Snake oil, water and acid – a very sad mix

A fiasco over a ‘Natural Therapy Clinic’ at Wanganui Hospital was finally resolved satisfactorily – but for the wrong reasons.

The attempted introduction of ‘natural therapy’ to Wanganui Hospital has been yet another appalling demonstration of the failed leadership, governance and management structure of the Whanganui District Health Board.

Whilst clearly recognising all our rights to pursue personal and spiritual health, wellbeing, happiness and pleasure, my view is this: New Zealand hospitals, established with public funds and administered by the Ministry of Health, must follow the principles of evidence-based care.

I have a high level of interest and involvement in things spiritual and religious. I am an ardent advocate of patient and broader human rights and strongly support and respect our indigenous people and the Treaty of Waitangi.

However, and a big however, as a trained scientist, specialist General Surgeon and third term elected member of the Whanganui DHB, I have been appalled at what has unfolded in the attempted introduction of ‘natural therapies’ to our public hospital here.

I think I understand the sentiments that might have driven this initiative. Indeed I also have a degree of sympathy with its proponents, who almost certainly meant well.

The arrogance of thinking within Western medicine that excludes possible benefits of other modalities of healing is not warranted. An environment lacking in empathy and caring is all too common in our public hospitals and also needs to be dealt with. So too, the awful health statistics of our under-privileged population – in which Maori are sadly over-represented.

However, even a cursory examination of what has transpired in this failed process reveals serious and very worrying realities of the state of stewardship of the provision of medical care in New Zealand.

The initiative to establish a ‘Natural Therapy Clinic’ at Wanganui Hospital saw the formal establishment of the service via an early morning blessing at Te Piringa Whanau on Monday 23 July at 7.45am. The service was led by local kaumatua John Maihi and Wanganui Hospital chaplain Rev Graham Juden.

Despite obvious months of planning and detailed preparation, this was announced via a press release of 19 July1, just three days before the formal launch.

This was the first word of this initiative breathed to members of the Whanganui District Health Board. Not a single mention of it was made by the CEO Julie Patterson to her board – not even a hint in her weekly email updates to board members, the last one appearing just days before the launch. For a board that runs on the premise of ‘no surprises’ from its CEO, this is disturbing.

This is especially concerning since the media release in January 2012 suggesting (with the blessing of local obstetric specialists) that Wanganui might soon have no obstetric service was also never formally discussed at a board meeting. This created six months of chaos and anxiety for our community.

Termination

Fortunately, like the absurd idea of not providing an acute obstetric service to a city of 45,000 people, the ‘Natural Therapy Clinic’ idea has been terminated.

Interestingly, the scheme was cancelled just days before it was to be presented to the board. The only way I was able to get it to the board table at all was to link the idea of allowing non-accredited ‘practitioners’ loose on our patients with the recent case of alleged sexual abuse of one of our patients by a mental health care assistant in our organisation.

The CEO reported at the time2:

” Almost 12 months ago we received a complaint from a young woman, one of our mental health clients. The complaint alleged that she had been raped by a Health Care Assistant (HCA). The staff member was immediately suspended and the complaint investigated. It was found that the staff member had had inappropriate contact with the woman (texting and meeting her away from the unit) and a strong suspicion that there had been a consensual sexual relationship. The staff member resigned but was informed in writing that the outcome of the investigation was that he would have been dismissed. As this person was part of the unregulated workforce, we had no other levers.”

How much more blatant a lesson does one need to realise the obvious pitfalls of not only allowing, but encouraging, unregulated workers access to our patients?

The ‘paper’ which was finally presented to the board was the usual inept documentation supplied for board members and was lacking in even the rudiments of scientific form or rigour.

The claim that the pilot programme received “overwhelmingly positive feedback from staff”3, is perhaps one of the more obvious areas of deception in all this.

A survey of the 75 staff members who chose to use the service at its pilot stage apparently showed a positive response. However, of course, this is a self-selected group of less than seven percent of hospital staff members who wanted to avail themselves of the service in the first place. The views of the other 93 percent of staff are not canvassed or recorded.

But this is characteristic of DHB doublespeak.

The first media release of 19 July concerned me on a number of levels. The fact that the board had not been consulted was one. Board sets policy; management is tasked with implementing it.

All too often in our fragile district, management has implemented unjustifiable actions and then looked to the board for support after the fact. That support has understandably and correctly for the most part not been forthcoming.

An open-ended field

The second concern was the lack of definition of ‘Natural Therapy’ and the open-ended inclusion of all comers, including traditional Maori healing, Christian prayer, massage, Reiki and meditation training, as treatment modalities.

More recently, and again without prior notification, we learn through the media3 that ‘colour therapy’ was also included in this array.

None of these can seriously or accurately be considered to be therapies any more than a warm bubble bath or hairdressing could be. That does not mean that they necessarily infer harm – of course the latter two do not. Furthermore, it does not mean that hairdressers and bubble bath are not allowed or even encouraged in our hospitals: of course they are. They simply are not therapies. They are nice things and we can choose to use them in or out of hospital if we wish at our own whim.

The provision of Traditional Maori Health is already recognised by our Ministry of Health and appropriately funded and provided outside of hospitals. One could well argue that this is a legitimate part of the history and culture of New Zealand and like the Maori language is worthy of respect and support. I agree. This is a noble sentiment, and one supported by our government, but any serious practitioner of traditional Maori healing would no sooner practise his art in a backroom of Wanganui Hospital then I would perform a laparotomy in the staff canteen.

Confusion

It is curious that the reported formal line of the organisation as to why the project was shelved was to “avoid confusion and anxiety in the community which we are here to serve”. That confusion, however, has been created by the management team of what is supposed to be a first-world public hospital formally suggesting through one of its most prominent specialists that the likes of ‘colour therapy’, prayer and body rubs might have any serious therapeutic benefit.

Indeed, in a study of some 1200 patients published in the American Heart Journal4 prayer clearly has been tested and shown to have no such effect.

My greatest concern, until recently, was that this project was initiated and sustained by a medical specialist colleague Dr Chris Cresswell, who is a Fellow of the Australasian College of Emergency Medicine (FACEM) and boasts vocational registration with the New Zealand Medical Council.

Code of Ethics

Our own Medical Association of New Zealand code of ethics requires us to “[a]dhere to the scientific basis for medical practice while acknowledging the limits of current knowledge.”5

It is entirely inappropriate for us to use our acquired medical positions and titles to actively promote in a formal way practices that clearly are not evidence based.

The issue is not that these modalities have no value. For individuals they clearly do. It is not that they might do harm; they probably will not. The issue is a gross breach of our commitment to our patients to apply best practice and evidence-based models to their care.

Furthermore, the notion that individuals who are essentially unaccountable and unrecognised by professional bodies and standards should be unleashed on our patients is at best irresponsible. That one of our senior doctors &#8212 Dr Cressell &#8212 in his professional capacity was using his medical qualifications and status to promote these people and suspect modalities should be a matter for the Medical Council to act on. These are not acceptable treatment options. They might well be nice and comforting and like hand-holding and hairdressing, patients are at liberty to use them at their own behest even in our hospitals. They are not to be formally prescribed by doctors using their medical credentials to promote snake oil. These are not therapies; these are not credentialed practitioners. These are at best warm fuzzies and do not require ‘clinics’ endorsed by our doctors. They have no place in our hospitals any more than homeopathy, devil worship or nail painting does.

I was surprised that the hospital CEO, Clinical Board and Association of Senior Medical Staff supported this poorly conceived idea at the outset. They did. They most certainly did.

Not one of my medical colleagues locally spoke out against this plan. Not one spoke out in support of high-quality, first-world, evidence-based medical care of which we should be unambiguously proud.

Common sense?

Then suddenly, the idea was dropped. I thought some common sense had prevailed.

The real and greatest concern, though, is this. Our CEO and board chair refused in the public section of our board meeting to properly explain why the project was so suddenly stopped in its tracks.

The answer lies not in medical ethics, science, patient concern or professionalism. Astoundingly, it seems, it lies not in a rational, scientific concern for evidence-based practice and a concern for who precisely we allow to have access to our patients. It lies, rather, in religiously based paranoia and bigotry.

A Wizard at the hospital

On 6 September 2012 an advertisement article appeared in the Wanganui River City Press titled ‘Dreams, magic, healing and medicine’6.

This promoted a talk to be given by Dr Cresswell on a number of topics including the ‘Natural Therapy Clinic’ and his proud introduction of it to Wanganui Hospital.

Sadly for Dr Cresswell and the ‘Natural Therapy Clinic’ the article disclosed the fact that Dr Cresswell is an ordained Wizard in the Whanganui School of Witchcraft and Wizardry, a clearly unchristian organisation and the meeting was part of Theosophy Wanganui.

I guess that degree of open mindedness, free spirit and lateral thinking on the part of Dr Creswell is what led him on his natural therapy crusade. I must confess to a degree of admiration, kinship and support for his wide raging interests, but alas, like business and pleasure, some things are best not mixed.

We can deduce it was the wizardry of Dr Cresswell that drove the medical professionals to object to the scheme. Not science, not ethics, not professionalism. Rather, we are told, “it was contrary to their religious beliefs”.

I’ve been told more than once my problem is that I think too much.

That’s probably true, but what has happened is not only mind boggling and sad, but frighteningly revealing on a whole number of levels.

A well-meaning ‘good guy’ doctor probably crossed the bounds of professionalism by formally elevating feel-good modalities to therapies. An ill-informed management team jumped on the bandwagon and Maori health was usurped in an attempt to ooze credibility over other unrelated claptrap practices.

The Health Board members were never consulted and some well-deserved bad press followed. Sadly, the Medical Council of New Zealand and the Ministry of Health provided no guidance and remained silent whilst all this unfolded. Happily, some very influential Wanganui senior doctors killed the project after previously supporting it. Sadly, it seems it was because of their own religious and personal bigotry that a silly idea was ended.

Great result, bad motivation. Very bad motivation.

Medical ethics

Vicki Hyde of the NZ Skeptics7 points out:

“It’s rare for public figures to come out against these ‘soft’ services. It´s easier to ignore the ethical and evidential issues associated with claims that these kinds of practices actually help to treat illness or disability beyond exploiting the well-recognised placebo effect.”

It is imperative that as doctors, our first responsibility must be to our patients. Of course, we need to be cognisant of our limitations, humble, not arrogant and open to all the needs of our patients. But we are trusted as a profession and that trust can only be maintained if we adhere to defined standards based on evidence and ongoing re-evaluation and scrutiny. We should not promote, via our medical qualifications, unproven modalities at the level of treatment modalities. But neither can we allow our own specific religious affiliations to affect our professional conduct with respect to our colleagues who might hold different or indeed no religious affinities.

As trained medical practitioners we must boldly uphold the scientific basis of our profession and never be compromised by political correctness or political claptrap and doublespeak.

Saving grace?

The supposed saving grace in all of this is that ( we are told) no taxpayer money was spent on this project. My Official Information Act application will shed some light on that. But note, apart from the media releases, the following occurred8:

  • A credentialing committee was established, including Dr Cherryl Smith (Co-Director of Te Atawhai o Te Ao), Dr Chris Cresswell, Gilbert Taurua and Runesu Masaisai (WDHB Clinical Therapies Manager).
  • Dr Chris Cresswell was to extend his professional development on natural therapy as part of his credentialing requirements as recommended by the clinical board.
  • An independent legal opinion was sought which resulted in the WDHB’s insurance company providing approved cover for the pilot.
  • Therapists were required to become honorary DHB staff ensuring compliance with all WDHB expectations, policies and procedures.
  • Systems were established to obtain confidentiality agreements from all therapists.
  • Therapists were required to be police checked.
  • Therapists were referee checked and cleared by both steering committee and credentialing committee.
  • A memorandum of understanding was developed specific to the therapists collective.
  • Informed patient consent expectations and documentation were established.
  • The orientation programme for therapists included: WDHB purpose, values and behaviours, fire and emergency evacuation, infection prevention and control, manual handling, patient safety and service quality including complaints, privacy and the code of rights, CPR and smoking cessation.

That appears to be a lot of taxpayer funded work to me.

Some appointed members of the Whanganui DHB tried to excuse this whole debacle by suggesting that this was all just a staff benefit scheme and never intended for patients. They clearly never read their press releases and have been patently out of touch with this important process, or worse, have compromised their own integrity in order to cover for a failing and flailing management.

To add insult to all these injuries, in an attempted justification of the failed project, Julie Patterson made the public comment that “in areas like ‘chronic pain’, Western Medicine has nothing to offer.” Really?

With views like that from high earning health bureaucrats, doctors, nurses, the Medical Council and the Ministry of Health have sure got a lot of work to do.

In the face of all of this nonsense, we cannot and should not remain silent.

References
1. Whanganui District Health Board Press Release 19th August 2012.
2. Weekly update, CEO Whanganui District Health Board 21st May 2010.
3. Wanganui Chronicle 26th September 2012. Hospital Ditches Natural Therapy, Anne-Marie Emerson.
4. Benson H et al. 2006: Am Heart J. 2006 151(4):934-42.
5. Medical Association of New Zealand Code of Ethics. www.nzma.org.nz/sites/all/files/CodeOfEthics.pdf
6. River City Press Sept 6th 2012 Dreams, magic, healing and medicine.
7. NZ Skeptics press release 24th August 2012,www.scoop.co.nz/stories/AK1208/S00554/consumer-wins-bent-spoon-again.htm
8. Wanganui District Health Board Meeting 28th September 2012 Item 10.2.
Clive Solomon is a Consultant General Surgeon, elected member of the Whanganui DHB (third term) and a Wanganui District Councillor. [Editor’s note: Organisations referred to in this article differ in their preferred spelling of Wanganui or Whanganui.]

Having our say on natural health

As part of the Memorandum of Understanding between the National and Green parties, the Ministry of Health has been developing proposals for a natural health products scheme to regulate such products on the New Zealand market. To kick this process off the ministry has produced a consultation paper setting out high-level proposals for the scheme and called for submissions on it. The NZ Skeptics were among those who sent in a submission in time for the closing date on 17 May. Vicki Hyde and Michelle Coffey were the principle authors, with contributions from several other society members.

In general, the NZ Skeptics support the scope, purpose and principles of the proposed legislation. We think it’s important that the industry has some regulatory oversight to support consumer protection, particularly in the area of claims and proof of efficacy, as well as safety, marketing material and labelling. The use of terms such as ‘natural’ concerns us as it is used to imply benign, which is not a supportable claim.

In addition we are concerned that there appears to be very little in the way of supervisory oversight or quality control in this industry, particularly with regard to imported products. This is potentially of major concern as, on the rare occasion when such checks have been made, product quality has been found to be severely compromised.

Some ‘natural health products’ have been found to have significant levels of contaminants such as heavy metals, or to contain pharmaceutical products, such as viagra and paracetamol, deliberately introduced to give the product a measurable effect not obtainable from the ‘natural’ products.

We believe that informed choice for the consumer is critical in this area, as in all areas relating to health. Labelling requirements need to be clearly defined to ensure that the natural health industry does not use archaic, misleading or inappropriate terminology to boost its claims to the detriment of consumer understanding.

Also, the definition of ‘natural health product’ needs careful deliberation. This industry has been seen in the past as quick to claim any and all modalities that suit their business. ‘Natural health’ should be regarded as a marketing term, not a scientific one. The extension of this business into ‘synthetic equivalents’ gives this industry even more scope for misleading consumers (cf the claims of BZP as providing a ‘herbal’ high).

There is a link to the full submission on the NZ Skeptics home page (www.skeptics.org.nz).

After the overdose

NZ Skeptics link up with a British campaign against homeopathy.

On January 30 there was a concerted global mass overdose – but no-one died because the ‘medication’ was homeopathic. The event grew from the UK-based 10:23 campaign (www.1023.org.uk), which was planning a mass homeopathic overdose to protest against the Boots pharmacy chain stocking homeopathic products.

At a Christchurch Skeptics in the Pub meeting (skepticsinthepub.net.nz) four days before the planned date, one attendee asked if the NZ Skeptics were going to be involved. After all, we had asked a number of times over the years for the professional pharmacy bodies to supply a conference speaker to talk about the ethics of selling products of doubtful efficacy. Things swung quickly into action…

We held the mass overdose in Christchurch’s Cathedral Square, with about 40 people taking part. The event also included an ‘underdose’ – homeopaths believe that the more dilute things are, the more potent they become, so we were careful to try that approach. There are also claims by product manufacturers that, in fact, dosage doesn’t matter at all – whether you take one pill or 100 – the important thing is the frequency of dosage. We covered that base too. No ill effects were reported, apart from a distinct drop in the level of cash in various wallets. While several members were keen to take part, many said they couldn’t in all good conscience bring themselves to buy the stuff in the first place. For the demonstration, we reluctantly purchased two boxes of tablets and a 25ml spray from a Unichem pharmacy, costing $51.95. That’s a lot to pay for less than two tablespoons of water and not much more than that in lactose milk sugar.

One of the homeopathic products downed by the participants had a label saying it contained chamomilia, humulus lupulus, ignatia, kali brom, nux vomica and zinc val. But those substances were actually in homeopathic dilutions, meaning that the kali brom, for example, was present in a proportion comparable to one pinch of sugar in the Atlantic Ocean – that is, not actually present at all.

Reaction

The pre-publicity from the Christchurch Press saw the New Zealand Council for Homeopaths admit publicly that their products had no material substance in them (our emphasis).

Council spokeswoman Mary Glaisyer said (maryglaisyer.com/2010/01/press-release-mass-overdose): “there’s not one molecule of the original substance remaining” in the diluted remedies that form the basis of this multi-million-dollar industry. This point was picked up by a columnist in the Guardian, who referred to the NZ homeopaths as finding “amusing and creative ways to dig themselves deeper into a hole”.

We got a flurry of interest in the first press release from TV, radio and print media, as well as great support from members, Skeptics in the Pub folk and others concerned about this issue.

TV One ran a very short news item on it; there was a longer, more thoughtful piece on TV3 News.

On TVNZ the Pharmacy Guild was quoted saying of homeopathic products: “there’s a place for them so long as customers are told they only may help”. We believe that that is unethical, and certainly that comment was not made at any of the pharmacists we visited to purchase these products.

TVNZ’s Close Up national current affairs programme covered the story on February 12. They spent two hours filming us swallowing pills, spritzing sprays, demonstrating how a homeopathic dilution is made, talking about the health and safety issues of relying on water as a medicine and a whole host of other issues, in the cosy confines of The Snug at the Twisted Hop, the bar of choice for the Christchurch Skeptics in the Pub gatherings.

That sterling effort was then diluted to a very short intro followed by a short interview sequence involving Vicki Hyde and Mary Glaisyer. Following on from this, we decided to put up a challenge of our own to the NZ Council of Homeopaths to join the campaign to call for pharmacies to stop selling homeopathic products, as both groups are opposed to the practice, albeit for different reasons.

The New Zealand Council of Homeopaths and others in the trade have stated that their customers require lengthy personalised sessions to “match the energy of the potency of the remedy with the person”. According to Mary Glaisyer, this involves matching symptoms with the huge range of materials on which homeopaths base their ultra-diluted preparations. For example, causticum, more mundanely known as potassium hydroxide, is said to manifest its homeopathic action in “paralytic affections” and “seems to choose preferable [sic] dark-complexioned and rigid-fibered persons”.

Pharmacists who sell homeopathic products in the same way they sell deodorants and perfumed soaps are clearly not meeting basic homeopathic practice. When a number of pharmacies in Christchurch were checked by purchasers of these products, no pharmacy staff asked about symptoms; one simply asked “do you want vitamins with that?”

Many people equate homeopathic products with herbal products, hence the belief that the products contain real substance. In addition, the products are commonly used for conditions which get better with time regardless of treatment, as well as exploiting the well-known placebo effect.

The call for the NZ Skeptics and homeopaths to join forces is not the first time such action has been considered. In 2002, when an Auckland pharmacy starting selling products labelled homeopathic “meningococcal vaccine” and homeopathic “hepatitis B vaccine”, we discussed with the late Bruce Barwell, at that time the president of the NZ Homeopathic Society, a joint release condemning this highly dangerous move. We were concerned that relying on water as a vaccine would lead to unnecessary deaths.

It’s bad enough when the product labelling misleads people into thinking they are buying something more than water. It’s far worse when they misuse a word like vaccine in such a life-threatening area.

The homeopaths were concerned then, as now, that their 200-year-old practices were being misrepresented by non-homeopaths keen to benefit from the multi-million-dollar industry.

A recent survey showed that 94 percent of New Zealanders using homeopathic products aren’t aware that the remedies commonly contain no molecules of the active ingredient – their homeopath or health professional hadn’t disclosed this. The customers believe they are paying for the substances listed on the box, but those were only in the water once upon a time before the massive dilution process began – along with everything else that the water once had in it – the chlorine, the beer, the urine…

You have to ask, at what point does it shift from being an issue of informed consent to become an issue of fraud?

Do pharmacists not know that homeopathic products are just water, or they do know and don’t care because people will buy it not realising the massive mark-up? Either way, that should be a big concern for the health consumer. Here’s a huge industry with virtually no regulatory oversight or consumer protection or come-back, and even its keen customers aren’t aware of the highly dubious practices involved.

When Billy Joel’s daughter attempted to commit suicide in December, she chose to take an overdose of homeopathic medication, and thus suffered no ill effects. While that case was fortunate, there are many cases where people have been harmed by the use of homeopathic products in the place of real medicine. There is a Coroner´s Court record of the death of a baby from meningitis; it had been treated with homeopathic ear drops and the mother was very reluctant for any hospital admission. And the website whatstheharm.net lists many cases from around the world where people have died or had horrible outcomes as a result of a mistaken reliance on homeopathy.

The alternative health industry has built a multi-million-dollar business exploiting the natural healing powers of the human body, as many conditions will get better within two to three days regardless of whether conventional or alternative treatments are used, or even if nothing is done at all. Independent testing has shown that homeopathic preparations take full advantage of this and homeopaths quickly take the credit for any improvement in their clients.

The NZ Skeptics have already had people asking for a list of ethical pharmacists that they can support with their business. We are happy to hear from any pharmacy willing to take a stand on this issue, and will start to create a database for concerned members of the public.

From the UK 10:23 campaign:

Thanks very much for the note, the support and the energy. We have been overwhelmed by the enthusiasm from the NZ side of things. It’s been great.

To mark the occasion, the NZ Skeptics have released a new Skeptics Guide to Homeopathy, available as a flyer on the website (skeptics.org.nz). It outlines the development of homeopathy from a relatively harmless attempt to help people some 200 years ago through to the multi-million industry of today.

The vertical limit for randomised trials

Alison Campbell considers the evidence for the efficacy of parachutes.

Recently a teacher sent me a paper titled: ‘Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials‘ (Smith and Pell, 2003, BMJ 327: 1459-1460). I have to say I chuckled when I read this – a common charge levelled against current medical practice by the alternative health lobby is that many medical techniques haven’t been subjected to randomised controlled trials (with the corollary that it’s thus unfair to demand evidence from such trials on alternative practices).

The authors state they conducted a literature search of some of the major science sources, using the search words ‘parachute’ and ‘trial’. However (and unsurprisingly), they found no randomised controlled trials (RCTs) of parachute use. Smith and Pell begin their discussion with the following inspired statement:

“It is a truth universally acknowledged that a medical intervention justified by observational data must be in want of verification through a randomised controlled trial.”

Many medical interventions probably fall into this category – for example, I doubt that surgery for severe appendicitis has ever been subjected to such a trial. That’s not to say that, where appropriate (and in the case of appendicitis it almost certainly isn’t!) such trials shouldn’t be performed. As Smith and Pell point out, hormone therapy for post-menopausal women seemed – on the basis of observational studies – to convey a number of health benefits. But RCTs showed that hormone replacement therapy actually increased the risk of ischaemic heart disease.

As the authors say, RCTs avoid a major weakness of observational studies: that of bias (eg selection bias and reporting bias). They note that individuals jumping from aircraft without the help of a parachute are likely to have a high prevalence of pre-existing psychiatric morbidity (ie they are probably not in their right minds when they jump. You have got to love this paper!). So any study of parachute use could well be subject to selection bias, in that those using them are likely to have fewer psychiatric problems than those who don’t. Smith and Pell also put forward the possibility that enforced parachute use is simply a case of mass medicalisation of the population by out-of-control doctors – or worse, by evil multinational corporations. (These are, of course, charges frequently levelled at the medical world, eg by those who are against interventions such as vaccination.)

This little gem of a paper contains some valuable lessons on the nature of science (and more particularly, science-based medicine). And it should be read by anyone who doubts that scientists have both creativity and a good sense of humour.

Newsfront

Flaky diagnostic tool fans toxin scare fire

Hard on the heels of the Bent Spoon awarded to the Poisoning Paradise ‘documentary’, the NZ Herald has produced an appalling piece on alleged pesticide poisoning of people and wildlife in Auckland (27 September).

According to the report, Waiheke Island environmental group Ocean Aware claimed samples from marine birds, oysters and dog vomit, taken from Waiheke and Rangitoto Islands, tested positive for brodifacoum and 1080.

The samples were tested by EAV machine, though nothing in the article explained what this means. EAV stands for ‘Electroacupuncture according to Voll’ – in the 1950s Reinhold Voll combined acupuncture theory with galvanic skin differentials to produce a machine which, when homeopathic solutions were introduced into the circuit, could be used to ‘diagnose’ all manner of toxin-related ailments (see NZ Skeptic 56). Needless to say the machine has no scientific basis.

A woman who became mildly ill after eating local snapper also tested positive for brodifacoum, said Ocean Aware’s Sarah Silverstar. Brodifacoum poisoning, however, causes internal bleeding, which the woman was not reported to suffer from, and does not otherwise generate feelings of illness. This is what makes it such an effective rat poison.

The electroacupuncture testing was done after the Department of Conservation dropped 147 tonnes of brodifacoum bait on Rangitoto and Motutapu Islands in August. Soon after, several marine animals were found dead on Auckland’s North Shore, and dogs which had walked on the beaches became ill or died. At least some of these cases were later linked to tetrodotoxin, a bacterial toxin found in several marine organisms, most famously the Japanese fugu puffer fish.

DoC, in alliance with Auckland Regional Public Health, MAF Biosecurity, Auckland Regional Council and North Shore and Auckland City Councils, says independent scientists have carried out extensive testings and determined none of the deaths were caused by brodifacoum. DoC spokeswoman Nicola Vallance said the department offered to have independent scientists test Silverstar’s samples, but she declined.

Dioxin risk over-rated

At least Bob Brockie brought some sense to the fraught subject of environmental toxins with his Dominion Post column (6 July) on the dioxin scare in New Plymouth.

Residents there were up in arms when it was discovered soils in a local park had minute traces of dioxin. But as Bob Brockie pointed out, dioxin at far higher levels than found in Taranaki generates no symptoms other than a form of acne. When Ukrainian presidential candidate Viktor Yushchenko had his soup laced with dioxin he was badly scarred, but today his face has largely healed and he appears in good health. Following the Seveso chemical factory explosion in 1976 residents were found to have up to 10,000 times the typical human tissue concentration. Fifteen years of testing revealed no excess cancer, stillbirths or genetic disorders – just the temporary acne.

Sadly, says Brockie, this is an argument that science and objectivity can never win. “The testimony of one or two residents carries more weight in New Plymouth than truckloads of refuting world statistics.”

Conspiracy? What conspiracy?

The Sunday Star Times (20 September) had a good piece on Matthew Dentith’s study of conspiracy theories at Auckland University. Why, asked reporter Mark Broatch, do otherwise ruthlessly rational people reject out of hand most conspiracies, yet give time and angst to ideas others find quite wacky?

Matthew Dentith says the problem is two-fold. Schools don’t teach critical thinking skills that might help us unravel our confusion, and we humans are exceptional at compartmentalising our beliefs. “It’s really easy to be absolutely staunch in, say, your adherence to evolutionary theory by natural selection. But when it comes to medical quackery…”

Look for more on this subject from Matthew Dentith in an upcoming issue of NZ Skeptic.

Placebo prescriptions widespread

Three out of four New Zealand doctors have prescribed placebo medications to patients, according to medical researcher Shaun Holt, who says the practice could cost the taxpayer several million dollars (Dominion Post 4 July).
Seventy-two percent of the 157 doctors surveyed admitted giving placebos, including vitamins, herbal supplements, salt water injections and sugar pills.

“But what surprised us was the most commonly prescribed placebos were antibiotics, which is obviously a concern because of the rise of antibiotic resistance and potential side-effects for patients,” Dr Holt said.

Patients’ unjustified demands for medication was cited as the most common reason for prescribing placebos (34 percent), followed by non-specific complaints (25 percent), and exhausting other treatment options (24 percent).

Dr Holt said he believed placebos were ethical as long as the doctor considered them to be in the best interests of the patient. “The placebo effect is quite powerful,” he said.

Rather than prescribing medications which were ineffective for the condition treated – such as antibiotics for viral infections – he said “there could be an argument for bringing back sugar pills, which are safer, just as effective and certainly cheaper.”

Pharmac medical director Peter Moodie said data showed doctors were prescribing antibiotics responsibly. He agreed it was not acceptable to waste money prescribing medicines with no effect.

Alternative therapies ‘too good to be true’

The Sunday News (20 September) has come up with a surprisingly sceptical article about alternative health treatments. Belief, says Barbara Docherty, a registered nurse and clinical lecturer at the Auckland University School of Nursing, is becoming a most important factor in a world where ‘alternative health’ has become a major growth industry.

After noting the most popular alternative therapies include naturopathy, chiropractic, homeopathy herbal remedies and acupuncture, she asks if this is the stuff of quacks and witch doctors.

Despite a wealth of available information, there is little or no strong scientific evidence and very little regulation about who and what is safe. Herbal and natural medicines, although widely used, are not subject to the same scrutiny as prescription or over-the-counter medications.

Skeptics might question the value of her advice to check out practitioners’ qualifications carefully – an ineffective treatment is ineffective no matter who is administering it – but not her final comment: “…bear in mind that anything that sounds too good to be true probably is.”

Ghost hunters hit the capital

Those who were at the conference this year will already know about James Gilberd and his Paranormal Occurrences team. They got a write-up in the Capital Times recently (26 August – 1 September). Reporter Dawn Tratt joined them for a ghost hunt at the Museum of Wellington City and Sea.

Claiming to be sceptical, though carrying baggage from a Pentecostal upbringing, Tratt’s scariest moment came when her colleague mistook one of the investigators, sitting on the floor, for a ghost.

It was only after she left that things supposedly got really spooky. One of the team says she saw the spirit of a Maori man.

I felt like he was upset with James. He kept trying to tell me something but I couldn’t pick up what it was.

It may, just possibly, be significant that the museum ran paranormal tours during one of the winter public programmes three years ago, and marketing manager Angela Varelas says they are looking to bring them back early next year.

As for James Gilberd, he brings a distinctly sceptical approach to his ghost-hunting, treating it as a form of performance art. In his day job he runs a photographic gallery, Photospace, and his conference presentation was mainly about the technical glitches that cameras, and particular digital cameras, can have that lead people to think they’ve photographed a ghost. Something else to look out for in an upcoming NZ Skeptic.

Bioresonance therapy for smoking – miracle cure or con?

A therapy marketed as a guaranteed way to stop smoking appears to lack a sound theoretical basis and to have little experimental support.

As health researchers in the field of tobacco smoking cessation our aim is to find effective ways to help people quit smoking, and to improve access to effective smoking cessation treatments. The New Zealand government is currently investing heavily in policies that support such actions.

Proven therapies for helping people to quit smoking

When people decide to quit smoking without any assistance (ie by going ‘cold turkey’), they have to cope with the loss of all the dependency-forming aspects of smoking at once. Consequently, approximately 90 percent of people who try and quit without any assistance fail1.

Most smoking cessation support strategies involve the use of nicotine replacement therapy (NRT). With NRT, people stop smoking and replace the ‘dirty’ nicotine they would normally get from smoking a cigarette with ‘clean’ nicotine delivered in a lower concentration (such as via patches, gum, inhaler, and lozenges) and in a safer way (that is, without the harmful constituents present in tobacco smoke). In this manner smokers can deal with cravings and other unpleasant nicotine withdrawal symptoms, thus making it easier for them to quit.

Research evidence for the use of NRT has shown it to approximately double the chances of long-term quitting(2-3). When combined with behavioural support, pharmacological support is even more effective. Good quality evidence from placebo-controlled randomised trials indicates that behavioural support can improve the chances of successfully quitting by two to seven percent(1,4-6). Behavioural support (eg counselling people about dealing with cravings and urges, encouraging them to persist, helping them to consider the benefits and possibilities of being an ex-smoker) can be delivered face-to-face, by telephone or through the internet.

In New Zealand, the cost of NRT patches, gum and lozenge is subsidised ($5 for four weeks’ supply). Subsidised NRT is available to smokers coming into contact with cessation support services (such as the national telephone- based Quitline services and the Maori cessation service Aukati Kai Paipa), which also offer behavioural support. The Government has plans to further improve access by promotion of low cost NRT through primary care (ie through a general practitioner).

Unproven therapies

Despite good access to inexpensive, effective treatment to assist in quitting smoking, unproven and costly therapies are still actively promoted in the media in New Zealand. A recent review of the scientific evidence for the effectiveness of alternative smoking cessation interventions reported that acupuncture, St. John’s Wort and NicoBloc are probably not effective(7). There was insufficient evidence to determine the effectiveness of Allen Carr’s Easyway Programme and Nicobrevin, and hypnosis did not appear to be any more effective than simple advice to quit.

Bioresonance therapy

Another therapy being marketed in New Zealand as a “guaranteed way to stop smoking” is bioresonance therapy. This therapy appears to have originated from Europe and according to its proponents has been in use since the 1970s. Claims made on a website (www.stopsmokingclinic.co.nz) state that “Bioresonance therapy works through the body’s energetic system” or more specifically, “the technique uses biophysics – the physics of the body”. According to the above website it works by eliminating nicotine from the body and thus takes away the cravings for cigarettes.

“All living cells give off energy as weak electromagnetic waves similar to brain waves used in orthodox medicine (EEG scans). Bioresonance therapy, using the Bicom machine, uses these and those of substances (cigarettes) for therapy. The Bicom separates these waves into harmonious (healthy) and disharmonious (unhealthy) components. The healthy signals can be boosted and sent back to the patient to strengthen normal functions, while the unhealthy signals are ‘inverted’ or turned upside down by an electronic mirror circuit before returning them to the patient through electromagnetic mats. What actually happens is more complicated but the ‘inverted’ wave cancels the harmful wave that was stressing the body’s energetic system. You can see this effect at the beach where a wave reflected from a rock flattens the next incoming wave.”

Furthermore, it is claimed that:

“…nicotine has an electromagnetic charge over your body giving you the craving to smoke. Bioresonance therapy inverts the energy patterns of nicotine which are then passed to the body via electrodes. This process produces phase cancellation which means that the electromagnetic charge of nicotine is reduced. Therefore, it becomes easier for the body to eliminate nicotine over the next 24 hours and your cravings dramatically reduce as your body detoxifies. Additionally, the phase cancellation removes the energetic pattern of nicotine from the body, erasing the ‘memory’ of nicotine which also reduces the cravings.”

To simplify this process even more, according to the Auckland proprietor of a bioresonance clinic, the patient smokes their last cigarette and places it into the bioresonance machine, which then measures the “frequency” of the cigarette. This frequency is then “reversed” and fed back to the patient via two brass electrodes which the patient holds.

The appointment takes about an hour and it appears some behavioural support is offered, as the website correctly mentions the need to avoid second-hand smoke exposure and smoky environments, known triggers for relapse. Patients are advised not to use NRT during treatment nor use any other pharmacological treatments for smoking cessation. “Detoxification” apparently takes a couple of days (patients are advised to drink water to help with this process) and can include the following symptoms: “headaches, fatigue, upset stomach, metallic taste in the mouth, sweaty palms or a sluggish feeling”. Most of these are classic symptoms of nicotine withdrawal.

Perhaps most bizarrely, patients are also:

“…provided with a Bicom chip that contains the memory of the stop smoking treatment provided. This information lasts for up to 4 weeks and is placed on the body, two finger widths below the navel. This chip will support the detoxification process and help if any cravings are experienced. Drops are also available to support you in times of stress in the following weeks.”

Does bioresonance therapy work?

The New Zealand Stop Smoking Clinic website states that Bicom Bioresonance therapy is “the most successful stop smoking therapy in New Zealand.” Even the authoritative BBC and New Zealand’s very own Close Up TV programme have extolled the virtues of this intervention – see www.stopsmokingclinic.co.nz for video links. However we were unable to locate any randomised controlled clinical trial evidence to support this treatment, despite an extensive search for the term “bioresonance” in a number of medical databases, specifically Medline (1948 to May 22 2009), Embase (1980 – week 21, 2009), AMED (Allied and Complementary Medicine) database (1985 – May 2009), Cochrane Central Register of Controlled Trials (2nd Quarter 2009), ACP Journal Club (1991 to April 2009), Cochrane Database of Abstracts of Reviews of Effects (2nd Quarter 2009), the Cochrane Database of Systematic Reviews (1st Quarter 2009) and the Conference Papers Index (1985 – present).

In total, only 13 articles were located that even mentioned the term, of which eight were non-English publications. The articles with English abstracts were commentaries, non-randomised rat studies, case-series studies or physiology studies. The papers were predominantly published in journals that focused on alternative therapies and no reference to smoking was made in any of the publication titles or English abstracts provided by the database searches. One paper discussed treating 12 athletes with “strain syndrome” with Bicom therapy and 12 with more traditional methods (eg ultrasound, stimulating current, etc)(8). This study reported less therapy time and treatment time in the Bicom group, but we were unable to determine if the study was truly randomised nor the validity of the rest of the study design. However, given the small sample size (24 people only), any positive findings could well be due to chance alone. Interestingly, one paper discussed the use of pseudo-scientific language to cloud important issues (how to present nonsense as science), using bioresonance therapy as an example.

The evidence is not there

Overall, no studies that stand up to the standard level of scrutiny used for orthodox treatments could be identified. The weight of evidence to support the use of this therapy (for any condition and not just smoking cessation) seems to consist of material in non-peer-reviewed publications, such as case studies provided on websites and in books(10-12) and promotional literature provided by those marketing the therapy. A number of Bicom websites (e.g. www.bioresonance.net.au/bicom_therapy.htm) mention the existence of three studies on allergic conditions supposedly published in Chinese medical journals(13-15). These studies were not identified by our search above, but translations for the papers are provided on the above website (although there are no details provided about the source journals so it is not possible to verify their authenticity), along with two additional studies (one on chronic inflammatory bowel disease16 and one on central nervous disorders in children)(17) – once again with no details provided about their source. Four of the five studies are case studies or case-series(14-17). One of the Chinese studies claims to have randomised 300 children, but no details were provided on how the randomisation was undertaken(13). Furthermore, if the randomisation had been done it seems not to have worked given 213 children were in one group and 87 were in the other. Our suspicions are that the study was not randomised and therefore the findings are likely to be biased and meaningless.

It is possible that our search may have missed identifying some papers. It remains odd, however, that so little research appears to have been published given that:

  • In May 2009 bioresonance therapists meet in Germany to celebrate the 49th (ie they have had 48 previous meetings) International Congress for Bicom Therapists. Most congresses and conferences (even those in the complementary and alternative medicine field) publish posters or presentations from their meetings and these are referenced on international databases – yet none of these conference proceedings were located.
  • The therapy is claimed to be so effective.
  • The therapy is claimed to be in widespread use. One website (www.bicom.co.nz) states that “the technique is almost mainstream in Germany, and the German-speaking countries, Austria and Switzerland”, and that the instrument is “widely used in Poland for helping smokers to quit and has over 70 percent success (over 100,000 people have been treated over six years).” And that in China, the therapy is “used exclusively in children’s hospitals mainly to treat eczema and asthma.”

If it truly worked surely you would be doing everything to show the world that it did … and there have been at least 35 years to show the world.

Accepted international criteria for what is regarded as an effective smoking cessation method use the benchmark of six months of continuously not smoking (not even a puff) after quitting. The New Zealand Stop Smoking Clinic website claims that Bicom Bioresonance therapy has “70-90 percent success after one hour” for stopping smoking. Anyone can stop smoking after an hour … it’s a bit like asking you to stop eating for an hour. The issue is when you start smoking again. The Auckland proprietor was unable to provide us with this information.

In conclusion

There is no evidence to support the therapeutic claims made by those promoting bioresonance therapy other than uncontrolled case studies. Any benefits are likely to be due to the placebo effect. A systematic review of 105 NRT trials (involving a total of 39,503 smokers) found that when the quit rates for all the trials were pooled using the longest duration of follow-up available from each trial (6-12 months), 17 percent of smokers allocated to NRT had quit compared to 10 percent in the placebo control/no NRT group2. Clearly the placebo effect plays a significant role in smoking cessation.

Is it therefore wrong to make a claim about a product when simply believing that the product will work makes it effective for some individuals? Does it matter how you try to give up smoking as long as you make an attempt to give up?

In 2002/3, 24.5 percent of New Zealand adults smoked (47.2 percent of Maori), with this figure dropping to 19.7 percent in 2006/7 (38 percent in Maori)18. Despite this recent evidence of change, based on the current rate of progress it is estimated that it will take 100 years before the New Zealand adult smoking rates reach five percent, the level of smoking in New Zealand doctors19. New approaches to assist smokers to quit are still urgently needed, ideally ones with proven efficacy and that are cheap, easily accessible, and acceptable to Maori and people from the lowest socio-economic group (who have a three times higher rate of smoking than people from the highest socio-economic group18). At $450 per treatment (second treatment free if taken within the first month), Bicom Bioresonance therapy is far from accessible to the people that need it most. One could argue that it is designed to generate revenue as quickly as possible, by using pseudoscience to bamboozle the innocent. Are we too cynical? One company (www.bicom2000.com) will gladly send you a detailed profitability calculation form.

For a rather interesting conversation of how another member of the skeptic community views this treatment, see www.sciencepunk.com/2007/03/monadith-bioresonance-smoking-cure/

References

  1. Stead L, Lancaster T, & Perera R. Cochrane Database of Systematic Reviews, The Cochrane Library 2003;1:CD002850.

  2. Silagy C, Lancaster T, Stead L, Mant D, & Fowler G. The Cochrane Database of Systematic Reviews, The Cochrane Library 2008;1.

  3. Hughes J, Stead L, & Lancaster T. The Cochrane Database of Systematic Reviews, The Cochrane Library 2008.

  4. Stead L, & Lancaster T. The Cochrane Database of Systematic Reviews, The Cochrane Library 2008.

  5. Lancaster T, Stead L. The Cochrane Database of Systematic Reviews, The Cochrane Library 2007(3).

  6. Strecher V, Shiffman S, & West R. Addiction 2005;100(5):682 – 688.

  7. McRobbie H, Hakej P, Bullen C, & Feigin V. . 2006; www.nice.org.uk/nicemedia/pdf/SmokingCessationNon-NHSFullReview.pdf

  8. Papcz, B & Barpvic J. Erfahrungsheilkunde 1999: 48(7): 449 – 450.

  9. Ernst E. Forschende Komplementarmedizin und Klassische Naturheilkunde 2004 Jun;11(3):171 – 173.

  10. Will, RD. Bioresonanz Therapie. Publisher: Jopp Verlag, 2001.

  11. Schumacher, P. Test Sets According to Dr. P. Schumacher. Publisher: dtp Tyrol – Klaus Leitner, Innsbruck, 2000

  12. Schumacher, P. Biophysical Therapy of Allergies. Publisher Thieme Medical Publishers 2005

  13. Jinzhi, Y & Li Z. www.bioresonance.net.au/bicom_therapy.htm#CL Accessed 25 May 2009.

  14. Ze, Y, Jiali, H, Haiyan W & Chunyan Y. www.bioresonance.net.au/bicom_therapy.htm#CL Accessed 25 May 2009.

  15. Jinzhi, Y. www.bioresonance.net.au/bicom_therapy.htm#CL Accessed 25 May 2009.

  16. Oesterle, R. www.bioresonance.net.au/bicom_therapy.htm#CL Accessed 25 May 2009.

  17. Barrie, A & Barrie A. www.bioresonance.net.au/bicom_therapy.htm#CL Accessed 25 May 2009.

  18. Ministry of Health. A portrait of health – Key results of the 2006/7 New Zealand Health Survey. Wellington: Ministry of Health, 2008.

  19. Laugesen M. New Zealand Smokefree enews. Auckland: Health New Zealand, 2004.

History denied is history repeated

Today, gonorrhoea infections in young girls are taken as certain evidence of sexual abuse. Yet there is an extensive but now-forgotten literature showing that this is not necessarily the case. This article is based on a presentation to the NZ Skeptics 2008 conference in Hamilton, September 26-28.

In 2006 I was asked for my forensic opinion in a case involving a 13 month old Pacific Island girl, Lana,* found to have a gonorrhoeal infection of her vagina and vaginal lips. Her 19-year-old mother and 20-year-old father had also tested positive for gonorrhoea. Her father had acquired this infection through having an affair when Lana was aged 10 months. Both parents had noticed they had a discharge but had not sought treatment, but when Lana developed symptoms they took her to their GP. Once gonorrhoea was diagnosed, it was immediately decided that either her mother or her father must have sexually abused her and she was taken into foster care.

The parents denied any abuse. They lived in an extended family household, shared a room, bed, and towels, sometimes bathed together, and the mother would use her sarong as a nappy when she ran out of disposables. They accepted that they must have been the source of Lana’s infection, but denied any sexual contact and said that she must have acquired the infection through contamination. They were battling in the Family Court to get their daughter back. The doctors for Child Youth and Family (CYF) insisted that gonorrhoea can only be transmitted by “mucous membrane to mucous membrane” and that gonorrhoea infection in a child under the age of puberty (ruling out vertical transmission when a newborn baby acquires the infection at delivery from the birth canal of an infected mother) is considered diagnostic of sexual abuse.

I was therefore asked by the parents’ lawyer whether gonorrhoea can be transmitted non-sexually in pre-pubertal children after the newborn period. In my opinion gonorrhoea was exclusively a sexually transmitted disease. Experts in the field, both in New Zealand (such as Auckland paediatrician Patrick Kelly) and internationally (for example Margaret Hammerschlag and Nancy Kellogg in the USA) say that gonorrhoea in a child, other than a newborn, is presumptive evidence of sexual abuse.

Various international guidelines indicate that gonorrhoea in pre-pubertal children is nearly always a sexually transmitted disease, although the possibility on non-sexual transmission is not conclusively excluded. In the US Committee on Child Abuse & Neglect (American Association of Paediatricians, 2005), gonorrhoea is said to be diagnostic of sexual abuse “if not perinatally acquired and rare nonsexual vertical transmission is excluded” and a positive culture for Neisseria gonorrhoeae makes “the diagnosis of sexual abuse a near medical certainty”. The UK National guideline for the management of suspected sexually transmitted infections in children and young people (2003) states that “The bulk of evidence strongly suggests that gonorrhoea in young people over one year is sexually transmitted and the isolation of a gonococcal infection is highly suggestive of sexual abuse”.

Certainly there is no doubt that children as well as adults can and do contract gonorrhoea from sexual contact and sexual abuse. I agreed to conduct a systematic literature review to establish whether there is evidence on the possible non-sexual transmission of N. gonorrhoeae in children after the neonatal period. After some months, having accessed and read several hundred papers, it was apparent that there is overwhelming evidence of thousands of reported instances of possible, probable and definite non-sexual transmission of gonorrhoea.

Results of the literature review

The bacteria which causes this infection, N. gonorrhoeae, will grow at temperatures between 25 and 39 degrees Celsius, It is killed by heat (five minutes at 55 degrees) and dies quickly if dried, but thrives in warm humid conditions. It grows on the mucous membranes of the body and hence can infect the mouth, throat, conjunctiva of the eyes, the urethra, anal canal and cervix. Pre-pubertal girls (but not adult women) are susceptible to infection of the vagina and vaginal lips (vulvovaginitis). The mucous membrane of a young girl’s vagina is more delicate than that of an adolescent or adult because of lack of oestrogen and it has a neutral pH which renders it an excellent culture medium for the bacteria.

Survival on inanimate objects

Studies have been conducted where various objects are contaminated with the organism and then attempts made to culture it after periods of time. It has been recovered and grown from a variety of surfaces including paper, swabs, fabric, rubber, wood, glass and condom after a number of hours, and has been grown from infected bathwater after 24 hours. It can live in pus on towels and other fabric for hours or days. Studies of toilet seats have found that these are unlikely to be sources of infection. Gonorrhoea was not grown in a study of random swabs of public toilet seats. When seats were inoculated with the bacteria, it died within 10 minutes if dried, although it could be grown from pus on the seat after two to three hours.

People are at greater risk from contaminated toilet paper rather than toilet seats. There is one case study of an eight-year-old Australian girl who travelled for 72 hours on a plane from Russia to Sydney. The toilets were very dirty and the girl, instructed by her mother, wiped the seat with toilet paper before using it. A few days after arriving in Australia she developed a gonococcal infection. Despite extensive questioning she remained adamant that she had never been subjected to any sexual contact and it was presumed that she had probably contracted the infection from self-inoculation, wiping herself with contaminated fingers.

Accidental transmissions

The literature contains a number of examples of accidental transmission. The three-year-old son of a laboratory technician was left in the car while his mother shopped, ate infected chocolate agar from a culture plate and subsequently developed gonorrhoea of the throat. Laboratory technicians have developed cases of infected eyes (conjunctivitis) from being struck in the eye with the strap of an infected face mask, and from accidentally spraying their face and eyes with infected fluid. There is an unusual cultural practice of Filipinos using their own urine as an eyewash, and a case series is reported of 13 men with genital gonorrhoea who inadvertently gave themselves gonorrhoeal infection in their eyes. Another case of indirect transmission is of a soldier immobilised in bed for many weeks with fractured legs who acquired urethral gonorrhoea from sharing a urinal bottle with an infected patient in the next bed. An even more bizarre case is one of a sea captain acquiring gonorrhoea from using an inflatable sex doll belonging to the chief engineer who had contracted the infection in a previous port.

Epidemics of conjunctivitis

Large-scale epidemics of gonorrhoeal infections, largely affecting the eyes, are reported in communities where there are overcrowded conditions in substandard housing, insufficient water supply with poor sanitation, inadequate hygiene and a high fly density. Such epidemics are prevalent in parts of rural Africa and outback Australia. For example in 1988 an epidemic involving over 9000 cases over an eight-month period was reported in a district in Ethiopia. Most of those infected were children aged under five years, with no concurrent genital outbreak in the adult population. Similar epidemics of gonococcal conjunctivitis have been reported in Aboriginal communities in outback Australia throughout the 1980s and 1990s. Those affected are predominantly children, most under five years of age. A prospective study of 432 cases in one epidemic in 1991 found that risk factors for infection were being aged under five years and having unwashed hands and faces. Although not definitively demonstrated, it appears likely that flies act as vectors of the disease in these African and Australian outbreaks.

Epidemics of gonorrhoea in children’s hospitals and orphanages

What my review uncovered through successive hand-searching of the references of various papers was a large body of academic literature published between the 1880s and 1920s. I found case reports of over 40 epidemics of gonorrhoea in institutions throughout Europe and the United States involving thousands of children. While the original case may have been sexually transmitted, once a young girl with gonorrhoea was admitted into a children’s hospital or orphanage, this infection would spread rapidly through the inmates. Because no antibiotics were available for treatment, these infections had a huge impact and were the subject of intense international discussion.

The most common site of infection was vaginal in prepubertal girls, but children also developed infections in the eyes, rectum, and joints. In cases of serious infections some children died. In 1883 after an infected girl was admitted into a Budapest hospital, 25 girls developed vulvovaginitis and a nurse contracted conjunctivitis. The infection was thought to be transmitted via contaminated bedding, instruments and bandages. In one case in Posen (now in Poland), 236 little girls developed the infection from sharing a public bath. In 1896 after an infected child was admitted into a New York City orphanage, 65 girls developed vulvovaginitis with some progressing to peritonitis. In this case the disease was spread by common bathing of 20 to 30 children in a tub. A boy also developed an infected eye from a towel. A 1927 epidemic in a Philadelphia hospital involved 67 babies in same ward. The initial case was likely a vertical transmission from birth but the infection was probably spread by the use of a rectal thermometer leading to the babies developing vulvovaginitis, rectal infection and arthritis.

For most of these cases there can be no doubt that the infective organism was gonorrhoea. Neisseria gonorrhoeae is a gram-negative diplococcal (‘double rod’ shaped) bacterium. It was diagnosed microscopically by seeing the bacteria inside cells from gram-stained smears of secretions and also by culture of the bacteria on selective media wiped with infected swabs. There are many other species of Neisseria as well as N. gonorrhoeae (for example, N. lactimica, N. cinera, N. meningitides) which may be present normally in the mouths and throats of adults and children. However these do not cause infections such as vulvovaginitis. The combination of the vaginal symptoms plus identification by both gram stain and culture realistically means there is no other organism that could have been responsible for these outbreaks.

The only means of control of these epidemics was identification and prevention of the source of transmission. Strict isolation strategies were introduced. In some institutions girls underwent vaginal cultures and were refused admission if they were found positive with gonorrhoea. In other cases, infected children were kept isolated with separate rooms and separate nurses. Strategies documented in the literature to curb outbreaks include no sharing of clothes, wash cloths, towels or bathwater. Infected children were provided with individualised thermometers, nursing bottles and combs. Nappies were sterilised or made of light muslin and then destroyed. Strict attention to hand-washing in caregivers, especially nurses, was introduced and in one institution an epidemic was finally brought under control by nurses wearing rubber gloves to change nappies.

Household transmission

There are a number of cases reported in the literature of clusters of gonorrhoea infection (vulvovaginal, urethral and conjunctival) occurring in over-crowded living conditions where there are many family members in small crowded dwellings. In these circumstances there is often sharing of bedding, towels and under-clothes, and lack of available water for personal and laundry washing. Case reports come from all over the world from countries such as Nigeria, Malaysia and Alaska. There is a British report of an eight-month-old boy who presumably developed gonococcal conjunctivitis from the towel of 21-year-old infected female lodger, and two preschool children similarly contracted eye infections from towels used by infected parents.

In household cases often it will not be possible to determine whether transmission has been sexual or non-sexual. However in these circumstances, especially where there is no disclosure of sexual abuse by the children, nor any sign of trauma on examination, some cases are likely to have resulted from contamination rather than sexual abuse.

What happened to Lana

Lana was 13 months old when she was taken into foster care. Her mother was pregnant at this time. Two months later her parents separated for a month in an attempt for Lana to be returned to her mother, but the doctors involved were adamant that either her mother or her father had sexually abused her and therefore she was safe with neither. A month later the couple reunited. When Lana was aged 18 months her brother was born. CYF had been considering uplifting him at birth but they decided to allow the parents to keep their boy. Lana was cared for in a number of different foster homes.

By the time the case was heard by the Family Court, she was aged two years six months. I wrote a report on the possibility of both sexual and non-sexual transmission, and provided the doctor for CYF with photocopies of all the papers in my review. However she stated that

Mothers and fathers can abuse children and there has had to have been transmission from and to mucous membranes

Furthermore:

It does not help that Dr Goodyear-Smith is suggesting that accidental contamination is possible when there is no scientific evidence in the literature that has ever confirmed this possibility

She dismissed all literature prior to 1980 as unreliable, and considered that the institutional cases were either all cases of unrecognised sexual abuse, or alternatively were caused by an organism other than gonorrhoea. She said that the vagina was a different “immunological compartment” to the conjunctiva (hence you could have non-sexual transmission in the eyes but not the vagina), and persisted with the orthodox view that gonorrhoea in a child beyond the newborn age is sexually transmitted.

The judgement was reserved for another two months, and was released when Lana was aged two years eight months. The judge accepted the orthodox view, decided that it was more likely than not that Lana’s infection had been sexually transmitted, could not determine whether it was her mother or her father who had abused her, expressed concern at her parents’ steadfast and united denial of sexual abuse, considered that there was a grave risk that Lana was likely to be sexually harmed if she was returned home and therefore made a declaration that the little girl was in need of care and protection as a ward of the state.

An Australian case

I was involved in a similar case in Australia where a father, who had transmitted gonorrhoea to his young daughter, was similarly accused of sexual assault. He had been acquitted in the criminal court but the social services would not allow him to have any contact with his wife and daughter. They were fighting to be reunited as a family and the case finally reached the Appeal Court in March 2008. I attended a conference of expert witnesses in Australia, where myself, an Australian pathologist, two Australian sexual health physicians and an American paediatrician spent a day with an independent mediator to discuss the possibilities of non-sexual transmission. The three Australians and myself were in agreement that non-sexual transmission could occur, and in our opinion was the likely cause of the child’s infection in this case. The paediatrician was adamant that non-sexual transmission was not possible. The case was heard in the Appeal Court over the next few days and resulted in the judgement being in favour of the opinion of myself and my Australian colleagues.

International controversy

British Medical Journal

Having conducted this comprehensive systematic review, I considered it important for this information to be disseminated professionally in the peer-reviewed academic literature. I submitted my paper for consideration to the British Medical Journal (BMJ). Their review process took considerably longer than usual. I later learnt that this was because of debates by the journal editors on whether to consider it for review, and then difficulty finding someone to review it. Eventually it received one of the best reviews I have had. The reviewer wrote:

“The paper tries to redress some balance to this emotive area and uses evidence to show that each case of infection should be judged on individual merit … the paper is important and should be accepted for publication.”

Despite this review, the BMJ editors then rejected the paper because:

“We can find no evidence that the guidelines (or anyone really) would suggest that a mere finding of this sort would merit removal of a child from its family as suggested in the intro to this piece. All authorities in the UK would say that it is just one piece of evidence to be added to others.”

Journal of Forensic and Legal Medicine

I subsequently, in 2007, published my review in a peer-reviewed forensic medical journal, the Journal of Forensic and Legal Medicine, (JFLM). I also presented my review at the Faculty of Forensic and Legal Medicine, Royal College of Physicians Conference in Torquay, England in 2007 to a responsive audience. My paper solicited a long and scathing Letter to the Editor by Nancy Kellogg, author of the USA guidelines (Committee on Child Abuse and Neglect. Clinical Report: the evaluation of sexual abuse in children, published in the journal Paediatrics in 2005). Kellogg described my review as “One person’s speculative journey into her belief that non-sexual transmission is not rare” claiming “She provides neither evidence nor a systematic review.” She suggested that the numerous institutional cases were either all cases of sexual abuse or alternatively were due to an organism other than gonorrhoea. She wrote:

” It is totally baffling why case reports met the criteria for this ”systematic review,” yet randomized controlled trials, comparing, for example, the gonorrhea rates of children who were sexually abused to children who were not, were excluded.”

Kellogg’s letter was published with my rebuttal. I responded that hers was a strawman argument, because fortunately gonococcal infection in prepubertal children is a rare event, by whichever means it has been acquired. Mine is in fact a rigorous systematic review, meeting all the required criteria, and the reason why no randomised controlled trials were included were because none exist, and would of course be unethical to conduct.

NZLawyer

An article about my review was published in the NZ Lawyer 12 October, 2007). NZ members of DSAC (Doctors for Sexual Abuse Care) Drs Janet Say and Patrick Kelly wrote a Letter to the Editor the following month, claiming that mine was not a systematic review, that the outbreaks in institutions were caused by non-gonococcal organisms, that the outbreaks in institutions were caused by sexual abuse, that “The eye (anatomically, immunologically, and physiologically) is different from the genitalia” and that I had not conducted a forensic sexual abuse examination in 20 years.

Again I had right of reply and had the opportunity to explain how the review was systematically conducted, and why the papers reviewed involved cases where the diagnosis of gonorrhoea in institutions was not in doubt.

The physical signs of child sexual abuse

The Royal College of Paediatrics and Child Health (RCPCH) was conducting a major revision of their child sexual abuse guidelines, and colleagues of mine in the Faculty of Forensic and Legal Medicine, Royal College of Physicians, sent them my review to include in their chapter on sexually transmitted diseases. The physical signs of child sexual abuse: An evidence-based review and guidance for best practice was published in March 2008. Despite receiving my review, this book persisted with the message that gonorrhoea in children after the newborn period indicates sexual abuse. They wrote:

“sexual abuse is the most likely mode of transmission in pubertal and prepubertal children with gonorrhoea”

and:

“In a recent systematic review, Goodyear (2007) considered the evidence for non-sexual transmission of gonorrhoea in children after the neonatal period. This review did not have the rigorous criteria used in this evidence-based guidance concerning the certainty of diagnosis/exclusion of abuse and included conjunctival infections”.

At the book launch the leading authors of this chapter, Drs Karen Rogstad and Amanda Thomas, said that there was no evidence of children acquiring gonorrhoea from non-sexual means. The full audiotape of the proceedings was posted on the RCPCH website. When asked about my review Dr Rogstad said that it was a very dangerous paper developed by someone producing papers to support an incongruous belief and that it was a harmful editorial that had not been peer-reviewed.

My subsequent complaint to the RCPCH has resulted in their removal of the audio-taped recording of the book launch from their website, and an apology that my work was not “a non-peer reviewed editorial”, but has made no concessions regarding the possibility of non-sexual transmission in children. What I asked for but did not receive was a page insert into the book (in those volumes not yet sold) explaining the importance of considering both non-sexual and sexual transmission when gonorrhoea is found in children, looking at it case-by-case for possibility of both sexual contact and accidental contamination, with reference to my review plus Kellogg’s letter and my reply. I also requested that this statement be posted on the RCPCH website at www.rcpch.ac.uk/Research/CE/RCPCH-guidelines where the book is promoted.

Does it matter?

While Drs Kellogg, Rogstad, Thomas, Kelly and others have made disparaging remarks about me and erroneously criticised and discredited my work, I am well used to such attacks which in themselves have little impact on me. However, The physical signs of child sexual abuse is a guidance published by the RCPCH which purports to promote best practice based on an evidence review. This potentially is a highly influential publication in the English-speaking world.

It is my presumption that my review is considered as “dangerous” because it was perceived that it might assist guilty men be acquitted, and children returned into unsafe homes. My view is that in the absence of any supporting evidence or suspicion of sexual abuse, the presence of gonorrhoea alone may not be adequate evidence to convict beyond reasonable doubt, nor even to remove a child from its family on the balance of probability that the child has been sexually abused. While I do not want guilty men to go free nor children returned to abusive situations, nor do I want innocent men convicted and non-abused children losing their families.

This has very significant medicolegal ramifications. In most instances where children are diagnosed with N. gonorrhoeae there has been no disclosure of child sexual abuse. Clearly the possibility of abuse must be immediately and seriously entertained and investigated. However forensic physicians and paediatricians using The physical signs of child sexual abuse as their guideline will be unaware that non-sexual (indirect or fomite) transmission may be the mode of infection in some children, and that this possibility must also be considered on a case-by-case basis.

Furthermore, doctors including myself who put forward the possibility of non-sexual transmission in particular cases in the courtroom, are likely to be presented with statements from The physical signs of child sexual abuse which will be used to discredit or override my review. These guidelines may serve to misinform some of those involved in the care of children and young people.

Apart for the cases in which I have been involved, it is clear that in New Zealand at least, if gonorrhoea is found in a pre-pubertal child beyond the newborn age sexual abuse is presumed a “medical certainty”. In 11 years there were 14 cases seen at the Auckland children’s hospital (Kelly P. 2002: NZ Med J 2002;115(1163). All were taken to their GP with genital symptoms and abuse was not suspected until the gonorrhoea was detected, but all cases were deemed sexual abuse. The identity of the perpetrator was deduced ‘based on who was in contact with child during incubation period’. The outcome of these cases were convictions of suspected abusers, children taken into care and families fleeing the country. It is not possible to know if at least some of these cases were the result of accidental transmission, because this possibility was not considered. It is not known how many cases are occurring in the UK and elsewhere where children are found to be positive for gonorrhoea and sexual abuse is automatically assumed.

Clearly it is difficult to determine whether transmission has been sexual or non-sexual. In the past, cases of sexual abuse may have been missed. The current thinking is that gonorrhoea is definitive evidence of sexual abuse or contact, yet there is conclusive evidence that accidental contamination may occur on occasions. It is my recommendation that all such cases must be taken seriously and considered on case-by-case basis. Missing sexual abuse has serious social and legal consequences, but removing children from their parents on wrongful assumptions can be equally damaging. Doctors and lawyers should be cognisant of the large body of literature demonstrating both sexual and non-sexual means of transmission of gonorrhoea in children.

Anti-oxidants: the key to nutritional success?

Extravagant claims are often made for the health-giving effects of anti-oxidants in the foods we eat. But sorting out the truth from the hype is not at all easy.

In the window of a health-food shop, I saw an advertisement extolling the merits of Goji berries. The advertisement said that an ‘ORAC test’ had shown that Goji berries have a lot of anti-oxidants in them. ‘ORAC test’ has a scientific ring about it-Goji berries must be good!

Anti-oxidants have attracted a reputation as beneficial ingredients of foods, nutritional supplements and cosmetics. So I thought I would try to describe what anti-oxidants are, and explain what the ORAC test is and its limitations. I’ll also give some examples of anti-oxidants in fruits and vegetables, and make some comments as to whether it’s worthwhile taking supplements containing these anti-oxidants in an attempt to get more of them inside you than is usual from a healthy diet.

What are anti-oxidants? Let’s start with oxidation and move onto food. Oxidation is a process in which electrons are removed from atoms and molecules. Oxygen is the classic oxidising agent. Digestion of food and extraction of energy from it is essentially an oxidative process. It occurs over many steps but one of the final outcomes is the transfer of electrons to oxygen (which is why our existence is dependent on a supply of this gas*). When the electrons are passed to oxygen, water is formed but oxygen ‘radicals’ are also formed as a side effect. Radicals are atoms or molecules which have one or more unpaired electrons. By virtue of the unpaired electrons, radicals (sometimes referred to as ‘free radicals’) are extremely reactive. The oxygen radicals are no exception and if not mopped up will cause all sorts of havoc by reacting with molecules that they shouldn’t react with. In short, oxygen radicals are toxic.

An example of an oxygen radical generated in our bodies is the ‘superoxide radical’: O2.-, two oxygen atoms linked together to form a molecule that has an unpaired electron (the dot) and a negative charge (the dash). It’s been estimated that an adult weighing 70 kg makes about 1.7 kg of superoxide radicals a year. This is equivalent to about one percent of total oxygen consumption.

Molecules that can neutralise free radicals are called anti-oxidants. Anti-oxidants do not react only with oxygen radicals. Other ‘reactive species’ capable of causing oxidative damage and that react with anti-oxidants may contain, for example, nitrogen and sulphur. Barry Halliwell and John Gutteridge give a more formal definition of an anti-oxidant in Free Radicals and Biology in Medicine (2007), which is: “any substance that delays, prevents or removes oxidative damage to target molecules”.

Reactive species in addition to oxygen radicals also end up in our bodies. Cigarette smoke, for example, contains free radicals. Given the toxicity of oxygen radicals and other reactive species, it’s not suprising that anti-oxidants are considered a good thing, and that it’s thought a good idea to make sure we have as much of them inside our bodies as possible. Fortunately, our bodies have a number of built-in anti-oxidant systems to protect us against oxygen radicals formed as we breathe, and other reactive species. I am not going to deal with these systems but will confine my attention to dietary sources of anti-oxidants as it is these which are usually discussed in dietary advice and turn up in nutritional supplements. These anti-oxidants are, by and large, derived from plants.

Measuring Anti-oxidants

The ORAC test is one of the principal assays used to estimate the anti-oxidant content of such materials. (If all this seems a bit dry, bear with me because the nature of assays for anti-oxidants is central to claims that supplements, foods, etc, contain a lot of them.)

When an analyst is faced with developing a chemical assay to find out how much of something is in a sample of fruit or vegetable, one approach is to find some reagents which when added to the sample react with the substance(s) in question and in so doing exhibit a measurable change in some property of the mixture, eg an increase in colour intensity. Hopefully the technique is sufficiently sensitive (will measure quantities that are of interest to the analyst), selective (ideally the reagents react only with the substance(s) in question) and quantitative (the properties of the mixture change in a regular way as the amount of substance changes). Many assays are quite selective; others only give an indication of the amount of a class of compound. The ORAC test is of this latter type.

There are dozens of molecules that can be classed as anti-oxidants and it would be a lengthy and expensive task to identify the compounds in a sample every time an estimate of the overall level of anti-oxidant activity was required. Tests like the ORAC assay are used to estimate overall activity in a sample, the amount of activity being expressed as ‘equivalent to’ an amount of a ‘standard’ anti-oxidant compound.

ORAC stands for Oxygen Radical Absorbance Capacity. The basic premise behind this assay is that the ability of a sample to neutralise free radicals indicates the presence of anti-oxidants. When exposed to light, a substance called fluorescein emits light of a longer wavelength than that shining on it; this ‘fluorescence’ can be measured using a fluorimeter. Fluorescein also has the useful property that its fluorescence is diminished in the presence of free radicals. We would have the basis of an assay if we mixed our sample with fluorescein and a source of free radicals and saw that the decrease in fluorescence was less than in the absence of the sample because of the protective effect of anti-oxidants. This wouldn’t get us very far as about all we could do would be to say that one sample had more or less anti-oxidant activity than another. The assay could be made more quantitative if we were able to compare estimates of activity from various samples with those obtained using a known standard anti-oxidant. A commonly used one is Trolox, a synthetic analogue of vitamin E.

So in the complete assay we would measure the fluorescence coming from a series of solutions containing increasing amounts of Trolox but constant amounts of fluorescein and free radicals. If we run everything correctly there will be a regular and positive relationship between the fluorescence emitted and the amount of Trolox present. We would also measure the fluorescence coming from solutions containing the free radicals and our extract of Goji berries (no Trolox), and calculate that a measured amount of Goji berries contained an anti-oxidant activity equivalent to that provided by a known amount of Trolox. Another way of looking at this is that we have estimated so many grams of berries as having the same ability as a certain amount of Trolox to protect fluorescein from oxidation by the free radicals.

Remember that the ORAC test only gives a measure of the ability of our extract to protect fluorescein from the action of free radicals in vitro (in vitro-in the test tube; in vivo-in the living body). It says nothing about the anti-oxidant activity of the extract once it has been ingested (in vivo). A high ORAC value simply tells us that the extract contains molecules that might have some anti-oxidant activity in vivo.

The principal value of an assay of this type lies in the ability to compare different samples of plants, foods etc according to a single property. The table below contains some ORAC values for anti-oxidant levels in some fruits and vegetables. These values have been taken from a larger set published by the United States Department of Agriculture (USDA, 2007).

The units of measurement are µmol Trolox Equivalents per 100 g fresh weight (FW) of fruit or vegetable. Fresh weight is the weight of the leaf, fruit etc as it is harvested with no adhering dirt, fully hydrated but with no surface drops of water. A mole (abbreviated as mol) is a measure of the amount of Trolox and 1 µmol of Trolox has a mass of 0.00025 g. So, if a vegetable has an ORAC value of 1000 TE per 100 g FW, then 100 g FW of the vegetable has the same ability, in the test-tube, to neutralise free radicals as 1000 µmol or 0.25 g of Trolox.

µmol TE / 100 g FW
Turmeric 119346
Curry powder 6665
Blueberries 6552
Apples, Granny Smith, raw with skin 3898
without skin 2573
Cashew nuts, raw 1948
Avocadoes, Hass 1933
Onions, raw 1034
Green peppers, raw 923
Bananas,raw 879
Carrots, raw 666
Cabbage,raw 508
Tomatoes, raw 367
…and Goji berries? It’s not easy to find a reputable ORAC value but it does seem to be considerably higher than most other plants tested.

Examples of anti-oxidants

What are these anti-oxidants of plant origin? Here are a few examples, with some comments as to whether they exert a beneficial effect in vivo.

Vitamin C or ascorbic acid: This is an essential nutrient, famous for its role in the prevention of scurvy. It is an anti-oxidant in vitro but it is uncertain as to whether it has any major effects as an anti-oxidant in vivo. Sufficient vitamin C to maintain health can be obtained from a diet including fruits and vegetables. With such a diet, there is no evidence of beneficial effects of supplementary doses.

(Scurvy is a deficiency disease of connective tissue. The role of vitamin C here is not that of an anti-oxidant but to ensure that enzymes involved in the synthesis of connective tissue function effectively.)

Vitamin E: Vitamin E was first defined as a fat-soluble ‘factor’ necessary for reproduction in rats. It is not a single compound, a number of substances having vitamin E activity. The principal ‘natural’ form is α-tocopherol. Mixtures of tocopherols are found, for example, in soybean, corn, walnut and rapeseed oils. The evidence for anti-oxidant effects in well-nourished humans is limited.

Carotenoids: These are orange and yellow pigments found in plants, most typically in carrots. ß-carotene is a common carotenoid. There is only weak evidence that they have an anti-oxidant role in vivo. (They do have an important role in the diet for other reasons, principally as a precursor for vitamin A.)

Polyphenols: Polyphenols are compounds that have groups of six carbon atoms linked together in rings. The rings have hydroxyl groups (-OH) attached to them. Polyphenols of plant origin are excellent anti-oxidants in vitro, but it does not follow that they have the same effect in vivo. This group contains the compounds found in blueberries and blackcurrants and some have become quite well known through discussion of their potential anti-oxidant properties, eg resveratrol from red wine, quercetin in teas and onions, and curcumin from turmeric.

Epidemiology

There is evidence from epidemiological studies of correlations between anti-oxidant levels in the body and good health, and between good health and diets rich in fruit and vegetables. Correlations however do not prove causation and it remains uncertain whether the correlations observed are due to compounds exerting anti-oxidant effects in vivo. A further problem in interpreting epidemiological studies is that it is difficult to be accurate about the relationship between dietary intake and incidence of disease, particularly when studies seek to understand data gathered across different countries. Intervention studies

Intervention studies (where one group of subjects is provided with a supplement, and their health and physiological status is compared to a matched group receiving a placebo) might help us decide whether supplements are worth taking, but it has proved difficult to obtain evidence of a cause and effect relationship in these. Halliwell & Gutteridge (2007) describe the literature on intervention studies seeking to demonstrate a link between diet and supplementary anti-oxidants as a “morass of confusing data”.

Some clarity on the effects of supplements of some anti-oxidants (ß-carotene, vitamins A, C, E) and selenium has been given by a recent Cochrane review (Bjelakovic et al., 2008). This review considered 67 trials, involving 232,550 people, of the effects of taking supplements of these anti-oxidants. The principal conclusion from consideration of all this data was that overall, there is no evidence for an effect of these supplements on mortality in healthy people or those with various diseases. When the effects of different supplements were looked at separately, there was an increased risk (which only just reached statistical significance) of mortality associated with supplements of vitamins A, E and beta-carotene. There were no significant effects on mortality from vitamin C or selenium supplementation. (Selenium is an essential nutrient and is a component of several enzymes, some of which are thought to have anti-oxidant functions.)

Conclusion

What to do? If we take the epidemiological evidence as our guide, eating lots of fruit and vegetables is sensible advice. They have established beneficial effects, such as being enjoyable to eat, providing fibre and helping to maintain adequate levels of vitamins and minerals. The anti-oxidants they contain might exert a direct beneficial effect in vivo. At this point in our knowledge of dietary anti-oxidants and their effects in vivo, there seems little, if any, point in spending money on supplements of anti-oxidants.

Alan Hart spent over 30 years doing biology research. The last 15 were spent developing assays of various kinds. He has an interest in the meaning and practice of biological measurement.

*An excellent and readable account of the role of oxygen in our world, including a discussion of oxygen radicals and anti-oxidants, is Nick Lane, 2002: Oxygen, The molecule that made the world, Oxford University Press.

The Royal healing touch

The medical community in Britain is suffering a severe attack of lèse majesté, and it is feared some distinguished heads will roll on Tower Green.

Prince Charles, in his untiring care for the health of his future subjects, has set up The Prince of Wales’ Foundation for Integrated Health, and, with the help of several hundred thousand pounds of taxpayers’ money, this Foundation has published Complementary Health Care: a guide for patients. It helps readers to locate homeopaths, reflexologists, cranio-sacral therapists, and other types of healer. This 45-page treasury is being sent free to all GPs in Britain.

This well-meaning attempt by the philanthropic heir to the throne and his disciples to help the sick has been spurned by the medical fraternity, in the harshest and most hurtful terms. The British Medical Association has criticised it for recommending treatments which have no evidential support. More biting remarks have come from Professor Edzard Ernst, occupant of Britain’s only Chair of Complementary Medicine. When he saw a draft version, he said it was “hair-raisingly flimsy, misleading and dangerous”. He offered to correct it free of charge, an offer which was declined (Of course! How dare he presume to rewrite a text which had the Imprimatur of HRH?).

Having seen the published version, the Professor is even more scathing (see www.guardian.co.uk/g2/story/0,,1442930,00.html) “… scandalous waste of public funds … the most spurious I have seen for years … reads like a promotional booklet”.

No expense seems to have been spared in the production of the “Guide”; it is in full colour, with lots of photos of folk receiving various therapies. Though it concedes, even emphasises, the need to see your doctor and to keep him/her fully informed, the contents will otherwise be familiar to students of Complementary Medicine; no mention of evidence (though a scholarly-looking list of 141 references), much talk of “… believe that … ” and “… used by many people for …” and of those mysterious entities beloved of these practitioners: “energy” and “meridians”. There is, of course, no discussion of the mutually exclusive nature of some of these therapies, nor of the complete absence in many cases of evidence of efficacy. You know, of course, the meaning of the verb “to heal”. It is therefore puzzling to see one of the 16 therapeutic modalities included in the “Guide” is known as “Healing”. Surely it is not implied that none of the other 15 can cure your trouble? “Healing”, in this context, looks to be our old fraudulent friend Therapeutic Touch. If you are visiting Britain, and feel the need for a little cranio-sacral therapy, help is at hand. The Guide, with relevant addresses, can be downloaded free from www.fihealth.org.uk. Be cheered, also, by the claim that over half the GPs in Britain will direct you to CAM practitioners; indeed, many have such people working in their medical centres.

Loose Talk from an Old Smoothie

Bob Brockie samples a health food that saw the dinosaurs come and go

We’ve all seen the claims – Spirulina! Nature’s Health Solution! The World’s Healthiest Superfood! Soulfood!
“Spirulina – the ancient blue-green micro-algae found growing in the lakes of Africa and Central and South America, derives its energy directly from the sun, contains 100 nutrients, is a rich source of iron, is extremely alkalising, energy-packed, supports the maintenance of the beneficial gut flora, is rich in antioxidants, contains 65% protein, etc.” Many firms claim that Spirulina “will reduce diabetes, cancer, hives, cataracts, wrinkles, anaemia, eczema, HIV, hypertension, detoxify the kidneys, help balance your RNA and DNA nucleic acids, and protect you against radiation.”

Small wonder that huge volumes of this cure-all are drunk or eaten daily. One US firm sells over $50 million worth of Spirulina every year. But most chemists and medicos think these claims are laughable.

“Found growing in the lakes of Africa and Central and South America?” Yes, this is true but Spirulina also grows in almost any stagnant fresh or brackish pool near you in New Zealand. Nevertheless, a lot of the Spirulina sold in New Zealand is produced in industrial vats in the US.

As for the nutritional claims – the same could be said about almost any green vegetable on Earth. Spinach or broccoli also contain 100 nutrients, are a rich source of iron and vitamins, are extremely alkalising in the stomach, support the maintenance of the beneficial gut flora, and are rich in antioxidants. If you want protein it’s cheaper to eat an egg, which is 87% protein. And what’s this? “Spirulina contains antioxidant ammunition in the form of the enzyme Superoxide dismutase!” Nobody can deny this but it’s a silly claim. Superoxide dismutase is the most abundant enzyme in the world. Every green plant is full of the stuff.

To be really pedantic, Spirulina is not an alga at all, it’s a bacterium. Ancient? Yes. Because Spirulina has a long fossil history it is often promoted as a “Dinosaur Drink”. “It must be good for you because it’s so old” but the promotion people got the date wrong. Spirulina was around 600 million years before dinosaurs trod the Earth. We should call it “The Proterozoic Drink”.

Raw Spirulina tastes vile, which is why Spirulina smoothies must be masked with pureed banana, kiwifruit and apricot. These additives provide more energy and vitamins than the Spirulina itself.

Who’s for a broccoli smoothie?
Originally published in the Dominion Post, 11 November 2002

Hokum Locum

Dioxin “Poisoning” or Hormesis in action?

It will be interesting to see how the government handles the latest health scare which is being helped along by the usual sensationalist media reporting. How about this example: “The men who made the poisons that blighted a New Plymouth community….” (Sunday Star Times, 12 September 2004).

There are many dioxins and the most toxic is considered to be TCDD, a contaminant found during the manufacture of the herbicide 2,4,5-T but also occurring naturally as a result of combustion, forest fires and smoking. Dioxin has been isolated from soot in prehistoric caves. Dioxin is found in body fat (lipid) and has a half life of around 7-10 years, meaning that a total body load diminishes by half during each such interval. The national average body level of TCDD is 3.5 picograms per gram of lipid. A picogram is one trillionth of a gram (ie. 1 x 10-12 grams, or if you like a lot of noughts: 0.000000000001 g). The mean TCDD level in residents of Paritutu was 10.8 picograms per gram of lipid with a range of 1.3-33.3. To date, there is no evidence of increased disease rates in the studied population. To put it bluntly, the Paritutu residents have 3-10 times the infinitesimal amount found in the general population, still well within international limits. I would like to see a similar study examining the levels of dioxin and mercury downwind from the local crematorium!

Hormesis is an effect where small doses of a toxic substance seem to promote health. A good example is alcohol, as was the Victorian habit of consuming small doses of arsenic and strychnine as a “tonic”. Rather than concentrating on looking at ill-health, researchers should be examining whether Paritutu residents are in fact healthier than most other New Zealanders.

Nevertheless, research will be ongoing and although not given to making predictions I offer the following observations:

  1. Residents will claim that every possible health problem they have ever had was caused by dioxin exposure.
  2. Residents will demand compensation in accordance with Welch’s Law (Claims expand to take up the amount of compensation available).
  3. Scientific evidence will be distorted and misinterpreted to justify any possible viewpoint.
  4. The “Greens” will claim that any amount of dioxin is “unsafe” and at some stage the phrase “cover up” will be used.

A former manager of the Paritutu chemical plant is quoted as saying that he worked there for 30 years and is still in perfect health at 85 years of age. Hormesis in action surely?

More Healthy Additives?

Britain is in the grip of such a serious depression that prescriptions for the anti-depressant “Prozac” (fluoxetine) have risen from nine million to 24 million per year. I read this as I sipped my ale in the Pint and Prozac, a quaint canal-side pub which I discovered while on my recent overseas trip to research taro cultivation by the gay and lesbian community (funded by a Community Education Grant – thanks Steve!).

Prozac is finding its way into ground water and hence into supplies of drinking water.

It is clear that I have been on the right track in calling for Ritalin (methyphenidate – a stimulant) to be added to the water supply as a Public Health measure. This combination of stimulant and antidepressant will surely lead to a euphoric and happy population. I am however concerned about problems of dosage as the Authorities have claimed that the Prozac is so “watered down” that it is unlikely to pose a health risk, except to those who believe in homeopathy.<br> Christchurch Press, 10 August

Touting for Business – “Chiropractic Kidz Week”

What better way to build up business than to convince parents and children of the need for regular assessment and treatment of “subluxations”, the core tenet of chiropractic pseudoscience. It is a matter of concern that “chiropractic kidz week” is a nationwide programme aimed at those “parents or caregivers or the child themselves (who) are not aware of a spinal problem.”

The reason such people are “unaware” is because they do not have any such “spinal problem”, which exists only in the self-deluded imagination of the chiropractor. Chiropractors interpret minor postural variations as signs of “disease” and requiring treatment. I wonder if any chiropractor has ever diagnosed a “perfect spine” unless it was achieved at the expense of 60 “treatments”. It is a national disgrace that this pseudo-science is funded by ACC and chiropractors should not be allowed to either take or bill the Health Service for x-rays.

Please keep an eye out for this scam next year and if possible get as many members as possible to take their children for a free assessment and report back to me what happens. Some tape recordings would be useful. A woman recently wrote to the paper and took Frank Haden to task for criticising alternative medicine. She went on to claim that chiropractic manipulations had cured her of migraine, cured her child’s squint and cured another child’s gait abnormality!

With such gullible beliefs out in the community it is no wonder that chiropractors continue to work their rich scams.
Blenheim Sun, 11 August
Letter to Editor, Sunday Star Times, 26 September

Anyone for Tennis?

A millionaire property owner has been getting $600 per week from ACC since 1974, despite earning $2400 per week from his investment portfolio. In a bizarre example of Welch’s Law, his claim was accepted under medical misadventure for psychological damage caused by prescription medicines, in this case benzodiazepines (Valium). His disability is “psychological” and prevents him from working at all but readers will be thrilled to know that the poor fellow is able to play tennis three days a week and in his own words “it’s better to have a peaceful life”. ACC have done a great service to tennis as the claimant is now in the top third of senior players in Auckland. Employers and taxpayers alike will be thrilled to know that their ACC levies are being put to such good use. Sunday Star Times, 26 September

In Brief

  • Despite local doctors showering sick notes like confetti, teachers at Hamilton’s Fraser High School failed in their bid for compensation from MAF for “illness” caused by the spray used to eradicate the Asian gypsy moth. Sorry people, no money for mass hysteria. Better to track down the millionaire’s doctor and go for PTSD caused by unruly pupils. (Dominion Post, 30 September)
  • In France the Académie de Médecine has upset homeopaths by issuing a damning report challenging the continued funding of homeopathy through the national health service. (Dominion Post, 9 June).
  • Acupuncture is ineffective for the treatment of tennis elbow. Hardly surprising given that “good evidence indicates that acupuncture does not work.” (Bandolier 126 Vol 11, Issue 8, www.bandolier.com).
  • Remember the Aoraki Polytechnic and their stupid proposal to run a degree course in naturopathy? They are at it again. They got $8165 community education funding for the New Zealand Council of Homeopaths’ Conference. (Sunday Star Times, 3 October).
  • For most of October I will be touring northern India by motorcycle and I intend filming and recording as much as possible. I have been asked by Paul Trotman to find him a “nose kettle”. If you want to know what that is you will just have to come to next year’s conference!

John Welch lives in Picton and is a retired RNZAF medical officer.

I Feel Sorry For Him

A French test of a therapeutic touch practitioner generates sympathy, but no positive results

We have recently received a message from OZ. Not transtasman Big Brother, but the cousins in France. OZ stands for Observatoire Zététique, a group of skeptical investigators (Zetetic is much the same as skeptic, as every Victorian schoolboy knew. The Greeks had not just one word for it, but two).

The message is an English translation of their report on a test of a Therapeutic Touch (TT) practitioner. This person, referred to as “Mr Z” had approached OZ with some keenness to be tested, and many discussions took place, not only on a detailed protocol for the tests, but about Mr Z’s philosophy and approach to his vocation.

OZ summarise Mr Z’s practice thus:

“[It] depends largely on subjective validation parameters: the [energy] is sensed either around the area affected by a given pathology or in the vicinity of the source of the problem. For example, ankle pathology can be the cause of muscular tension in the neck; thus the signal might be perceived either in the ankle or the neck area. This complicates any attempt to identify the signal by comparison to objective means of observation (eg scanners, x-rays, MRI and so forth). The same is true of treatments carried out by means of ‘magnetic passes’; the area to be treated cannot be determined by reference either to the affected area or to the area deemed to be the cause of the pathology. Moreover, a validation based on the sensations of patients would be lengthy and difficult to implement, and would not furnish a satisfactory solution to the problem of observation according to objective parameters.”

After long consultation two tests were set up. In the first, preliminary test, Mr Z determined for each investigator from which part of the body he detected the strongest signal. He was then blindfolded, and he examined each in random order. Result, two successes out of nine attempts: failure.

For the second and definitive test, Mr Z chose the skeptic whose “body energy” he found to be the strongest. This was a female member of the investigating group. The two members with the weakest “energies” assisted Mr Z. A screen was set up across a doorway between two rooms, with Mr Z and his assistants on one side, and the other investigators and the subject on the other. In several dummy runs Mr Z claimed to feel the “energy” through the screen when the subject was present, so a series of 100 tests, with 50 “positives” (subject behind screen), and 50 “negatives” (subject not behind screen). Mr Z expressed himself satisfied with the test, and was keen to have the results published. Of 100 tries, two were discarded because, by reason of misunderstanding of signals, the subject’s position did not match that indicated by the previously randomly selected positives and negatives. For statistical significance, 98 tries require 64 correct answers. Unfortunately for Mr Z, he achieved only 55. These unsurprising results confirm previous findings and our expectations from our present knowledge of the physical world. What did surprise me was the great empathy between the skeptics and Mr Z. Their report shows almost great disappointment that he failed. Is this the stuff skeptics are supposed to be made of?

The title of this article is quoted by the investigators as the comment by the president of OZ when the news was reported to him.