing treatement. They were also taken to court, at one stage facing manslaughter charges, and were generally condemned in the media.

I have had many discussions with legal, media and medical people about the differences between this case and that of Liam Williams-Holloway, and the treatment the two families got in the press and in the court of public opinion.

I think that it would be possible to argue that Peni and Faafetai Laufau, the parents of Tovia, deserved a more sympathetic treatment in some respects because (1) they were doing it on sincere religious beliefs, not based on a book which touts conspiracy theories and coffee enemas as cancer treatments and (2) their son was of an age to arguably be a part of the informed consent process, and expressed his own wish to refuse treatment.

Much in all as I hate to say it, the main points of difference can be attributed to a couple of factors I suspect — the Laufaus were Pacific Islanders, of lower socio-economic status, and religious. Treena and Brendan were white, middle-class, articulate and constantly described as making a “well-informed choice”.

It’s a most uncomfortable set of differences in its implications…

I do think that there is culpability in both the cases you cite and in that of the Laufaus. There is a great deal regarding the Liam Williams-Holloway case which was not adequately addressed by the media, and I can understand why those involved continue to feel a certain amount of despair and anger at what happened. (I’d be happy to discuss this further if you like, or if you have any questions about it.)

And you are so right that it is vital we cast a critical eye over any claims in all areas. What we have to do is to ensure that we have some way of helping us determine what claims there are, what the level of evidence is to support those claims, and what the risks are in accepting or rejecting that evidence.

All the best,
Vicki Hyde

B.Sc.(Astrol.) anyone?

Ever felt queasy about the courses the New Zealand Qualifications Authority gives its approval to? Remember the fuss over the Indian government’s encouragement of university courses in astrology? The infection is spreading; some well-known British universities are also up to some curious activities. A recent correspondent to the science journal “Nature” reports on a charity called The Sophia Project, which has money to give away for work that sets out to establish that astrology is a genuine science. Four institutions are named as having accepted funds for this. Studies include: planetary influences on fertility and childbirth, and on alcoholics, and looking for correlations between birthdate and prostitution.

The correspondent is concerned that, despite the private funds provided, some taxpayers’ money is inevitably going to support this “bogus research”. Of perhaps greater concern is that these universities are giving undeserved respectability to this nonsense.

Bernard Howard

A Letter from the Skeptical Left

I admire your work against creationism, but I have to ask why it is that proponents of lesbian and gay rights and reproductive choice on abortion have to fight junk science from the Christian Right on our own.

I am concerned that you appear to have swallowed petrochemical industry propaganda against the Kyoto Treaty, surely akin to the tobacco industry’s pro-smoking agenda in motive, intent and overall poor empirical rigour. As well as that, there is a wide-ranging debate over questions of “false” and “recovered” memories within the mental health professions, yet your organisation seems to be listening to the male backlash lobby, quite capable of its own imaginary junk science when it comes to its own control freak agenda against victims of family violence.

Craig Young, Palmerston North

…And one from the Skeptical Greens

When I read Professor Dutton’s vitriolic attack on the Greens in the Weekend Herald of September 28/29, I immediately thought he must have been inspired by the frantic ravings of another American whom we’ve heard quite a bit from lately. However, to give Professor Dutton his due, he did stop short of suggesting we should wage a war of attrition upon Green subversives.

His passionate defence of science reminded me of the attitude adopted by devout religionists over the centuries. Professor Dutton accuses environmentalists of a similarly distorted mindset, but despite the fact that all movements have extremist factions, he is well off track with his generalisations, if for no other reason than that the Greens are concerned for the well-being of things that actually exist, and have been carefully examined. Religionists on the other hand operate for the most part on pure supposition.

Science is not a religion. However it would seem that there are several people involved in that noble art who regard it as such. That is indeed sad, and a reprehensible distortion of mankind’s only reliable method of inquiry into most subjects. The scientific method should be an intelligently used force that will tell us often bumbling humans how far in any direction we should attempt to go. Unfortunately, the caution factor is all but ignored these days in favour of the hedonistic delight of having found something new that works. Apart from the financial and economic benefits, the other outcomes of a new discovery are often made less transparent, until of course, somewhere down the track something highlights a hidden disaster factor that was not thought worthy of mention at the time of the discovery’s introduction.

My final word to Professor Dutton is that he should place the blame for the world’s starving millions exactly where it belongs. Greedy corporate giants, environmental exploiters, warmongers, and corrupt officials will do for a start. Compared with that lot, we greenies aren’t even in the picture. (Abridged)

Peter E Hansen, Auckland

Forum

Ritalin and ADHD

Professor JS Werry deserves thanks for his contribution in these pages regarding the present use/abuse of methylphenidate (Ritalin) and ADHD.

Despite the Professor’s reassurances regarding the reality of ADHD, I’m afraid I remain an unconvinced sceptic.

Perhaps Professor Werry could explain where ADHD comes from. It certainly wasn’t a feature of our lives in the fifties and sixties, and now millions of young children worldwide, many of them under 10, are being treated for many years of their lives with a powerful amphetamine-like drug for a “non-disease” epidemic.

Time magazine in its (admittedly dated) July 18, 1994 cover story reported that many European countries, notably France and England, have only 1/10 as many ADHD cases as the USA. Japan seems to have little experience of ADHD at all – yet it has been termed “the educational disorder of the 1990s.” The USA has experienced a four-fold increase in ADHD since 1990.

Contrary to Professor Werry’s assurances, academics are by no means united over ADHD and its treatment with methylphenidate/Ritalin. Indeed, an increasing number of professionals decry this alarming and controversial trend of labelling children with this psychiatric condition.

One of the dissenters is Thomas Armstrong, Ph.D., former special education teacher and author of The Myth of the ADD Child. Armstrong strongly questions the rush to label a child having problems in school as “ADHD.” He asks how ADHD can be a “mental disorder” when its symptoms are so selectively displayed – for example when an ADHD child is internally motivated to focus – as when deeply engrossed in a video game – the inability to pay attention is apparently not present.

I would be very interested to find out whether a diagnosis of ADHD at an early age has any bearing on later youth suicide, whether ADHD children are more or less likely to come from a dysfunctional family background, and the reason for the apparent prevalence of ADHD in some countries and not others. The overwhelming preponderance of young males in the statistics is also of concern.

Mike Houlding, Mt Maunganui

Possum Peppering

Perhaps John Welch is a little unfair to the Green Party when he condemns them for claiming that burnt possum testicles deter possums from eating vegetation. As a doctor, he will know that removing testicles not only annoys the possum, but also reduces its chances of reproduction.

The Green Party does not go far enough. If they would guarantee to remove every testicle from every possum in this country, they would certainly get my vote. the whole exercise would give relief to our forests, and possibly also to the female possums, who in one possum generation would die childless but lonely. (Abridged.)

David L Smith, Titirangi

Behind the Screen

Mass screening programmes have generated considerable controversy in this country. But these programmes have inherent limitations, which need to be better understood

In 1996 the Skeptical Inquirer published an article by John Allen Paulos on health statistics. Among other things this dealt with screening programmes. Evaluating these requires some knowledge of conditional probabilities, which are notoriously difficult for humans to understand.

Paulos presented his statistics in the form of a table; a modified version of this is shown in the table below.

Have the
condition
Do not have
the condition
Totals
Test Positive 990 9,990 10,980
Test Negative 10 989,010 989,020
Totals 1,000 999,000 1,000,000
Table 1

Of the million people screened, one thousand (0.1%) will have the condition. Of these 1% will falsely test negative (10) and 99% will correctly exhibit the condition. So far it looks good, but 1% of those who do not have the condition also test positive, so that the total number who test positive is 10980. Remember that this is a very accurate test. So what are the odds that a random person who is told by their doctor that s/he has tested positive, actually has the condition? The answer is 990/10980 or 9%.

In this hypothetical case the test is 99% accurate, a much higher accuracy rate than any practical test available for mass screening. Yet over 90% of those who test positive have been diagnosed incorrectly.

In the real world (where tests must be cheap and easy to run) a very good test might achieve 10% false negatives and positives. To some extent the total percentage of false results is fixed, but screening programmes wish to reduce the number of false negatives to the absolute minimum; in some countries they could be sued for failing to detect the condition. This can only be done by increasing the chance of false positives or inventing a better test. Any practical test is likely to have its results swamped with false positives.

Consider a more practical example where the base rate is the same as previously, but there are 10% false negatives and positives, ie the test is 90% accurate. Again 1 million people are tested (see Table 2 below).

Have the
condition
Do not have
the condition
Totals
Test Positive 900 99,000 100,800
Test Negative 100 889,100 899,200
Totals 1,000 999,000 1,000,000
Table 2. Base rate is 0.1%. Level of false positives=10%; level of false negatives=10%

This time the total number testing positive is 100800. But nearly one hundred thousand of them do not have the condition. The odds that any person who tested positive actually has the condition is 900/100800, or a little under 1%. This time, although 90% of these people have been correctly diagnosed, 99% of those who test positive have been diagnosed incorrectly.

In both these cases the incidence of the condition in the original population was 0.1%. In the first example the screened population testing positive had an incidence two orders of magnitude higher than the original population, but this was unrealistic. In the second example those testing positive in the screened population had an incidence one order of magnitude higher than the general population.

This is what a good mass screening test can do – to raise the incidence of the condition by one order of magnitude above the general population. However any person who tests positive is unlikely to have the condition and all who test positive must now be further investigated with a better test.

So screening programmes should not be aimed at the general population, unless the condition has a very high incidence. Targeted screening does not often improve the accuracy of the tests, but it aims at a sub-population with a higher incidence of the condition. For example, screening for breast cancer (a relatively common condition anyway) is aimed at a particular age group.

Humans find it very difficult to assess screening, and doctors (unless specifically trained) are little better than the rest of the population. It has been shown fairly convincingly that data are most readily understood when presented in tables as above. For example the data in Table 3 was presented to doctors in the UK. Suppose they had a patient who screened positive; what was the probability that that person actually had the condition?

When presented with the raw data, 95% of them gave an answer that was an order of magnitude too large. When shown the table (modified here for consistency with previous examples) about half correctly assessed the probability of a positive test indicating the presence of the disease.

Have the
condition
Do not have
the condition
Totals
Test Positive 8,00 99,000 107,000
Test Negative 2,000 891,000 893,000
Totals 10,000 990,000 1,000,000
Table 3. Base rate is 1%. False negative rate=20%; False positive rate=10%

This time the total number who test positive is 107 000. But nearly one hundred thousand of them do not have the condition. The odds that any person who tested positive actually has the condition are 8000/107 000 or about 7.5%. Now remember that nearly half the UK doctors, even when shown this table could not deduce the correct result. If your doctor suggests you should have a screening test, how good is this advice?

Patients are supposed to be supplied with information so that they can make an informed decision. Anybody who presents for a screening test in NZ may find it impossible to do this. My wife attempted to get the data on breast screening from our local group. She had to explain the meaning of “false negative”, “false positive” and “base rate”. The last is a particularly slippery concept. From UK figures the chances of a 40-year-old woman developing breast cancer by the age of 60 is nearly 4% (this is the commonest form of cancer in women). However, when a sample of women in the 40-60 age group are screened, the number who should test positive is only about 0.2%. Only when they are screened each year, will the total of correct positives approach 4%.

The number of false positives (again using overseas figures) is about 20 times the number of correct positives so a women in a screening programme for 20 years will have a very good chance of at least one positive result, but a fairly low probability of actually having breast cancer. I do not think NZ women are well prepared for this.

The Nelson group eventually claimed that the statistics my wife wanted on NZ breast cancer screening did not seem to be available. But, they added, “we (the local lab) have never had a false negative.” From the recent experience of a close friend, who developed a malignancy a few months after a screening test, we know this to be untrue. What they meant was that they had never seen a target and failed to diagnose it correctly as a possible malignancy requiring biopsy. This may have been true but it is no way to collect statistics.

Screening for breast cancer is generally aimed at the older age group. In the US a frequently quoted figure is that a woman now has a one in eight chance of developing breast cancer, which is higher than in the past. This figure is correct but it is a lifetime incidence risk; the reason it has risen is that on average women are living longer. The (breast cancer) mortality risk for women in the US is one in 28. A large number who develop the condition do so very late in life and die of some other condition before the breast cancer proves fatal.

Common Condition

Breast cancer is a relatively common condition and would appear well suited for a screening programme. The evaluation of early programmes seemed to show they offered considerable benefit in reducing the risk of death. However later programmes showed less benefit. In fact as techniques improved, screening apparently became less effective. This caused some alarm and a study published in 1999 by the Nordic Cochrane Centre in Copenhagen looked at programmes world wide, and attempted to better match screened populations with control groups. The authors claimed that women in screening programmes had no better chance of survival than unscreened populations. The reactions of those running screening programmes (including those in NZ) were to ignore this finding and advise their clients to do the same.

If there are doubts as to the efficacy of screening for breast cancer, there must be greater doubts about screening for other cancers in women, for other cancers are rarer. Any other screening programme should be very closely targeted. Unfortunately the risk factors for a disease may make targeting difficult. In New Zealand we have seen cases where people outside the target group have asked to be admitted into the screening programme, so they also “can enjoy the benefits”. Better education is needed.

Late-onset diabetes is more common among Polynesians than among New Zealanders in general, and Polynesians have very sensibly accepted that this is true. Testing Polynesians over a certain age for diabetes makes sense, particularly as a test is quick, cheap and easy to apply. Testing only those over a certain body mass would be even more sensible but may get into problems of political correctness.

Cervical cancer is quite rare so it is a poor candidate for a mass screening programme aimed at a large percentage of the female population. The initial screening is fast and cheap. If the targeted group has an incidence that is one order of magnitude higher than the general population, then the targeting is as good as most tests. Screening the whole female population for cervical cancer is a very dubious use of resources.

My wife and I were the only non-locals travelling on a bus in Fiji when we heard a radio interview urging “all women” to have cervical screening done regularly. The remarkably detailed description of the test caused incredible embarrassment to the Fijian and Indian passengers; we had the greatest difficulty in concealing our amusement at the reaction. The process was subsidised by an overseas charity. In Fiji, where personal hygiene standards are very high, and (outside Suva) promiscuity rates pretty low, and where most people pay for nearly all health procedures, this seemed an incredibly poor use of international aid.

Assessment Impossible

Screening for cervical cancer has been in place in NZ for some time. Unfortunately we cannot assess the efficacy of the programme because proper records are not available. An attempt at an assessment was defeated by a provision of the Privacy Act. The recent case of a Gisborne lab was really a complaint that there were too many false negatives coming from a particular source. However this was complicated by a general assumption among the public and media that it is possible to eliminate false negatives. It should be realised that reducing false negatives can only be achieved by increasing the percentage of false positives. As can be seen from the data above, it is false positives that bedevil screening programmes.

Efforts to sue labs for false negatives are likely to doom any screening programme. To some extent this has happened in the US with many labs refusing to conduct breast xray examinations, as the legal risks from the inevitable false negatives are horrendous.

Large sums are being spent in NZ on screening programmes; taxation provides the funds. Those running the programmes are convinced of their benefits, but it is legitimate to ask questions. Is this spending justified?

Some Post-Scripts:

January 15 2000 New Scientist P3: Ole Olsen & Peter Gøtzsche of the Nordic Cochrane Centre in Copenhagen published the original meta-analysis of seven clinical trials in 2000. The resulting storm of protest, particularly from cancer charities, caused them to take another look. They have now reached the same conclusion: mammograms do not reduce breast cancer deaths and are unwarranted.

October 2001: In recent TV interviews some people concerned with breast cancer screening in NZ were asked to comment on this meta-analysis. Once again the NZ commentators stated firmly that they were certain that screening programmes in NZ “had saved lives” but suggested no evidence to support their view.

March 23 2002 New Scientist P6: The International Agency for Research on Cancer (IARC) funded by the WHO claims to have reviewed all the available evidence. They conclude that screening women below the age of 50 is not worthwhile. However, screening women aged from 50-69 every two years reduces the risk of dying of breast cancer by 35%.

According to New Scientist, the figures from Britain are that of 1000 women aged 50, 20 will get breast cancer by the age of 60 (2%); of these six will die. Screening every two years would cut the death rate to four. [It is obvious that these are calculations, not the result of a controlled study!]

The IARC states that organised programmes of manual breast examination do not bring survival benefits (they call for more studies on these). If NZ has similar rates then screening programmes aimed at 50-60 year old women should save approximately 50 lives per annum.

Dummy pills just the trick

Dummy pills just the trick

The best paper in New Zealand (Waikato Times, May 6 – and it’s got nothing to do with the fact that I work there) reports that depressed patients tricked into thinking they are being treated have undergone healing brain changes.

The discovery is “conclusive proof of the power of the ‘placebo effect’ – the mind-over-body influence of believing that a drug will work.”

Scientists at the University of Texas, San Antonio say patients given a dummy pill experienced brain changes remarkably like those attained by taking Prozac.

World’s biggest ghost hunt

Hertfordshire’s Dr Richard Wiseman involved 250 volunteers and an array of hi-tech equipment in what became the world’s biggest ghost hunt, according to the Guinness Book of World Records.

The Evening Post (March 3) says despite a number of creepy tales from volunteers, no definite proof of the supernatural was found during the experiment conducted in Edinburgh early last year. Wiseman said it was truly fascinating but “…none of the stories convinced me ghosts exist … I used to be a magician and I saw how easily people could be tricked.”

The tour guide who worked in the underground vaults of the 18th Century chamber, was in no doubt of the presence of ghosts, the paper said. These included a little boy, a dog and “the spectre of a nasty man who whispers obscenities in people’s ears.

“He has foul, stinky breath and he’s really horrible … The vaults … have been closed for 180 years so I think all that paranormal energy has been bottled up and is only just now being released.”

Maybe the tour guide needs Scooby Doo to deal with the wee doggie.

Measles epidemic hits anti-vaccine town

A measles epidemic involving 700 children that ravaged a small German town is being blamed on two homeopathic doctors who denounced the MMR vaccine, says the Dominion on March 7.

Debate on the merits of the vaccine is reaching fever pitch and 30 children had been admitted to hospital where there were fears there could be deaths.

On one side are “alternative health enthusiasts” who dominate Coburg, an affluent Bavarian town. Two of the town’s seven child health doctors fiercely oppose MMR. And then there are the public health experts, who “accuse a ‘nest’ of militant anti-MMR activists … of putting children’s lives in danger.”

Germany, the paper reports, is becoming famous as a world leader in “exporting measles”, according to leading specialists.

Dr Helmut Weiss, head of the state health office in Colburg, said the stronghold of the epidemic was the Waldorf School.

He’s at it again

And the Evening Post (April 13) informs us that psychic Uri Geller is to look for the site of the battle featured in the movie Braveheart.

The “paranormal expert” has been called in by historian John Walker, to try to pinpoint the exact location of the Battle of Falkirk which was fought between King Edward I of England and William Wallace, in 1298. The location has been lost, and no bodies or artefacts ever found.

Mr Walker stumbled on to Uri Geller while on the internet one evening, and read how he’d helped discover the location of a wrecked submarine. Since, he said, conventional methods to discover the graves of the combatants had failed, “… we need to try the unconventional.”

And Mr Geller said the battle was mysterious. “…the fact that very little was found could mean they have not been looking in the right place for the site.”

As they say, watch this space. And, by the way, William Wallace was not a homespun-wearing, oatmeal-eating fighting man of the glens as depicted in that movie, but grew up in a genteel manor house where he probably had very good table manners. So there.

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.